Review Paper: Coding Systems in Health Care

J. J. Cimino

doi:10.1055/s-0038-1634682

Methods of Information in Medicine, Table of Contents

Methods Inf Med 1996; 35(04/05): 273-284
DOI: 10.1055/s-0038-1634682

Original Article

Schattauer GmbH

Review Paper: Coding Systems in Health Care

Authors

J. J. Cimino

¹Department of Medical Informatics Columbia University College of Physicians and Surgeons New York, NY, USA

Abstract

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

Full Text

References

References
1 Hammond WE. The role of standards in creating a health information infrastructure. Int J Biomed Comput 1994; 34: 185-94.
2 Cimino JJ. Data Storage and Knowledge Representation for Clinical Workstations. Int J Biomed Comput 1994; 34: 29-44.
3 Anderson J. The computer: medical vocabulary and information. Brit Med Bull 1968; 24 (03) 194-8.
4 Bates JAV. Preparation of clinical data for computers. Brit Med Bull 1968; 24 (03) 199-205.
5 Howell RW, Loy RM. Disease coding by computer: the “fruit machine” method. Brit 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, D.C.: USGAO/IMTEC-93-17; April 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 Informatics Assoc 1994; 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 Gardner RM. ed.: Proceedings of the Nineteenth Annual Symposium on Computer Applications in Medical Care. Philadelphia: Hanley & Belfus; 1995
10 World Health Organization. Ninth Edition. International Classification of Diseases Index. Manual for the International Statistical Classification of Diseases. Geneva: 1977
11 World Health Organization. International Classification of Diseases Index. Tenth Revision. Volume 1: Tabular List. Geneva: 1977
12 Slee VN. The International Classification of Diseases: ninth revision. Ann Intern Med 1978; 88 (03) 424-6.
13 Kurtzke JF. ICD-9: A regression. Am J Epidemiol 1979; 109 (04) 383-93.
14 White KL. Restructuring the international classification of diseases. Need for a new paradigm. J Fam Practice 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. AP-DRGs: All Patient Diagnosis Related Groups. 3M Health Care. Wallingford, CT: updated annually.
17 Lambert H, Wood M. eds. International Classification of Primary Care. Oxford: University Press; 1987
18 American Medical Association. Current Procedural Terminology. Chicago, IL: The Association; updated annually.
19 American Psychiatric Association. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders. Revised Third Edition. Washington, DC: The Association; 1987
20 American Psychiatric Association. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders. Forth Edition. Washington, DC: The Association; 1994
21 Thompson JW, Pincus H. A crosswalk from DSM-III-R to ICD-9-CM. Am J Psychiat 1989; 146 (10) 1315-9.
22 Wake MM, Murphy M, Affara FA. et al. Toward an International Classification for Nursing Practice: a literature review and survey. Intern Nursing Rev 1993; 40 (03) 77-80.
23 Henry SB, Holzerner 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 Informatics Assoc 1994; 1: 61-74.
24 Ozbolt JG, Fruchtnicht JN, Hayden JR. Toward data standards for clinical nursing information. J Am Med Informatics Assoc 1994; 1 (02) 175-85.
25 McCormick KA, Lang N, Zielstorff R. et al. 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 Informatics Assoc 1994; 1 (06) 421-7.
26 New York Academy of Medicine. Standard Nomenclature of Diseases and Operations. 5th ed.. 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, MD: The Library; updated annually.
29 Mullin RL. Diagnosis-Related Groups and severity. ICD9-CM, the real problem. JAMA 1985; 254 (09) 1208-10.
30 McMahon LF, Smits HL. Can Medicare prospective payment survive the ICD-9-CM disease classification system. Ann Intern Med 1986; 104 (04) 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: McGraw-Hill; 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 (05) 349-52.
34 Campos-Outcalt DE. Accuracy of ICD-9-CM codes in identifying reportable communicable diseases. Quality Assurance and Utilization Review 1990; 5 (03) 86-9.
35 Jollis JG, Ancukiewicz M, DeLong ER. et al. Discordance of databases designed for claims payment versus clinical information systems. Implications for outcomes research. Ann Intern Med 1993; 119 (08) 844-50.
36 Stead WW, Hammond WE. Computer-based medical records: the centerpiece of TMR. MD Computing 1988; 5 (05) 48-62.
