Code groups (also known as value sets ) are codes and terms taken from standard terminologies which are used to define clinical concepts.
In essence, code groups are collections of codes that represent such ideas as a category of drugs or a reportable disease. For example, a health system could group together all of the ICD-9, ICD-10, SNOMED-CT and RxNorm codes that could indicate patients with diabetes. In this case, “patients with diabetes” is the clinical concept defined by the code group.
One can think about code groups as the clinical building blocks of important healthcare programs and initiatives. Here are two examples of how code groups can take on healthcare challenges many healthcare delivery organizations face today.
In one key application, healthcare informaticists can use code groups to define the building blocks of a quality measure or other metric. Quality measures, like the Clinical Quality Measures (CQMs) provided by Centers for Medicare and Medicaid Services (CMS) are used to measure and track the quality of healthcare services that providers deliver. They measure elements of patient care including health outcomes, patient safety, care coordination, population health, public health and adherence to clinical guidelines.
These measures consist of denominators and numerators, which are used to measure performance. A denominator describes a patient population or a portion of that population -- patients with a certain disease, for example. A numerator is a subset of the patient population contained in the denominator. The numerator could represent patients who received a certain clinical service or treatment. Both the numerator and the denominator are defined by one or several code groups, or value sets. The code groups are the building blocks for the metric.
A health organization could define code groups to create a measure in which a group of patients with myocardial infarction are placed in the denominator and those patients who have been prescribed aspirin are placed in the numerator. The denominator code groups would include the ICD-9, ICD-10 or SNOMED codes indicating myocardial infarction. The numerator would include a code group referencing the RxNorm codes for drugs containing aspirin.
In this application, code groups can help providers meet the requirements of the federal government’s Meaningful Use initiative, which provides financial incentives for electronic health record (EHR) adoption. In order to qualify for those incentives, physicians and hospitals must submit CQM data from a certified EHR system, according to CMS.
The CQMs used in the Meaningful Use program come from the National Quality Forum, which has endorsed nearly 700 different measures. Under Meaningful Use, eligible providers must report on 9 out of 64 CQMs, while eligible hospitals must report on 16 out of 29 CQMs.
Healthcare delivery systems must create cohort identification rules within IT systems so that their care management programs can properly identify at-risk patients. Clinical informaticists can use a code group to identify the codes from various terminologies to be used within the rule.
In this use case, one top challenge for health systems is to maintain clinically accurate rules based on up-to-date terminology standards. A rule can become stale quickly when terminology standards or business rules are frequently updated. Fragmentation is another issue. Clinical informaticists working within the various departments of a healthcare facility can duplicate efforts as they research terminologies to define which codes should be used within a particular rule.
To address those problems, organizations should manage code groups at the enterprise level. An enterprise strategy for code group management helps health systems achieve economies of scale and provides consistent policy and governance. Code group management also automates the task of updating codes to reflect business rules or standards changes.
Working With Code Groups
Effective use of code groups can help you improve care management programs and pursue such high-profile health IT initiatives as Meaningful Use. Is your healthcare organization beginning to work with such code groups or looking for a better way to manage them? Leave your comments below.