January 2015

From the Desk of the Managing Editor

Coding of clinical terms
The start of the New Year brings about the start of new opportunities. This brings to mind the increasing interest in and uptake of electronic medical records (EMR). Use of coded medical information aids doctors at the point of care when the information is used to populate decision support modules, such as allergy alerts. Effective sharing of patient information has been shown to increase the quality of patient care by the improved coordination across different healthcare disciplines.

It has been identified that one of the barriers to the use of electronic transfer of medical information is the lack of a standard. Although various terminology standards are available, each uses different naming conventions, codes and hierarchies. This makes marrying information across software based on different terminology sets difficult.

In order to allow integration and interoperability between various softwares, coding of medical terminology will need to be standardised by mapping terminology sets between different industry standards. This will deliver solutions satisfying various functions and ensure that information is safely transmitted between different softwares.

The Australian Medicines Terminology (AMT) is an example of coded medicines information. By mapping MIMS medicines data to AMT term sets, the transfer of information across medical dispensing and prescribing softwares that utilise AMT is standardised.
Similarly, medical conditions have classification standards such as ICD-10 and SNOMED. Utilising the standard codes in data entry and delivery allows for the collection of accurate data for use in clinical decision support. Data collected may also be used to implement clinical pathways that help to improve processes and optimise clinical programs.

Besides mapping to the AMT, MIMS has been actively looking for opportunities to map our information to various classification standards. Parts of our decision support suite have been mapped to ICD-10 and more recently we have also included SNOMED in certain products. Undoubtedly we are only at the start of this journey, but as the need for interoperable data grows, MIMS intends to be able to support our users through the provision of mapped data.

References:
Bates DW and Gaw ande AA. Improving safety with information technology. New Engl J Med 2003; 348: 2526-34.
Department of Health 2012. Electronic medical record benefits: a literature review. Victorian Government, Melbourne.

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