Mundane Excogitations

The General Accounting Office of the Information Management and Technology Division reported the need for a standardized coding system due to the frequent use in medical practices of the same term for various ailments; such as describing hepatitis as a liver inflammation (GAC, 8).  “The use of different terms and codes…to indicate the same condition…complicates retrieval and reduces data reliability and consistency.” (GAC, 9)  Coding systems for electronic record keeping differs from coding systems utilized in medical billing primarily because billing code sets are too generalized to offer specific information about a condition or diagnosis (Gartee, 64).  Ideally, information entered into an electronic medical record should be standardized amongst all facilities, no matter the software system or user which is the basis for using a universal system of codes (Bowman).

Systematized Nomenclature of Medicine-Clinical Terms, referred to as SNOMED-CT, is one of the coding systems accepted for electronic records (National Libraries).  SNOMED began as a language developed for use in describing pathology specific issues, developed by the College of American Pathologists, yet it has been refined over time to become an international medical coding standard, maintained by the International Health Terminology Standards Development Organization of Denmark (National Libraries), and is used in over fifty countries around the world (IHTSDO).  And as a result of an agreement with the National Library of Medicine, this code set is available for use at no cost for all health care institutions and vendors (Chiang et al).  It currently supports coding of diseases, diagnosis in a clinical setting, medical treatments, procedures and results (NHS).

MEDCIN is another coding system accepted for use in electronic records and has been in development for over a quarter of a century by physicians and educators from Harvard, Johns Hopkins, and Cornell (Clinical Transformation Management, 1).  MEDCIN supports coding of patient history, physical examine results, diagnosis, medical tests, treatments and results (Encyclopedia.com).  This is the coding set utilized by the United States Department of Defense and has the added benefit of while being written to its own unique code, it can adapt to the codes from SNOMED-CT (Clinical Transformation Management, 2).  The latter is hugely significant in that codes need to be able to be translated from one set to another depending on the type used by a facility sending out records.

This brings up one of the biggest challenges with having so many different accepted coding systems – making them work together, to make them interoperable.  This is one of the four core goals of the US Department of Health and Human Services (US DHHS), and it is supported by the Electronic Health Record Association, whose sole priority is to work towards creating a single language across all coding sets (EHRA, 3).  “Without (the harmonization of standards) the industry has no mechanism for resolving conflicts, no timetables for standards release and maintenance,” said David Brailer, the National Coordinator for Health Information Technology, regarding interoperability (EHRA, 1).  To achieve this goal, the code language needs to be fluid enough to parallel the physician’s medical language and yet maintain enough structure to have an electronic signature, basically meaning to allow a software system to recognize words and apply their fundamental meaning so that alerts can be triggered (Bruwaene et al, 2).  Even so, the codes have to be specific enough to ensure that the physician’s intended meaning is maintained.

While there are many other code sets that have been tested and used in electronic medical record keeping, SNOMED-CT and MEDCIN seem to be the forerunners for achieving the goals of interoperability and interpretability.  Though these two languages are decades old, the dedication to keeping them current, relevant and maintained is noteworthy.  And there are likewise, several objectives and goals that need to be realized before EMR and EMR software is adopted as a trusted mainstay.  However, writing with the experience of designing data bases and data keying information, having a firm foundation that allows for adaptation and growth is, in this writer’s opinion, the most critical step to prevent lost time and efforts.

Work Cited

Bowman, Sue. “Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems.” AHIMA. 26 May 2005. Mon. 03 May 2010. <http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027179.html&gt;.

Bruwaene, B. Van, K. Mies, J. Schots, and R. Van De Velde. “Can SNOMED CT Replace ICD-coding?” Sat. 01 May 2010. <http://users.telenet.be/benny.vanbruwaene/0510%20SNOMED%20CT.pdf&gt;.

Chiang, Michael F., John C. Hwang, Alexander C. Yu, Daniel S. Casper, James J. Cimino, and Justin Starren. “Reliability of SNOMED-CT Coding by Three Physicians Using Two Terminology Browsers.” American Medical Informatics Association. 2006. Tue. 04 May 2010. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839418/&gt;.

“Understanding EMR Issues: Codified Medical Nomenclatures Medcin and SNOMED: What Are the Differences?” Clinical Transformation Management, LLC. Wed. 05 May 2010. <www.cmp-services.com/files/Barr._WP.CTM_Medcin.pdf>.

“Medcin Terminology.” CSI : Computer Service Innovations. 2006. Mon. 03 May 2010. <http://www.csinov.com/emr/&gt;.

“White Paper on Interoperability.” EHRA. 29 Apr. 2005. Tue. 04 May 2010. <www.himssehra.org/docs/EHRVAExpandedPositionStatementfinal042905.pdf>.

Business Wire. “HealthPoint to Integrate MEDCIN Vocabulary into Its Ambulatory Computerized Patient Record System.” Encyclopedia.com. 20 Feb. 1998. Wed. 05 May 2010. <http://www.encyclopedia.com/doc/1G1-20331312.html&gt;.

Gartee, Richard. Electronic Health Records Understanding and Using Computerized Medical Records. Upper Saddle River: Prentice Hall Ptr, 2007. Print.

United States of America. Information Management and Technology Division. General Accounting Office. Http://archive.gao.gov/t2pbat5/149267.pdf. By William Oelkers, Jerilynn B. Hoy, Douglas D. Nosik, Ira S. Sachs, William A. Moffitt, Bruce Holmes, Jennifer Arns, and Michael Tovares. Washington, D.C., 1993. AUTOMATED MEDICAL RECORDS Leadership Needed to Expedite Standards Development. Apr. 1993. Tue. 04 May 2010. <http://archive.gao.gov/t2pbat5/149267.pdf&gt;.

“Who Is Using SNOMED CT?” International Health Terminology Standards Development Organisation. Tue. 04 May 2010. <http://www.ihtsdo.org/snomed-ct/who-is-using-snomed-ct/&gt;.

Johnston, Doug, Eric Pan, and Blackford Middleton. “Finding the Value in Healthcare Information Technologies.” Center for Information Technology Leadership. 2002. Tue. 04 May 2010. <http://www.citl.org/findingTheValue.pdf&gt;.

“SNOMED Clinical Terms.” National Library of Medicine. 20 July 2009. Sun. 02 May 2010. <http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html&gt;.

“Progress Made on Creation of SNOMED Standards Development Organisation.” NHS Connecting for Health. 12 Oct. 2006. Sat. 01 May 2010. <http://www.connectingforhealth.nhs.uk/newsroom/news-stories/snomed121006/&gt;.

“Focus on Medical Coding: Health Sciences Library – UNC-Chapel Hill.” UNC Health Sciences Library. Health Sciences Library, UNC-Chapel Hill, 7 Feb. 2006. Sun. 02 May 2010. <http://www.hsl.unc.edu/Services/Guides/focusonmedcoding.cfm&gt;.

“Goals of Strategic Framework.” United States Department of Health and Human Services. 10 Dec. 2004. Wed. 05 May 2010. <http://www.hhs.gov/healthit/goals.html&gt;.