Coding systems and classifications in healthcare: the link to the record

Autor: P.E. Zanstra, Werner Ceusters, P.F. de Vries Robbé, Alan L. Rector
Rok vydání: 1998
Předmět:
Zdroj: International Journal of Medical Informatics, 48, pp. 103-110
International Journal of Medical Informatics, 48, 103-110
ISSN: 1386-5056
Popis: Currently, the third phase of the introduction of information technology to the health care delivery system is underway. The first phase is mainly concerned with automating the administrative process. The second phase involves delivering medical applications. The third phase integrates a diversity of medical and administrative systems into one coherent inter-operable environment. As a result, a need for safe and sensible communication between these applications has emerged. Along with a good insight into what information is really necessary for exchange, the language used is also important. For instance the slow progress in the implementation of knowledge based systems may, to a large extent, be attributed to the lack of semantical coupling with the patient record. In the literature pertaining to this subject, the adjective ‘electronic’ is carefully avoided when dealing with the healthcare record. The fact that a record is stored by some electronic means is not sufficient. It is possible to make a perfect electronic image of the paper record, as well as a perfect 1:1 image of a paper-based classification. The point is we now no longer are constrained by the paper format. There is an opportunity now to give the record a formal basis, leading to a number of advantages with regard to manipulating the stored data. It would therefore be more appropriate to talk about the Formalised Health Care Record (FHCR). The urgent needs are reflected in the many projects around the Computerised Medical Record (GEHR, MARGOT, etc.), projects * Corresponding author. Tel.: +31 243 615430; fax: +31 243 613505.
Databáze: OpenAIRE
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