The Standardization of Data and the Personal Health Record

Health data standards are part of almost every discipline and industry. Within healthcare, there are standards from laboratory and radiology procedures to network protocols. With Meaningful Use stages 1, 2, and now 3, there are certain healthcare standards that were incorporated to dictate standardization between users to ease interoperability.

We have LOINC for laboratory procedures that will be linked with RADLEX for radiology procedures. RxNorm Codes are on the rise in collaboration with NDC numbers, and CVX codes for immunizations. CPT codes and ICD-9 codes are the words that are always heard when it comes to billing, and who can forget about Snomed-CT, DICOM, and HL7?

Using standards provides a common jargon for easier communication. But are there other areas in healthcare that need to be reviewed as a common foundation? How about gender?

We all document gender or sex of the patient. However, gender can be defined differently when speaking to multiple people and disciplines, and the choices for gender can range from three choices (male, female, other) to four (male, female, unknown, other) and even more. Depending upon the country (or countries) of the person being asked, they may choose up to 10 options.

This value can be collected differently in some areas by stating what the patient was born as one option and also what the patient currently chooses. Some may choose not to differentiate between the two and ask the biological basis of the gender only. In certain countries, there may be the option to choose being genderless or transgender.

Why does this matter to us? For those who create or monitor customized forms or healthcare data, we create these choices based upon what is seen in our region or country. We then mine data on this information and pass this information from region to state, then state to national, and then finally national to international.

We make assumptions that others may want to define the same choices and base decisions upon that same information. The information is often crucial to provide a proper treatment.

Gender definition is just one piece of the demographic information puzzle.

Will we ever get to a point where a common personal health record exists that is both portable and able to be documented by any provider, wherever you are? The benefits are obvious.

Patients often travel abroad for medical treatment. Their demographic and clinical information will either be transmitted to a designated destination electronically or carried on paper to be entered into the next application. There currently are multiple solutions for documenting data, but what will future solutions look like? Can patients, systems and vendors afford to wait until all semantic differences are resolved? What is your vision of the future?

The following two tabs change content below.

Deepika Patel

PACS Regional Coordinator
Deepika Patel, MBA, is a certified radiologic technologist who has extensive experience as a clinical systems analyst, working directly with all clinical departments, interdisciplinary teams, and private practices. She also previously worked as a PACS administrator team lead and is CPHIMS certified. "The views and opinions expressed in this blog are Deepika's and are subject to change. They are not necessarily representative of the views and opinions of my current and past employers and/or other organizations that she works with."