Coding Systems in Health Care

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).

Keywords:

Controlled Medical Vocabulary - Nomenclature - Taxonomy - Electronic Medical Records - Medical Record Coding - Review

• References

• 1 Hammond WE. The role of standards in creating a health information infrastructure. Intern J Bio-Med Comp 1994; 34: 185-94.
• 2 Cimino JJ. Data storage and knowledge representation for clinical workstations. Intern J Bio-Med Comp 1994; 34: 29-44.
• 3 Anderson J. The computer: medical vocabulary and information. Br Med Bull 1968; 24: 194-8.
• 4 Bates JAV. Preparation of clinical data for computers. Br Med Bull 1968; 24: 199-205.
• 5 Howell RW, Loy RM. Disease coding by computer: the “fruit machine” method. Br J Prev Soc Med 1968; 22: 178-81.
• 6 United States. General Accounting Office. Automated Medical Records: Leadership Needed to Expedite Standards Development: Report to the Chairman/Committee on Governmental Affairs, U.S. Senate Washington, DC: USGAO/IMTEC-93-17 1993
• 7 Board of Directors of the American Medical Informatics Association Standards for medical identifiers, codes and messages needed to create and efficient computer-stored medical record. J Am Med Inform Assoc 1: 1-7.
• 8 Dimitroff A. Medical informatics conference papers: a content analysis of research in a new discipline. Comput Biomed Res 1994; 27: 276-90.
• 9 Ozbolt JG. ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medical Care. . New York: McGraw-Hill; 1994
• 10 World Health Organization Ninth Edition. International Classification of Diseases Index. Manual for the International Statistical Classification of Diseases . Geneva: The Organization; 1977
• 11 World Health Organization. International Classification of Diseases Index. Tenth Revision. Volume 1: Tabular List . Geneva: The Organization; 1992
• 12 Slee VN. The International Classification of Diseases: ninth revision. Ann Intern Med 1978; 88: 424-6.
• 13 Kurtzke JF. ICD-9: a regression. AmJ Epidem 1979; 109: 383-93.
• 14 White KL. Restructuring the international classification of diseases. Need for a new paradigm. J Fam Pract 1985; 21: 17-20.
• 15 Commission on Professional and Hospital Activities. International Classification of Diseases, Ninth Revision, with Clinical Modifications ( ICD-9-CM). Ann Arbor 1978
• 16 3M Health Information Systems. APDRGs: All Patient Diagnosis Related Groups. Wallingford: 3M Health Care, updated annually.;
• 17 Lambert H, Wood M. eds. International Classification of Primary Care . Oxford: Oxford University Press; 1987
• 18 American Medical Association. Current Procedural Terminology. Chicago: The Association, updated annually.;
• 19 American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Washington: The Association; 1987
• 20 American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Forth Edition. Washington: The Association; 1994
• 21 Thompson JW, Pincus H. A crosswalk from DSM-III-R to ICD-9-CM. Am J Psychiat 1989; 146: 1315-9.
• 22 Wake MM, Murphy M, Affara FA, Lang NM, Clark J, Mortensen R. Toward an international classification for nursing practice: a literature review and survey. Intern Nurs Rev 1993; 40: 77-80.
• 23 Henry SB, Holzemer WL, Reilly CA, Campbell KE. Terms used by nurses to describe patient problems: can SNOMED III represent nursing concepts in a patient record?. J Am Med Inform Assoc 1994; 1: 61-74.
• 24 Ozbolt JG, Fruchtnicht JN, Hayden JR. Toward data standards for clinical nursing information. J Am Med Inform Assoc 1994; 1: 175-85.
• 25 McCormick KA, Lang N, Zielstorff R, Milholland DK, Saba V, Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice. J Am Med Inform Assoc 1994; 1: 421-7.
• 26 New York Academy of Medicine. Standard Nomenclature of Diseases and Operations (Fifth Edition). New York: Mcgraw-Hill; 1961
