Review paper: Coding systems in health care

Methods of Information in Medicine

Volumn 35, Issue 4-5, 1996, Pages 273-284

  Cimino, J J ^a,b  

^a The New York Presbyterian Hospital   (United States)

^b New York State Psychiat Inst and New York Presbyterian Hospital Columbia University Medical Center   (United States)

Author keywords

controlled medical vocabulary; electronic medical records; medical record coding; nomenclature; review; taxonomy

Indexed keywords

HEALTH CARE; INFORMATION SYSTEM; MEDICAL RECORD; PRIORITY JOURNAL; REVIEW; TAXONOMY;

EID: 0030483673     PISSN: 00261270     EISSN: None     Source Type: Journal    
DOI: 10.1055/s-0038-1634682     Document Type: Review

References (73)

1. Hammond WE. The role of standards in creating a health information infrastructure. Int J Biomed Comput, 1994; 34: 185-94.
2. Cimino JJ: Data Storage and Knowledge Representation for Clinical Workstations. Int J Biomed Comput, 1994; 34: 29-44.
3. Anderson J. The computer, medical vocabulary and information. Brit Med Bull 1968; 24 (3): 194-8.
4. Bates JAV. Preparation of clinical data for computers. Brit Med Bull 1968; 24 (3): 199-205.
5. Howell RW, Loy RM. Disease coding by computer: the "fruit machine" method. Brit J Prev Soc Med 1968; 22: 178-81.
6. United States. General Accounting Office. Automated Medical Records: Leadership Needed to Expedite Standards Development. Report to the Chairman/Committee on Governmental Affairs. U.S. Senate. Washington, D.C.: USGAO/IMTEC-93-17, April 1993.
7. Board of Directors of the American Medical Informatics Association. Standards for medical identifiers, codes and messages needed to create and efficient computerstored medical record. J Am Med Informatics Assoc 1994; 1: 1-7.
8. Dimitroff A. Medical informatics conference papers: a content analysis of research in a new discipline. Comput Biomed Res, 1994; 27: 276-90.
9. Gardner RM, ed.: Proceedings of the Nineteenth Annual Symposium on Computer Applications in Medical Care; Philadelphia: Hanley & Belfus 1995.
10. World Health Organization. Ninth Edition. Internanonal Classification of Diseases Index. Manual for the International Statistical Classification of Diseases. Geneva, 1977.
11. World Health Organization. International Classification of Diseases Index. Tenth Revision. Volume 1: Tabular List. Geneva, 1977.
12. Slee VN. The International Classification of Diseases: ninth revision. Ann Intern Med. 1978; 88 (3): 424-6.
13. Kurtzke JF. ICD-9: A regression. Am J Epidemiol. 1979; 109 (4): 383-93.
14. White KL. Restructuring the international classification of diseases. Need for a new paradigm. J Fam Practice, 1985; 21: 17-20.
15. Commission on Professional and Hospital Activities. International Classification of Diseases. Ninth Revision, with Clinical Modifications (ICD-9-CM). Ann Arbor: 1978.
16. 3M Health Information Systems. AP-DRGs: All Patient Diagnosis Related Groups. 3M Health Care. Wallingford, CT: updated annually.
17. Lambert H, Wood M, eds. International Classification of Primary Care. Oxford: University Press, 1987.
18. American Medical Association. Current Procedural Terminology. Chicago, IL: The Association, updated annually.
19. American Psychiatric Association. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders. Revised Third Edition. Washington, DC: The Association, 1987.
20. American Psychiatric Association. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders. Forth Edition. Washington, DC: The Association, 1994.
21. Thompson JW, Pincus H. A crosswalk from DSM-III-R to ICD-9-CM. Am J Psychiat, 1989; 146 (10): 1315-9.
22. Wake MM, Murphy M, Affara FA et al. Toward an International Classification for Nursing Practice: a literature review and survey. Intern Nursing Rev, 1993; 40 (3): 77-80.
23. Henry SB, Holzerner WL, Reilly CA, Campbell KE. Terms used by nurses to describe patient problems: can SNOMED III represent nursing concepts in a patient record? J Am Med Informatics Assoc 1994; 1: 61-74.