37 Pryor TA, Gardner RM, Clayton PD, Warner HR. The HELP system. J of Med Syst 1983; 7 (02) 87-102.
38 Pryor TA. The HELP medical record system. MD Computing 1988; 5 (05) 22-33.
39 Wong ET, Pryor TA, Huff SM, Haug PJ, Warner HR. Interfacing a stand-alone diagnostic expert system with a hospital information system. Comput Biomed Res 1994; 27 (02) 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. Med Care 1978; 16 (11) 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 Computing 1992; 9 (24) 206-17.
42 Van der Lei J, Duisterhout JS, Westerhof HP. et al. The introduction of computer-based patient records in The Netherlands. Ann Intern Med 1993; 119 (10) 1036-41.
43 Duisterhout JS, van der Meulen A, Boersma J, Gebel R, Kjoo KH. Implementation of ICPC coding in information systems for primary care. In: Lun KC, Degoulet P, Piemme TE. Rienhoff, eds. MEDINFO 92. Amsterdam: North Holland Puble Comp; 1992: 1483-8.
44 Barnett GO, Jenders RA, Chueh HC. The computer-based clinical record – where do we stand?. Ann of Intern Med 1993; 119 (10) 1046-8.
45 Heathfield HA, Hardiker N, Kirby J, Tallis R, Gonsalkarale M. The PEN & PAD medical record model: development of a nursing record for hospital-based care of the elderly. Meth Inform Med 1994; 33: 464-72.
46 Cimino JJ, Clayton PD, Hripcsak G, Johnson SB. Knowledge-based Approaches to the Maintenance of a Large Controlled Medical Terminology. J Am Med Informatics Assoc 1994; 1 (01) 35-50.
47 Cimino JJ, Johnson SB, Hripcsak G, Hill CL, Clayton PD. Managing Vocabulary for a Centralized Clinical System. In: Kaihara S, Greenes RA. eds. MEDINFO 95. Vancouver, Canada: 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 Medical Care. New York: McGraw-Hill; 1994: 135-9.
49 Côté RA, Rothwell DJ, Palotay JL, Beckett RS, Brochu L. eds. The Systematized Nomenclature of Medicine. SNOMED International. Northfield, Illinois: 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 Applications in Medical Care. New York: McGraw-Hill; 1993: 354-8.
51 Rothwell DJ, Côté 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. Brit J Health Care Comput 1986; 22-5.
53 Read JD. Computerising medical language. In: De Glanville H, Roberts J. eds. Current Perspectives in Health Computing HC90 Brit J Health Care Comput 1990; 203-8.
54 NHS Centre for Coding and Classification. Read Codes, Version 3. NHS Management Executive, Department of Health; London: 1994
55 NHS Centre for Coding and Classification. Read Codes and the terms projects: a brief guide. NHS Management Executive, Department of Health; Leicestershire, Great Britain: 1994
56 Gabrieli ER. A new electronic medical nomenclature. J Med Syst 1989; 13 (06) 355-73.
57 ASTM. Standard Guide for Nosologic Standards and Guides for Construction of New Biomedical Nomenclature. Standard E1284-89. 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 Informatics Assoc 1995; 2 (01) 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. EUCLID ES 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 Informatics Assoc 1994; 1 (03) 207-217.
62 Friedman C, Huff SM, Hersh WR, Pattison-Gordon E, Cimino JJ. The Canon effort: working toward a merged model. J Am Med Informatics Assoc 1995; 4-18.
63 Humphreys BL. ed. UMLS Knowledge Sources – Fifth Experimental Edition Documentation. Bethesda, Maryland: National Library of Medicine; April 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: Kaihara S, Greenes RA. eds. MEDINFO 95. Vancouver, Canada: 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, CA: Stanford University; March 1994
69 Cimino JJ. Saying what you mean and meaning what you say: coupling biomedical terminology and knowledge. Acad Med 1993; 68 (04) 257-60.
70 McCarn DB. MEDLINE: an introduction to on-line searching. J Am Soc Inform Sci 1980; 181-92.
71 Tuttle MS, Sherertz DD, Erlbaum MS. eds. Adding Your Terms and Relationships to the UMLS Metathesaurus. In: Clayton PD. ed. Proceedings of the Fifteenth Annua Symposium on Computer Applications in Medical Care. New York: McGraw Hill; 1991: 219-23.
72 Van Bemmel JH, McCray AT. eds. IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer; 1995
73 Chute CG, Cohn SP, Campbell KE, Oliver DE, Campbell JR. The content coverage of clinical classifications. J Am Med Informatics Assoc 1996; 3: 224-33.