The language of rheumatology. I: Nomenclature and coding.

Effective communication is essential in an efficient health service. Increasingly, such communication involves the electronic transfer of data from one computer system to another. The Information Management Group (IMG) of the National Health Service (NHS) plans eventually to introduce an electronic patient record which will be accessible wherever the patient is treated. If this plan is to function effectively, then all patient based information collected within the NHS must be consistent, unambiguous, and exchangeable. Thus it has become important to consider very carefully the way in which medical terms are coded and then grouped. This paper deals with the development of a national thesaurus of agreed clinical terms (the Clinical Terms Project) and the assignment of computer codes (Read codes) to these terms. A subsequent paper will discuss the need for systems of classification (such as International Classification of Disease (ICD) 10) and grouping (such as healthcare resource groups) for statistical analysis, research, costing, and resource management.