Healthcare Standards Overview: HL7, FHIR, DICOM, CCD, ICD-9, ICD-10

Healthcare Standards Overview: HL7, FHIR, DICOM, CCD, ICD-9, ICD-10
In the case of health care, the term 'data standards' comprise protocols, methods, specifications, and terminologies for the collection, exchange, storage, and retrieval of information associated with healthcare applications. This may include medical records, radiological images, medications, payment and reimbursement, medical devices, monitoring systems as well as administrative processes.

The HL7 is a not-for-profit, ANSI-accredited standards-developing organization committed to contributing as a comprehensive framework and related standards.

These standards are especially for the integration, exchange, sharing, and retrieval of electronic health information, which supports clinical practice and the management, delivery, and evaluation of health services.

The HL7 Organization

To put it in simple words, a set of standards, formats, and definitions for exchanging and developing electronic health records (EHRs) is what we call HL7 (Health Level Seven International).

The standards which are developed and promulgated by the IT healthcare standard-setting authority HL7 International are the de facto standards in healthcare IT. However, some HL7 users even have called on Congress to create stronger legal interoperability standards for the healthcare IT industry.

It is a non-profit organization with members in more than 50 countries. It was founded in 1987 and accredited by the American National Standards Institute in 1994. HL7 international develops new standards via multi-year balloting system.

The members vote and add commentary in successive balloting rounds until negative comments are eliminated and draft standards and draft standards for trial use (DSTU) are commonly agreed upon. Also, it promotes global interoperability in  IT healthcare by offering guidance about how to implement its standards.

Here, "7" stands for Layer 7 in the Open Systems Interconnection (OSI) reference model. And, the 7th layer is the final layer (the application layer) in the communication model, the International Organization for Standardization developed for OSI.

Additionally, these standards determine and provide formats for messaging, data exchange, rules syntax, and decision support. Common health data definitions in clinical documents and EHR and personal health record (PHR) claims attachments, product labels for prescription medications, quality reporting, and clinical genomics.

Healthcare Standards

Some of the Healthcare Standards are:

1. HL7
4. CCD
5. ICD-9
6. ICD-10

So, let’s learn about all of them in detail:

1. HL7 Standard

A standard for exchanging information between medical applications is what we call HL7 (Health Level Seven). It defines a format for the transmission of health-related information.

Moreover, the information sent using the HL7 standard is transmitted as a collection of one or more messages. However, each of which transmits one record or item of health-related information. Well, patient records, laboratory records, and billing information are some examples of HL7 messages.

Even though HL7 and their messages are broadly used, numerous systems don’t know to speak the language and thus require a translator. Additionally, HL7 interface engines work alongside existing applications as an interpreter.


DICOM has been developed by the American College of Radiologists (ACR) and National Electrical Manufacturers Association (NEMA), especially for handling imaging data. It assists communication between various image-based modalities & accessories to each other.

Mainly, it focuses on the workflow of images. It gives reliable protocols for the integration of image data between imaging, non-imaging modalities, devices, and systems. The functional elements consist of Protocols, Services, Objects, Service Class, and Conformance.

Selectively, a group of operations which a user wants to perform on data from a modality is DICOM Service Class. Though, some instances of Service Classes are Print Management Service Class which deals with printing images on film or paper printer, with flexible film formats, move and get SOP (Service Object Pair) Classes, Storage Service Class that implies "sending" images and Query/Retrieve Service Class that deals with issues of "finding."

However, to query for images "find" is used, whereas to commence a transfer, "move" and "get" are used. Some other classes of service include Media storage, Verification Service Class, Study content notification, Patient management, Print management, Result management, Study management, Modality Performed Procedure Step management States, and Structured reporting.


To put it in simple words, a set of "resources" for health is what we call Fast Healthcare Interoperability Resources (FHIR). It represents granular clinical concepts which we can exchange to quickly and effectively solve problems in healthcare and related process.

Moreover, it includes the basic elements of healthcare, like patients, diagnostic reports, admissions, medications, and problem lists, along with their typical participants.

Also, it offers support to a range of richer and more complex clinical models. However, resources are generally based on thorough requirements gathering, formal analysis, and extensive cross-mapping to other relevant standards.

4. CCD-Continuity of Care Document

By using the HL7 Clinical Document Architecture (CDA) elements, the Continuity of Care Document (CCD) is built. It consists of data which is defined by the ASTM Continuity of Care Record (CCR). This is used to share summary information about the patient within the broader context of the personal health record.