• 27 College of American Pathologists. Systematized Nomenclature of Pathology. Chicago: The College; 1971
• 28 National Library of Medicine. Medical Subject Headings. Bethesda: The Library, updated annually;
• 29 Mullin RL. Diagnosis-related groups and severity. ICD9-CM, the real problem. JAMA 1985; 254: 1208-10.
• 30 McMahon LF, Smits HL. Can Medicare prospective payment survive the ICD-9-CM disease classification system. Ann Intern Medic 1986; 104: 562-6.
• 31 Campbell JR, Payne TH. A comparison of four schemes for codification of problem lists. In: Ozbolt JG. ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medical Care . . New York: McGrawHill; 1994: 201-5.
• 32 Cimino JJ, Hripcsak G, Johnson SB, Clayton PD. Designing an introspective, controlled medical vocabulary. In: Kingsland LW. ed. Proceedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care. . New York: IEEE Computer Society Press; 1989: 513-8.
• 33 Bourgeois P. Statistics, CPT, ICD-9, CDM and Level III codes: what are they and how did I get this job?. The Diabetes Educator 1991; 17: 349-52.
• 34 Campos-Outcalt DE. Accuracy of ICD~9-CM codes in identifying reportable communicable diseases. Quality Assur Utiliz Rev 1990; 5: 86-9.
• 35 Jollis JG, Ancukiewicz M, DeLong ER, Pryor DB. Muhlbaier LH, Mark DB. Discordance of databases designed for claims payment versus clinical information systems. Implications for outcomes research. Ann Intern Med 1993; 119: 844-50.
• 36 Stead WW, Hammond WE. Computerbased medical records: the centerpiece of TMR. MD Comput 1988; 5: 48-62.
• 37 Pryor TA, Gardner RM, Clayton PD, Warner HR. The HELP system. J Medic Syst 1983; 7: 87-102.
• 38 Pryor TA. The HELP medical record system. MD Comput 1988; 5: 22-33.
• 39 Wong ET, Pryor TA, Huff SM, Haug PJ, Warner HR. Interfacing a standalone diagnostic expert system with a hospital information system. Comp BiomedRes 1994; 27: 116-29.
• 40 Barnett GO, Winickoff R, Dorsey JL, Morgan MM, Luire RS. Quality assurance through automated monitoring and concurrent feedback using a computer-based medical information system. Medical Care 1978; 16: 962-70.
• 41 McDonald CJ, Tierney WM, Overhage JM, Martin DK, Wilson GA. The Regestrief Medical Record System: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Comput 1992; 9: 206-17.
• 42 van der Lei J, Duisterhout JS, Westerhof HP, van der Does E, Cromme PVM, Boon WM, van Bemmel JH. The introduction of computer-based patient records in The Netherlands. Ann Intern Med 1993; 119: 1036-41.
• 43 Duisterhout JS, van der Meulen A, Boersma J, Gebel R, Kjoo KH. Implementation ofICPC coding in information systems for primary care. In: Lun KC, Degoulet P, Piemme TERienhoff. eds. MEDINFO 92. Amsterdam: Elsevier North-Holland Press; 1992: 1483-8.
• 44 Barnett GO, Jenders RA, Chueh HC. The computer-based clinical record – where do we stand?. Ann Intern Med 1993; 119: 1046-8.
• 45 Heathfield HA, hardiker N, Kirby J, Tallis R, Gonsalkarale M. The PEN PAD medical record model: develop. ment of a nursing record for hospital. based care of the elderly. Meth Infor Med 1994; 33: 464-72.
• 46 Cimino JJ, Clayton PD, Hripcsak G, Johnson SB. Knowledge-based ap: pro aches to the maintenance of a large controlled medical terminology. J Am Med Inform Assoc 1994; 1: 35-50.
• 47 Cimino JJ, Johnson SB, Hripcsak G, Hill CL, Clayton PD. Managing vo’. cabulary for a centralized clinical sys tern. In: Kaihara S, Greenes RA. eds. Proceedings of the World Congress on Medical Informatics – Medinfo ‘95, Vancouver. 1995. (in press).
• 48 Cimino JJ, Clayton PD. Coping with changing controlled vocabularies. In: Ozbolt JG. ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medica Care . . New York: McGraw-Hill; 1994: 135-9.
