Data collection and changing health care systems. 1. United Kingdom

The adoption of "Read Clinical Codes" for computerised patient records could profoundly alter the nature and quality of Western medicine in the next decade. The increasing awareness of the need for a standardised coding system has led to the funding of a pilot project to test Read codes in Australian general practice. Read codes are a comprehensive nomenclature of clinical terms incorporating over 100,000 codes in a structured hierarchical form. Designed by a general practitioner, they are now owned, controlled, and developed by the British National Health Service (NHS). Selected as the basis for clinical coding across the NHS, they form the cornerstone of computerised patient records. Computer use has been encouraged in general practice in the UK, with financing schemes and functional inducements resulting in 70% of practices being at least partly computerised, and 84% of these using Read codes. Their promotion has been backed by a major development program to broaden the codes to include all clinical specialities, nursing, and professions allied to medicine. The codes will require significant adaptation for Australian use, including the development of an administrative chapter and a pharmaceutical classification. The impact of information management systems on health care in the UK has relevance for the continuing development of the Australian National Health Information Strategy and for future record keeping in general practice in Australia. If the trial proves successful, the adoption of Read codes as a standard for information management in patient medical records will need to be considered.