Stuart-Buttle C D, Read J D, Sanderson H F, Sutton Y M
NHS Centre for Coding and Classification, England.
Proc AMIA Annu Fall Symp. 1996:75-9.
A cornerstone of the Information Management and Technology Strategy of the National Health Service's (NHS) Executive is fully operational, person-based clinical information systems, from which flow all of the data needed for direct and indirect care of patients by healthcare providers, and local and national management of the NHS. The currency of these data flows are firstly Read-coded clinical terms, secondly the classifications, the International, Classification of Disease and Health Related Problems, 10th Revision (ICD-10) and The Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, 4th Revision (OPCS-4), and thirdly Healthcare Resource Groups and Health Benefit Groups, all of which together are called the "language of health", an essential element of the electronic clinical record. This paper briefly describes the three main constituents of the language, and how, together with person-based, fully operational clinical information systems, it enables more effective and efficient healthcare delivery. It also describes how the remaining projects of the IM&T Strategy complete the key components necessary to provide the systems that will enable the flow of person-based data, collected once at the point of care and shared amongst all legitimate users via the electronic patient record.
国民健康服务体系（NHS）行政部门信息管理与技术战略的基石是全面运行的、基于个人的临床信息系统。医疗服务提供者对患者进行直接和间接护理以及NHS进行地方和国家管理所需的所有数据，都来源于该系统。这些数据流的核心要素，首先是采用Read编码的临床术语，其次是分类标准，即国际疾病及相关健康问题统计分类第10次修订版（ICD - 10）和人口普查与调查局手术操作与程序分类第4版（OPCS - 4），第三是医疗资源组和健康受益组。所有这些共同构成了所谓的“健康语言”，它是电子临床记录的一个基本要素。本文简要介绍了这种语言的三个主要组成部分，以及它如何与基于个人的、全面运行的临床信息系统一起，实现更有效和高效的医疗服务提供。本文还描述了信息管理与技术战略的其余项目如何完善提供基于个人的数据流动系统所需的关键组件，这些数据在护理点一次性收集，并通过电子病历在所有合法用户之间共享。