24. Ozbolt JG, Fruchtnicht JN, Hayden JR. Toward data standards for clinical nursing information. J Am Med Informatics Assoc, 1994; 1 (2): 175-85.
25. McCormick KA, Lang N, Zielstorff R et al. Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice. J Am Med Informatics Assoc 1994; 1 (6): 421-7.
26. New York Academy of Medicine. Standard Nomenclature of Diseases and Operations, 5th ed. New York: Mcgraw-Hill, 1961.
27. College of American Pathologists. Systematized Nomenclature of Pathology. Chicago: The College, 1971.
28. National Library of Medicine. Medical Subject Headings. Bethesda, MD: The Library, updated annually.
29. Mullin RL. Diagnosis-Related Groups and severity. ICD9-CM. the real problem. JAMA 1985; 254 (9): 1208-10.
30. McMahon LF, Smits HL. Can Medicare prospective payment survive the ICD-9-CM disease classification system. Ann Intern Med. 1986; 104 (4): 562-6.
31. Campbell JR, Payne TH. A comparison of four schemes for codification of problem lists. In: Ozbolt JG, ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medical Care. New York: McGraw-Hill, 1994: 201-5.
32. Cimino JJ, Hripcsak G, Johnson SB and Clayton PD. Designing an introspective, controlled medical vocabulary. In: Kingsland LW. ed. Proceedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care. New York: IEEE Computer Society Press 1989: 513-8.
33. Bourgeois P. Statistics, CPT, ICD-9, COM and Level III codes: what are they and how did I get this job? The Diabetes Educator 1991: 17 (5): 349-52.
34. Campos-Outcalt DE. Accuracy of ICD-9-CM codes in identifying reportable communicable diseases. Quality Assurance and Utilization Review 1990; 5 (3): 86-9.
35. Jollis JG, Ancukiewicz M, DeLong ER et al. Discordance of databases designed for claims payment versus clinical information systems. Implications for outcomes research. Ann Intern Med, 1993; 119 (8): 844-50.
36. Stead WW, Hammond WE. Computerbased medical records: the centerpiece of TMR. MD Computing 1988; 5 (5): 48-62.
37. Pryor TA, Gardner RM, Clayton PD, Warner HR. The HELP system. J of Med Syst 1983; 7 (2): 87-102.
38. Pryor TA. The HELP medical record system. MD Computing 1988; 5 (5): 22-33.
39. Wong ET, Pryor TA, Huff SM, Haug PJ, Warner HR. Interfacing a stand-alone diagnostic expert system with a hospital information system. Comput Biomed Res 1994; 27(2): 116-29.
40. Barnett GO, Winickoff R, Dorsey JL, Morgan MM, Luire RS. Quality assurance through automated monitoring and concurrent feedback using a computer-based medical information system. Med Care, 1978; 16 (11): 962-70.
41. McDonald CJ, Tierney WM, Overhage JM, Martin DK, Wilson GA. The Regestrief Medical Record System: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Computing 1992; 9 (24): 206-17.
42. Van der Lei J, Duisterhout JS, Westerhof HP et al. The introduction of computerbased patient records in The Netherlands. Ann Intern Med 1993; 119 (10): 1036-41.
43. Duisterhout JS, van der Meulen A, Boersma J, Gebel R, Kjoo KH. Implementation of ICPC coding in information systems for primary care. In: Lun KC, Degoulet P, Piemme TE, Rienhoff, eds. MEDINFO 92. Amsterdam: North Holland Puble Comp. 1992: 1483-8.
44. Barnett GO, Jenders RA, Chueh HC. The computer-based clinical record - where do we stand? Ann of Intern Med 1993; 119 (10): 1046-8.
45. Heathfield HA, Hardiker N, Kirby J, Tallis R, Gonsalkaraie M. The PEN & PAD medi- cal record model: development of a nursing record for hospital-based care of the elderly. Meth Inform Med 1994; 33: 464-72.
46. Cimino JJ, Clayton PD, Hripcsak G, Johnson SB: Knowledge-based Approaches to the Maintenance of a Large Controlled Medical Terminology. J Am Med Informatics Assoc 1994; 1 (1): 35-50.
47. Cimino JJ, Johnson SB, Hripcsak G, Hill CL, Clayton PD. Managing Vocabulary for a Centralized Clinical System. In: Kaihara S, Greenes RA, eds. MEDINFO 95. Vancouver, Canada: 1995 (in press).
48. Cimino JJ, Clayton PD. Coping with changing controlled vocabularies. In: Ozbolt JG, ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medical Care. New York: McGraw-Hill, 1994: 135-9.
