Encoding Clinical Information
Encoding refers to the use of code system concepts to represent clinical information. Not all useful information in a clinical record is encoded. There is significant value in simply providing free text to support clinician-to-clinician information exchange, particularly if the free text is in specifically identified sections within the electronic health record. However, encoded content is critical to computable interoperability because it enables computer-based systems to find and operate upon data without human intervention.
Encoding also benefits clinical interoperability by enabling clinicians from one organization to understand the meaning of transmission of information from another organization. That is not to say that encoding results in perfect representation of clinical information such that no review or human analysis is necessary; encoding of the nuances in clinical care is fraught with difficulty and almost always requires compromises in precision.
The best approach for measure developers is to use data standards to reduce the number of mapping steps required. The Health Level Seven International® Quality Improvement (QI)-Core Implementation Guide has mappings from the datatypes and attributes in Quality Data Model v5.6 to QI-Core. The Interoperability Standards Advisory and the United States Core Data for Interoperability (USCDI) also have tables of data elements and their associated recommended standard terminologies. USCDI v1 is adopted as a standard in the Office of the National Coordinator for Health Information Technology (ONC) Cures Act final rule. Find more information on the Data Standards page.
Measure developers should focus on content that measured entities can easily capture during clinical care (if appropriate), where the metrics useful in the care of the patient match those used in quality assessment and decision support systems.