Is the routine health information system ready to support the planned national health insurance scheme in South Africa?

Implementation of a National Health Insurance (NHI) in South Africa requires a reliable, standardized health information system that supports Diagnosis-Related Groupers for reimbursements and resource management. We assessed the quality of inpatient health records, the availability of standard discharge summaries and coded clinical data and the congruence between inpatient health records and discharge summaries in public-sector hospitals to support the NHI implementation in terms of reimbursement and resource management. We undertook a cross-sectional healthrecords review from 45 representative public hospitals consisting of seven tertiary, 10 regional and 28 district hospitals in 10 NHI pilot districts representing all nine provinces. Data were abstracted from a randomly selected sample of 5795 inpatient health records from the surgical, medical, obstetrics and gynaecology, paediatrics and psychiatry departments. Quality was assessed for 10 pre-defined data elements relevant to NHI reimbursements, by comparing information in source registers, patient folders and discharge summaries for patients admitted in March and July 2015

COVID-19 terminologie

Het Terminologiecentrum heeft ten behoeve van registratie en onderzoek relevante COVID-19-termen (concepten) aangemaakt. Hier wordt een actueel overzicht van de beschikbare codes in SNOMED CT en LOINC. Deze resources kunnen gebruikt worden om data over COVID-19 gestandaardiseerd vast te leggen, uit te wisselen en te analyseren

Documenting social determinants of health-related clinical activities using standardized medical vocabularies

Objectives:Growing recognition that health is shaped by social and economic circumstances has resulted in a rapidly expanding set of clinical activities related to identifying, diagnosing, and intervening around patients' social risks in the context of health care delivery. The objective of this exploratory analysis was to identify existing documentation tools in common US medical coding systems reflecting these emerging clinical practices to improve patients' social health. Materials and Methods:We identified 20 social determinants of health (SDH)-related domains used in 6 published social health assessment tools. We then used medical vocabulary search engines to conduct three independent searches for codes related to these 20 domains included in common medical coding systems (LOINC, SNOMED CT, ICD-10-CM, and CPT). Each of the 3 searches focused on one of three clinical activities: Screening, Assessment/Diagnosis, and Treatment/Intervention. Results:We found at least 1 social Screening code for 18 of the 20 SDH domains, 686 social risk Assessment/Diagnosis codes, and 243 Treatment/Intervention codes. Fourteen SDH domains (70%) had codes across all 3 clinical activity areas. Discussion:Our exploratory analysis revealed 1095 existing codes in common medical coding vocabularies that can facilitate documentation of social health-related clinical activities. Despite a large absolute number of codes, there are addressable gaps in the capacity of current medical vocabularies to document specific social risk factor screening, diagnosis, and interventions activities. Conclusions:Findings from this analysis should help inform efforts both to develop a comprehensive set of SDH codes and ultimately to improve documentation of SDH-related activities in clinical settings