• 49 Cote RA, Rothwell DJ, Palotay JL, Beckett RS, Brochu L. eds. The Sys. tematized Nomenclature of Medicine: SNOMED International . Northfield: College of American Pathologists; 1993
• 50 Campbell KE, Musen MA. Representation of clinical data using SNOMED III and conceptual graphs. In: Safran C. ed. Proceedings of the Seventeenth Annual Symposium on Computer Ap plications in Medical Care. . New York: McGraw-Hill; 1993: 354-8.
• 51 Rothwell DJ, Cote RA, Cordeau JP, Boisvert MA. Developing a standard data structure for medical language – the SNOMED proposal. In: Safran C. ed. Proceedings of the Seventeenth Annual Symposium on Computer Applications in Medical Care. . New York: McGraw-Hill; 1993: 695-9.
• 52 Read JD, Benson TJR. Comprehensive coding. Br J Health Care Comp 1986. May 22-5.
• 53 Read JD. Computerising medical language. In: De Glanville H, Roberts J. eds . Current Perspectives in Health Computing HC90. Br J Health Care Comp 1990: 203-8.
• 54 NHS Centre for Coding and Classification. Read Codes, Version 3. London: NHS Management Executive, Depart ment of Health; 1994
• 55 NHS Centre for Coding and Classifica tion. Read Codes and the Terms Projects: a Brief Guide. Leicestershire: NHS Man agement Executive, Department of Health; 1994
• 56 Gabrieli ER. A new electronic medical nomenclature. J Med Syst 1989; 13: 355-73.
• 57 ASTM. Standard Guide for Nosologic Standards and Guides for Construction i of New Biomedical Nomenclature. Stan-Indard El 284-89 Philadelphia: ASTM; 1989
• 58 Rector AL, Glowinski AJ, Nowlan WA, Rossi-Mori A. Medical concept models and medical records: an approach based on GALEN and PEN&PAD. J Am Med Inform Assoc 1995; 2: 19-35.
• 59 ASTM. A Standard Specification for Representing Clinical Laboratory Test and Analyte Names. Standard E3113.2 (Draft). Philadelphia: ASTM; 1994
• 60 EUCLIDES Foundation International. EUCLJDES Coding System Version 4.0. The Foundation 1994
• 61 Evans DA, Cimino JJ, Hersh WR, Huff SM, Bell DS. Toward a medical concept representation language. J Am Med In-form Assoc 1994; 1: 207-17.
• 62 Friedman C, Huff SM, Hersh WR, Pattison-Gordon E, Cimino JJ. The Canon effort: working toward a merged model. J Am Med Inform Assoc 1995: 4-18.
• 63 Humphreys BL. ed. UMLS Knowledge Sources – Fifth Experimental Edition Documentation . Bethesda, MA: National Library of Medicine; 1994
• 64 Lindberg DAB, Humphreys BL, McCray AT. The unified medical language system. Meth Inform Med 1993; 32: 281-91.
• 65 Nowlan W, Rector AL, Rush T, Solomon W. From terminology to terminology services. In: Ozbolt JG. ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medical Care. . New York: McGraw Hill; 1994: 150-4.
• 66 McCray AT, Razi A. The UMLS knowledge source server. In: Kai hara S, Greenes RA. eds. Proceedings of the World Congress on Medical Informatics – MedInfo ‘95. Vancouver. 1995. (in press)
• 67 Rocha RA, Huff SM, Haug PJ, Warner HR. Designing a controlled medical vocabulary server: the VOSER project. Comput Biomed Res 1994; 27: 472-507.
• 68 Campbell KE. Distributed Development of a Logic-Based Controlled Medical Terminology. Dissertation Proposal . Stanford: Stanford University; 1994
• 69 Cimino JJ. Saying what you mean and meaning what you say: coupling biomedical terminology and know ledge. Ac Med 1993; 68: 257-60.
• 70 McCarn DB. MEDLINE: an introduction to on-line searching. J Am Soc In-form Sc 1980. May 181-92.
• 71 Tuttle MS, Sherertz DD, Erlbaum MS, Sperzel WD, Fuller LF, Olson NE, Nelson SJ, Cimino JJ, Chute CG. Add ing your terms and relationships to the UMLS metathesaurus. In: Clayton PD. ed. Proceedings of the Fifteenth Annual Symposium on Computer Applications in Medical Care. . Washington: 1991: 219-23.