Page 326 - ANUAL REPORT MOH 2017

ii. Systemized Nomenclature of Medicine-Clinical Terms (SNOMED CT),
iii. Laboratory Observation Investigation Names and Codes (LOINC),
iv. Malaysian Health Reference Data Model (MyHRDM),
v. Malaysian Health Data Dictionary (MyHDD),
vi. International Health Terminology Standards Development Organisation (ISO/TC 215: Health
Informatics)

The unit activities revolve around training, monitoring, evaluating, and improving the quality of medical
coding and documentation in Malaysia to generate quality health information. Training conducted in
2017 included certification courses for ICD-10 and ICD-9-CM; SNOMED CT e-learning courses; internal
training on terminology standards and data modelling; and introduction to proper documentation of
diagnosis for medical students and newly appointed house officers during the Program Transformasi
Minda (PTM) courses throughout the year. Refresher courses were conducted along with evaluation
studies, such as ICD-10 Coding Error Rate study and Evaluation of Documentation of Diagnosis both
for Medical Record Officers and Medical Officers respectively.

Development, revision, and implementation of these standards are also under the purview of this unit.
For example, MyHRDM book was first published in 2017 as a reference for health organisations in
Malaysia when developing health information systems. SNOMED CT Cardiology Reference set were
refined to include relevant Cardiology terms to be implemented in the MyHarmony project is led by
this unit. Whereas LOINC mapping continued to be reviewed against the latest international version to
be used by the Laboratory Information System (LIS) project led by the Medical Development Division.

This unit is also responsible for several meetings nationally and internationally. Nationally, this unit
is the secretariat for National Health Informatics Council chaired by the Director General of Health
Malaysia, and Health Informatics Standards Committee chaired by the Director of Planning Division.
Both committees coordinate members from within and outside of MoH. Internationally, this unit is
involved in two (2) IHTSDO Business Meetings, namely General Assembly and Member Forum, and
ISO/TC 215: Health Informatics.

Image 8
Health Informatics Standards Unit Activities

MyHRDM published Technology Testing

MINISTRY OF HEALTH MALAYSIA ANNUAL REPORT 2017 325