Value sets, also called code groups, are essentially bags of codes that represent clinical concepts.
Those sets consist of terms and their associated numerical codes, which are derived from various terminologies such as ICD-10, SNOMED CT®, RxNorm and LOINC®. Each bag, or grouping, of codes could represent a population of patients with a particular disease (myocardial infarction) or a particular class of drug (aspirin).
Code groups (or value sets) are building blocks in clinical quality measures (CQMs), which are often associated in high-profile healthcare IT initiatives such as the federal government’s Meaningful Use program. Eligible professionals and hospitals participating in the program must submit CQMs via their electronic health record (EHR) systems in order to qualify for incentive payments.
Quality measures are also used outside of the Meaningful Use program including the HEDIS and STARS programs utilized by health plans and other pay-for-performance programs like ACOs. Once code groups are established for one set of quality measures, they can easily be tweaked or re-used for other purposes.
But outside of quality measures, code groups have other uses as well. Consider the following:
Code groups can be used to create a rule that identifies a cohort, or population, to be evaluated in a care management program to track a group of at risk patients. To arm the team of nurses tasked with patient outreach, clinical informaticists can use code groups representing problems and diagnoses data from a defined patient population to construct the population cohort rule. For example, the care management program might be interested in tracking diabetic patients who have been to the emergency room in the past month, excluding those patients with renal failure. That particular population cohort would involve three code groups.
Decision Support & Real-Time Care Alerts
Another use case for code groups are decision support or real-time care alerts. These alerts are complex rules built on code groups that may be included within an EHR, deployed as a standalone system by a provider, or used to conduct preauthorization by health plans.
Code groups may also be used to create physician pick lists within EHR systems and other health IT applications. A pick list, for instance, could list all the codes related to Atrial fibrillation (Afib) and Atrial flutter (Aflutter). In the case of Caradigm USA LLC, the company provides pick lists within its population health platform. Those pick lists, for example, put all the different types of angiotensin-converting-enzyme (ACE) inhibitors into a code group. That way a physician who wants to prescribe an ACE inhibitor can peruse the code group-based pick list within the Caradigm application.
The Growing Challenge and The Call for Reuse
Beyond the examples above, code groups have wide applicability. Today, they’re often downloaded from the Value Set Authority Center and managed locally in spreadsheets to create specific rules for a variety of use cases. In practice, these business rules are often hard-coded in data warehouses and a variety of clinical and IT applications. As terminologies are updated or the intent of the rule changes, they can quickly become stale or require maintenance. In addition, clinical informaticists working for different departments within a healthcare facility or health plan may duplicate their efforts to support their specific initiatives.
To address these problems, organizations should abstract code groups from their specific use cases and manage them at the enterprise level. An enterprise strategy for code group management lets health systems achieve economies of scale, while providing consistency in policy and governance. Code group management also automates the task of updating codes to reflect business rule or standards changes. This approach improves the accuracy of your quality measures and ultimately can have financial upside as organizations participate in more fee-for-value programs.
Have you thought about use cases for code groups within your healthcare enterprise? Are you looking at applications beyond CQM? Leave your comments below.