Cimino J J
Department of Medical Informatics, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Methods Inf Med. 1996 Dec;35(4-5):273-84.
Computer-based patient data which are represented in a coded form have a variety of uses, including direct patient care, statistical reporting, automated decision support, and clinical research. No standard exists which supports all of these functions. Abstracting coding systems, such as ICD, CPT, DRGs and MeSH fail to provide adequate detail, forcing application developers to create their own coding schemes for systems. Some of these schemes have been put forward as possible standards, but they have not been widely accepted. This paper reviews existing schemes used for abstracting, electronic record systems, and comprehensive coding. It also discusses the remaining impediments to acceptance of standards and the current efforts to overcome them, including SNOMED, the Gabrieli Medical Nomenclature, the Read Clinical Codes, GALEN, and the Unified Medical Language System (UMLS).
以编码形式呈现的基于计算机的患者数据有多种用途，包括直接的患者护理、统计报告、自动化决策支持和临床研究。不存在支持所有这些功能的标准。诸如国际疾病分类（ICD）、现行程序术语（CPT）、诊断相关分组（DRG）和医学主题词表（MeSH）等抽象编码系统未能提供足够的细节，迫使应用程序开发者为系统创建自己的编码方案。其中一些方案已被提出作为可能的标准，但尚未被广泛接受。本文回顾了用于抽象、电子记录系统和综合编码的现有方案。它还讨论了标准接受方面仍然存在的障碍以及当前为克服这些障碍所做的努力，包括医学系统命名法（SNOMED）、加布里埃利医学术语表、里德临床编码、盖伦医学本体和统一医学语言系统（UMLS）。
