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Related Experiment Videos

Evolving to clinical terminology.

Brian Levy1

  • 1University of Colorado-Affiliated Hospital, USA.

Journal of Healthcare Information Management : JHIM
|August 11, 2004
PubMed
Summary
This summary is machine-generated.

Electronic medical records (EMRs) are increasing, driving the need for clinical terminologies like SNOMED CT. These will enhance patient documentation within EMRs, shifting administrative codes to billing roles.

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Area of Science:

  • Health Informatics
  • Clinical Documentation Standards

Background:

  • The increasing adoption of electronic medical records (EMRs) necessitates advanced clinical terminologies.
  • Current administrative classifications (ICD-9-CM, CPT, HCPCS) are used for billing and basic documentation.

Purpose of the Study:

  • To explore the transition from administrative classifications to clinical terminologies in EMRs.
  • To highlight the role of clinical terminologies in enhancing patient data capture.

Main Methods:

  • Analysis of the evolving role of terminologies in healthcare documentation.
  • Discussion of the shift in terminology usage from point-of-care to post-encounter processes.

Main Results:

  • Clinical terminologies like SNOMED CT are poised to become the primary interface in EMRs.

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  • Administrative classifications will be relegated to billing and payer functions.
  • Conclusions:

    • The integration of richer, granular clinical terminologies in EMRs represents a key evolution in health informatics.
    • Training and support from clinical informaticists are crucial for healthcare providers during this transition.