( ) is widely recognized as the leading global clinical terminology for use in . It is maintained and developed by an International body (the ) which has a growing community of Members and Affiliates. It is available free for use in countries and can also be used in other countries based on openly published licensing terms that are designed to be affordable. policies allow for the open involvement of its Members and in the development of content and the design of future enhancements.
The features of include:
is designed to enable effective representation of clinical information in . While there are other potential uses for , the potential benefits are greatest where it is implemented as a part of a centered on the delivery of health care services to individuals and populations.
The benefits actually realized by implementation depend on the technical design of applications and the way they integrate with other essential elements. These technical issues are addressed in this guide. Another critical success factor is a process for managing implementation across an organization, region or country. Although the guide does not address broader issues of operational implementation within an organisation, it does provide a key source of reference for those specifying the practical details of a plan for large scale implementation of .
Implementation of , as part of a well-designed , is the key to unlock many of the potential benefits of .
enables consistent representation of clinical information within . Its content and design allow most types of clinical information to be represented at levels of detail appropriate to a wide range of different use cases. The hierarchical and defining of facilitate effective meaning-based retrieval and reuse of this information. By using these , a can to extract, analyze and aggregate relevant data recorded in different settings and at different levels of detail.
Many of the benefits of require an effective retrieval and reuse of clinical information. These include:
Delivering these benefits depends on consistent representation of the various types of information that are represented in a health record. It must be possible to represent this information at different levels of detail and it must be possible to this information from various perspectives and at different levels of detail. To meet these requirements need a well-maintained terminology that meets the criteria specified in Desiderata for Controlled Medical Vocabularies in the Twenty-First Century( Cimino JJ in Methods Inf Med. 1998 Nov;37(4-5):394-403). addresses these requirements and additional practical requirements for an implementable, globally applicable but locally extensible, multilingual solution.
Implementation of within a knowledge resource, such as an electronic reference book, clinical guideline, decision support protocol, facilitates effective access from, or integration with, .
The use of in enables consistent processable representation of clinical information. Potential uses of this information include linkage to knowledge sources to assist its understanding and interpretation.
Developers of decision support protocols, care pathways or data analysis packages can benefit by using to represent requirements for clinical information collection and processing. This allows direct translation of the protocol into queries that can be applied directly to a enabled .
Publishers of knowledge based resources can benefit by tagging their information using . These tags can be used to index information by rather than by keywords. As a result, relevant information can be identified by users during interaction with an . For example, when selecting a particular item during data entry or review potentially relevant articles can be listed and/or displayed.
also offers benefits during the development of knowledge resources. Tagging information using while authoring knowledge artifacts may identify potential ambiguities that would otherwise be overlooked.
Implementation of offers the benefit of a global approach to the requirements for clinical terminology.
Any country or large organization that is developing or deploying needs to consider the requirements for consistent representation of clinical information. One element of the solution is usually a coding scheme, controlled vocabulary or terminology. The breadth or scope and depth of detail in clinical records means that the set of codes or required is large and grows rapidly as additional disciplines and specialties become involved. Similarly the interdependency of used in different domains leads to a significant level of complexity.
Developing and maintaining a terminology that adequately addresses clinical requirements is a substantial task. A global approach has significant benefits by enabling economies of scale for National bodies and health care service providers.
A global approach also encourages common solutions to some of the challenges posed by requirements for consistent representation of complex information. The resulting reduction in divergence provides a more secure foundation for implementers who wish to deploy their applications in many countries.
Implementing a global clinical terminology also enables applications to be deployed in other countries without needing to switch between terminologies. It also allows use of other standards and materials that incorporate or are designed for use with that terminology. The ability to integrate components and standards based on a common terminology is a major advance over solutions that depend on a local or proprietary code system.
A global clinical terminology also provides a foundation for communication and sharing of information. The information communicated may include clinical records used to support delivery of health care to a mobile population. It may also include aggregations of records used for epidemiology and multi - center research.
Implementation of allows common approaches to be applied to extend and configure the terminology for use in a particular environment.
Most clinical are relevant in all countries, organizations and specialties but some are relevant only to a particular environment. allows national, local or organizational requirements to be addressed by separately maintained . can benefit from the content in these without the need for any additional software development because have exactly the same structure as the .
covers a broad domain to depth of detail appropriate to a range of health care disciplines and clinical specialties. As a result, it has an extensive content, different parts of which are needed in particular environments. The design includes the mechanism which provides a standard way to refer to a set of . can be used to configure different views of by constraining searches or representing short lists of terms for a data entry field. They can also be used to meet other requirements including checking that a id falls within a permitted set of values for a field in a data structure or message (e.g. to represent an ).