This was formed through a collaboration between Health Level 7 and ASTM International as a way to address the divide between those who had adopted ASTM CCR and those who had adopted HL7 CDA.

In June 2008, it was endorsed by the Certification Commission for Health Information Technology (CCHIT) as part of their Electronic Health Record (EHR). Also, it was predicted to drive the use of electronic exchange for clinical data.

The goals of Continuity of Care Document (CCD) are:

  • To the already accepted framework of CDA, apply CCR content.
  • Offer the important health information for the continuation of care.
  • Reduce medical errors.
Moreover, with any document or standard that uses RIM-based specifications, CCD is compatible. It even includes new versions of HL7, IHE specifications, new types of public safety reports, CDISC, and the Healthcare Information Technology Standards Panel (HITSP) specifications. CCD can be universally rendered as HTML or PDF without requiring specialized communication efforts because of its small fixed XML tag set.

Additionally, it uses a detailed set of constraints (or templates) for CDA elements, offering the framework of the CCD. These templates explain how to use CDA elements to communicate clinical data, yet the scope of the data within the templates is determined by the CCR dataset.

5. International Classification of Diseases, Ninth Revision (ICD-9)

For promoting international comparability in the collection, processing, classification, and presentation of mortality statistics, the International Classification of Diseases (ICD) is designed.

It introduces providing a format for reporting causes of death on the death certificate. Further, through the use of the classification structure, the reported conditions are translated into medical codes and also the selection and modification rules contained in the applicable revision of the ICD, published by the World Health Organization.

Basically, by giving preference to certain categories, these coding rules improve the usefulness of mortality statistics. The underlying cause of death is the single selected cause for tabulation, and the non-underlying causes of death are the other reported cases. And, multiple causes of death is the combination of underlying and non-underlying causes.

However, to incorporate changes in the medical field, the ICD has been revised periodically. Around ten revisions of the ICD are available. The years for which causes of death in the United States have been classified by each revision are as follows:

Revision Years Covered

1st 1900-09
2d 1910-20
3d 1921-29
4th 1930-38
5th 1939-48
6th 1949-57
7th 1958-67
8th 1968-78
9th 1979-98
10th 1999-present

The US health system's adaptation of international ICD-9 standard list of six-character alphanumeric codes to describe diagnoses is the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Usage of this improves consistency among physicians in recording patient symptoms and diagnoses for the payer claims reimbursement as well as clinical research.

Moreover, it comprises a list of codes corresponding to procedures and diagnoses recorded in conjunction with hospital care in the United States. However, these codes may be entered into a patient's electronic health record and are further used for diagnostic, reporting, and billing purposes. Also, related information organized and codified in the system comprises patient complaints, symptoms, causes of injury, and mental disorders.

ICD-9-CM was created by the United States Department of Health & Human Services and the Centers for Medicare and Medicaid Services (CMS) as an extension of the Ninth Revision, which the World Health Organization (WHO) established to track mortality statistics over the world.

6. International Classification of Diseases, Tenth Revision (ICD-10)

To promote international comparability in the processing, collection, classification, and presentation of mortality statistics is the International Classification of Diseases (ICD).

And, to incorporate changes in the medical field, the ICD has been revised periodically. ICD-10 is a little different from the Ninth Revision ICD-9 in several ways. Even the overall content is similar, some differences are:

  • ICD-10 is printed in a three-volume set whereas ICD-9 is two-volume set. 
  • Rather than numeric categories, ICD-10 has alphanumeric categories.
  • Some titles have changed, some chapters have been rearranged, and also conditions have been regrouped. 
  • Moreover, ICD-10 has almost twice as many categories as ICD-9. 
  • And, for mortality, some fairly minor changes have been made in the coding rules.
Some of the features that ICD-10 consists are:

  • Tabular lists consist of cause-of-death titles and codes (Volume 1)
  • Exclusion and inclusion terms for cause-of-death titles (Volume 1)
  • An index (alphabetical) to diseases and nature of an injury, external causes of injury, table of drugs and chemicals (Volume 3)
  • Guidelines, description, & coding rules (Volume 2)


So, here we have seen many of the Healthcare standards, such as  HL7, FHIR, DICOM, CCD, ICD-9, ICD-10. Above discussion offers an overview of each standard. 

We hope this blog helped you to get a better idea of all these healthcare standards.
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