Electronic Medical Records and Coding Systems

5 05 2010

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;.

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26 responses

5 05 2010
Jan

Healthcare data pooling is a crappy idea

6 05 2010
Deidra

:) I love it Tif!!
Deidra

20 05 2010
protogere

Thank you Deidra!

7 05 2010
Tweets that mention Electronic Medical Records and Coding Systems « Mundane Excogitations -- Topsy.com

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19 05 2010
Texas Patients, Families May Be Unwitting Victims Of Federal Privacy Laws

People are victims every day and don’t realize it

20 05 2010
protogere

I think that is probably the most nerve wrecking aspect – the not realizing you are a victim. Typically, it isn’t until something disastrous has occurred that you even know of the problem, and by then what can you do?
Not entirely related, but similar in situation: I used to be a member of the Disney Movie Club. It operated much like the old Columbia House did, but not as much of a scam. I had a lot of control over what I ordered and bought etc. Anyhow, I get a letter one day saying that they discovered an employee had stolen credit card data from their files, and that my CC information had been stolen. They suggested I check my statements. I did that, but I also cancelled that card, had to change my billing information for several companies, and stress and wonder what information went along with those 16 digits. I never did business with them again.
The panic of realizing what could have happened and what did happen and my total lack of being able to control either was unbelievable – I can only imagine how it would be with something more serious such as medical records.
Thanks for reading!

20 05 2010
Pam

your just scratching the surface of coding methods lol

20 05 2010
protogere

Pam:
Our school papers have to be a certain character length and this was over by about 300, after I weeded out as much as I could.
Some days I think how coding could be a lot of fun, and other days I’m sane.
Thanks for reading!

20 05 2010
Pinky

Ive never figured out why we can bank online, file taxes online, pay our bills online, pay tickets online, renew drivers license and tags onine, even get our visa or passport apps done online but the idea of putting our medical records even so much as on a computer is a foreign concept.

21 05 2010
Quantum

Yeach this aint even close to all the codes and crap we have to memorize

21 05 2010
Billing And Coding | degree at home

[…] Electronic Medical Records and Coding Systems « Mundane Excogitations […]

8 06 2010
nessy

Nice read

10 06 2010
Dade

Tia,
I wish you luck in your career and your coming on at a great time in medicine but you’ll have your work cut out for you.
God Bless,
Dade

13 06 2010
Nee

Once they do finally implement electronic records it will help a lot for people who move or stuff.

15 06 2010
CHea

I think this is something they should be doing now, make them jobs for the unemployed to key all the old info in and then you can kill two birds with one stone.

15 07 2010
protogere

I could not agree more CHea!

16 06 2010
knilky

It’s electric!

15 07 2010
protogere

LoL

30 06 2010
cecil grass

I gotta say I love it! I’ve been in the emr system over at http://www.drfirst.com for a bit and I love the convenience of it all so far. They are worth a look if you are on fence.

14 07 2010
protogere

I will certainly look into that link Cecil, I appreciate it!

11 11 2010
serega82x

well.. it’s like I thought!

1 12 2010
Electronic Medical Records and Coding Systems « Claudia Bronson's Blog

[…] Read full article here… […]

9 01 2011
Cucvas

Wow! This can be 1 of the top blogs I’ve actually arrive throughout on this subject. Merely Magnificent

13 01 2011
Withington85

A actually great submit by you my friend. We have bookmarked this page and will appear back following several days to examine for any new posts that you simply make.

5 02 2011
Fuselier334

I quite agree with your submission, however, lam having problem subscribing to your rss

4 01 2014
Graciela

An attention-grabbing dialogue is price comment. I feel that you
should write extra on this topic, it may not be a taboo topic however generally

individuals are not enough to talk on such topics. To the next.
Cheers

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