Current Projects

Procedure Nomenclature Project

©Copyright by Stasia Sands-Kahn MD. All Rights Reserved.

For the past two years, I have been working with a core group of medical informaticians to develop a procedure nomenclature. The project grew out the need to standardize the manner in which my partners and I order tests and procedures from our EMR and then electronically file the results in our EMR. In addition, I have been exchanging summary documents (CCRs) in the PDF/Healthcare format with consulting physicians and my patients. Unfortunately, the lack of standardization in describing tests and procedures leads to inefficiencies when selecting attachments to accompany summary documents such as the CCR or CCD.

The project is, in essence, an end- user friendly, standardized order set for 80% of the ambulatory tests including labs, imaging, and procedures used in primary care and dentistry. This same comprehensive order set can be used by providers who order the tests using CPOE and by administrative personal that attach the results of the tests and procedures to the electronic medical record.

The goals of this project are to improve efficiency and workflow in ambulatory healthcare settings and improve patient safety by ensuring that patients have the correct test and procedure ordered and filed appropriately in their chart.

The vision is that the database will be used as a reference terminology for standards organizations. For example, the laboratory section of the Procedure nomenclature project was included as a source for the Common Lab Order LOINC Value Set Version1.1.

We are seeking physician and dental volunteers to review the database and complete a simple survey that should take under five minutes to complete. The survey will provide valuable feedback to the project. The feedback will be used to validate the content of the current database and to provide valuable input and direction towards the final version.

For those with HIM, HIT, and Standards Expertise, we are asking for assistance mapping the procedures and tests to the appropriate procedure codes including mapping all entries to LOINC, SNOMED-CT, CPT, CDT, and ICD-10 PCS.

Procedure Nomenclature Core Team Members

Stasia Kahn, MD is the Co-Owner of Fox Prairie Medical Group and Vice President of Northern Illinois Physicians For Connectivity. She is a lecturer in Medical Informatics at Northwestern University and Founder of EMRSurvival.com

Arden Forrey, PhD is on the faculty at the University of Washington and has represented AACC (American Association for Clinical Chemistry) in ASTM E-31 since the 1970s and contributed to the E-31 standards profile. He also participates in the ANSI (American National Standards Institute) HITSP Technical Committee and will be encouraging participation of AACC members in this project.

Imran Khan earned his Bachelor’s degree in Computer Engineering and is currently working at Advocate Health Care as a System Administrator for their Ambulatory EMR application in which he implements roll-outs, supports existing sites and trains clinical and ancillary staff. In addition, he is pursuing his Masters in Medical Informatics (MMI) at Northwestern University and serves as a guest speaker / mentor for the College of Engineering at the University of Illinois.

Shelley Myers, RN, CPHIMS is involved with standards through the PDF-Healthcare Workgroup, and is currently working on an exciting research project with Dr. Kahn which involves exchanging health information electronically between her EHR and her patient’s PHR.

Steven Stanford is the COO and co-founder of Cygnet Information Systems, a Healthcare IT firm focused on developing and bringing to market an intuitive and affordable EHR for the outpatient practitioner. He is currently pursuing his Masters degree in Medical Informatics at Northwestern University. His anticipated graduation date is December 2010.

Rita Scichilone, MHSA, RHIA, CCS, CCS-P, CHC-F is currently Director of Practice Leadership for AHIMA. Responsibilities include direction and support of projects involving clinical data standards and health informatics. Standards development work includes ISO 215 Technical Committee for Health Informatics (US TAG expert for WG3), HL7 Vocabulary Working Group, IHTSDO Mapping SIG, Education SIG and WHO-FIC Education Committee and Terminology Reference Group. .

Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA, has a comprehensive background in the field of clinical terminologies, classification, and data standards with more than thirty years of experience in the health information management (HIM) field. In her current position as the director of content management for Apelon, Inc. she oversees the terminologies found within the Core Content suite, assists with the design and development of data sets and subsets to meet specific customer needs, and helps clients define terminology requirements, create or extend structured terminologies, or integrate terminology components into their products.

Muveddet Harris is a Project Coordinator at Northwestern University at a Head and Neck Cancer Therapy Research Lab. She earned Masters of Medical Informatics (MMI) Degree in December 2007 at Northwestern University as first graduate of the Program. In addition to full-time position at Northwestern, Muveddet has been a teaching assistant in the MMI program.