Classification, Vocabulary, and Terminology Standards
One of the most difficult problems in exchanging health care information and
building longitudinal electronic health records (EHRs) is coordinating the vast
amount of health information that is generated in diverse locations for patients and
populations. To date, no single vocabulary has emerged to meet all the information
exchange needs of the health care sector. The most widely recognized coding and
classification systems, ICD—9-CM, Current Procedural Terminology (CPT), and
diagnosis related groups (DRGs), were discussed in Chapter One. Although these
systems do not meet the criteria for full clinical vocabularies, they are used to
classify diagnoses and procedures and are the basis for information retrieval in health
care information systems.
Classification, Vocabulary, and Terminology StandardsOne of the most difficult problems in exchanging health care information andbuilding longitudinal electronic health records (EHRs) is coordinating the vastamount of health information that is generated in diverse locations for patients andpopulations. To date, no single vocabulary has emerged to meet all the informationexchange needs of the health care sector. The most widely recognized coding andclassification systems, ICD—9-CM, Current Procedural Terminology (CPT), anddiagnosis related groups (DRGs), were discussed in Chapter One. Although thesesystems do not meet the criteria for full clinical vocabularies, they are used toclassify diagnoses and procedures and are the basis for information retrieval in healthcare information systems.
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