This volume in the CHC series is an overview of the critical information structures and standards required to build multifunctional electronic medical records (EMR). Description and critique of present clinical coding systems is emphasized, followed by the development of ideal design criteria required for a practical classification environment to support the electronic capture, presentation, and analyses of patient observations, findings, and events. The relationship of medical knowledge representation to patient data classification is examined, in the context of integrating clinical decision support systems and contextually appropriate guidelines into EMR systems. The role of messaging and content standards for the EMR is considered, covering the existing standards today, and those under active development that are likely to influence system implementation and functionality in the near future.
I. Classifications: An Historical Overview of Clinical Classifications. Classifying Patient Findings and Events. The ICDs. Procedure Coding. Reimbursement Applications and Distortions. Cancer Classification: Historical Precedents. Multi-Axial Systems: Combinatorial Resolution. SNOMED. The Read System. Images. Laboratory Data. Specialty Classifications. Ideal Criteria. Towards a Global Healthcare Vocabulary. II. Standards: Historical Overview. Messaging Standards. Electronic Data Interchange. Reimbursement and Resource Accounting. Administrative Data. The European Investment: CEN TC251. Standards Bodies. Global Standards: The Case for an ISO Committee in Healthcare. Index.