Methods of Information in Medicine · 1996 · 103 citations · 42 references
ComputingBiomedical InformaticsHealth InformaticsClinical Classification SystemsClinical Information SystemsElectronic Health RecordsCoding ConventionsData CodingElectronic Health Record CodingHealthcare Coding SystemsHealthcare Data StandardsMedical Coding SystemsClassification Coding SystemsCoding SchemesCoding StandardizationCoding SystemsElectronic Record SystemsHealth Data Coding StandardsHealth Record CodingUnified Medical Language System
Computer‑based patient data encoded in systems such as ICD, CPT, DRGs, and MeSH are used for patient care, reporting, decision support, and research, yet no single standard adequately supports all these functions, and existing schemes lack sufficient detail and widespread adoption. This review surveys the coding schemes employed for abstracting, electronic record systems, and comprehensive coding. The authors examine barriers to standard acceptance and evaluate ongoing initiatives such as SNOMED, the Gabrieli Medical Nomenclature, Read Clinical Codes, GALEN, and UMLS.
Abstract: Computer-based patient data which are represented in a coded form have a variety of uses, including direct patient care, statistical reporting, automated decision support, and clinical research. No standard exists which supports all of these functions. Abstracting coding systems, such as ICD, CPT, DRGs and MeSH fail to provide adequate detail, forcing application developers to create their own coding schemes for systems. Some of these schemes have been put forward as possible standards, but they have not been widely accepted. This paper reviews existing schemes used for abstracting, electronic record systems, and comprehensive coding. It also discusses the remaining impediments to acceptance of standards and the current efforts to overcome them, including SNOMED, the Gabrieli Medical Nomenclature, the Read Clinical Codes, GALEN, and the Unified Medical Language System (UMLS).
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