Evolving to clinical terminology.
The electronic medical record (EMR) is slowly replacing the paper chart for documenting patient details. As the adoption curve for EMRs rapidly increases, so will the need for clinical terminologies. Currently, administrative classifications such as ICD-9-CM, CPT and HCPCS serve not only billing and reporting purposes, but also are used by healthcare providers for documentation and capturing patient procedures and problem lists. But the use of clinical terminologies, such as SNOMED CT, will assume the interface role in EMRs and thus replace these administrative classifications at the point of care. These billing terminologies will then be relegated back to the coders and payers for use, enabling the clinicians to document using richer and more granular terminologies. During this transition phase to the clinical terminology, training will likely be required as healthcare providers adjust to using terminologies in more robust ways. Clinical informaticists and early adopters will play a role in this training and help to demonstrate the many advantages of richer documentation. The use of clinical standards in EMRs is one of the key evolutions in informatics.
University of Colorado-Affiliated Hospital, USA.
Brian
B
Levy
D004059:Diffusion of Innovation; D006751:Hospital Information Systems; D016347:Medical Records Systems, Computerized; D009626:Terminology as Topic; D014481:United States