49. Côté RA, Rothwell DJ, Palotay JL, Beckett RS, Brochu L, eds. The Systematized Nomenclature of Medicine. SNOMED International. Northfield, Illinois: College of American Pathologists, 1993.
50. Campbell KE, Musen MA. Representation of clinical data using SNOMED III and conceptual graphs. In: Safran, C, ed. Proceedings of the Seventeenth Annual Symposium on Computer Applications in Medical Care. New York: McGraw-Hill 1993: 354-8.
51. Rothwell DJ, Côté RA, Cordeau JP, Boisvert MA. Developing a standard data structure for medical language - the SNOMED proposal. In: Safran C, ed. Proceedings of the Seventeenth Annual Symposium on Computer Applications in Medical Care. New York: McGraw-Hill, 1993: 695-9.
52. Read JD, Benson TJR. Comprehensive coding. Brit J Health Care Comput, 1986; 22-5.
53. Read JD. Computerising medical language. In: De Glanviile H, Roberts J, eds. Current Perspectives in Health Computing HC90. Brit J Health Care Comput 1990: 203-8.
54. NHS Centre for Coding and Classification. Read Codes, Version 3. NHS Management Executive. Department of Health. London: 1994.
55. NHS Centre for Coding and Classification. Read Codes and the terms projects: a brief guide. NHS Management Executive, Department of Health. Leicestershire, Great Britain: 1994.
56. Gabrieli ER. A new electronic medical nomenclature. J Med Syst 1989; 13 (6): 355-73.
57. ASTM. Standard Guide for Nosologic Standards and Guides for Construction of New Biomedical Nomenclature. Standard E12S4-S9. Philadelphia: ASTM. 1989.
58. Rector AL, Glowinski AJ, Nowlan WA, Rossi-Mori A. Medical concept models and medical records: an approach based on GALEN and PEN & PAD. J Am Med Informatics Assoc 1995; 2 (1): 19-35.
59. ASTM. A Standard Specification for Representing Clinical Laboratory Test and Analyte Names. Standard E3113.2 (Draft). Philadelphia: ASTM, 1994.
60. EUCLIDES Foundation International. EUCLIDES Coding System Version 4.0. The Foundation. 1994.
61. Evans DA, Cimino JJ, Hersh WR, Huff SM, Bell DS. Toward a Medical Concept Representation Language. J Am Med Informatics Assoc 1994; 1 (3): 207-217.
62. Friedman C, Huff SM, Hersh WR, Pattison-Gordon E, Cimino JJ. The Canon effort: working toward a merged model. J Am Med Informatics Assoc, 1995: 4-18.
63. Humphreys BL. ed. UMLS Knowledge Sources - Fifth Experimental Edition Documentation. Bethesda, Maryland: National Library of Medicine, April 1994.
64. Lindberg DAB, Humphreys BL, McCray AT. The Unified Medical Language System. Meth Inform Med 1993; 32: 281-91.
65. Nowlan W, Rector AL, Rush T, Solomon W. From terminology to terminology services. In: Ozbolt JG. ed. Proceedings of the Eighteenth Annual Symposium on Computer Applications in Medical Care. New York: McGraw-Hill, 1994: 150-4.
66. McCray AT, Razi A. The UMLS Knowledge Source server. In: Kaihara S, Greenes RA, eds. MEDINFO 95. Vancouver, Canada: 1995 (in press).
67. Rocha RA, Huff SM, Haug PJ, Warner HR. Designing a controlled medical vocabulary server: the VOSER project. Comput Biomed Res, 1994; 27: 472-507.
68. Campbell KE. Distributed development of a logic-based controlled medical terminology. Dissertation proposal. Stanford, CA: Stanford University, March 1994.
69. Cimino JJ. Saying what you mean and meaning what you say: coupling biomedical terminology and knowledge. Acad Med 1993; 68 (4): 257-60.
70. McCarn DB. MEDLINE: an introduction to on-line searching. J Am Soc Inform Sci 1980; 181-92.
71. Tuttle MS, Sherertz DD, Erlbaum MS, eds. Adding Your Terms and Relationships to the UMLS Metathesaurus. In: Clayton PD, ed. Proceedings of the Fifteenth Annual Symposium on Computer Applications in Medical Care. New York: McGraw Hill, 1991: 219-23.
72. Van Bemmel JH, McCray AT, eds. IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer, 1995.
73. Chute CG, Cohn SP, Campbell KE, Oliver DE, Campbell JR. The content coverage of clinical classifications. J Am Med Informatics Assoc 1996; 3: 224-33.