The problem of providing effective computer support for clinical coding has been the target of many research efforts. A recently introduced approach, based on statistical data on co-occurrences of words in clinical notes and assigned diagnosis codes, is here developed further and improved upon. The ability of the word space model to detect and appropriately handle the function of negations is d...

Newborn screening (NBS) is a complex process that has high-stakes health implications and requires rapid and effective communication between many people and organizations. Currently, each NBS laboratory has its own method of reporting results to state programs, hospitals and individual providers, with wide variation in content and format. Pediatric care providers receive reports by mail, email,...

There has been massive investment in the development of clinical terminologies for use in electronic patient records. However, there has been little published evidence for the added value for primary care that implementation of such a terminology would offer. This paper outlines a methodology that has been used to compare two existing coding schemes (Read codes 5 byte set and Clinical Terms Ver...

The need for structured data in electronic health records has not been fully addressed by reference terminologies (RT) due to difficulties of use for end-users. Interface terminologies (IT), built for specific usage and users, and linked to RT, may solve this issue. We propose an IT for medical imaging prescription, based on the French nomenclature for procedure (CCAM), and its qualitative eval...

General practitioner (GP) computing has its origins in the 1970s when the benefits of clinical coding and prescribing were demonstrated. During the early 1980s Dr James Read, working with Abies Informatics Ltd, developed the eponymous Read Codes, which were broader and more comprehensive than other schemes, yet intuitive and easy to use. In 1988 a joint working party of the Royal College of Ge...

A standardised terminology for describing medical devices can enable safe and unambiguous exchange of information. Proposed changes to EU-wide medical devices regulations mandate the use of such a system. This article reviews two important classification systems for medical devices in the UK. The Global Medical Device Nomenclature (GMDN) provides a classification system specifically for medical...

The Systematized Nomenclature of Medicine-Clinical Terminology (SNOMED CT®) has been endorsed as an international standard reference terminology to facilitate e-health initiatives. SNOMED CT is developed and supported in an international collaborative effort through the International Health Terminology Standards Development Organization (IHTSDO) and the member countries (approximately15) functi...

OBJECTIVES As controlled medical terminologies evolve from simple code-name-hierarchy arrangements, into rich, knowledge-based ontologies of medical concepts, increased demands are placed on both the developers and users of the terminologies. In response, researchers have begun developing tools to address their needs. The aims of this article are to review previous work done to develop these to...

The Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) is a clinical terminology with a broad coverage of health care, which has been developed with the help of a rather inexpressive description logic dialect known as EL [1]. The advantage of using a description logic (DL) for defining a medical ontology is that, instead of error-prone “hierarchy engineering,” where each newly in...

The situation of medical coding and medical economics is quite specific in France. Besides ICD10, two specific terminologies are used: the International Nomenclature of Human and veterinary Medicine (SNOMED International) developed by the College of American Pathologists and CCAM. This work aims at creating and optimizing inter and intra terminology relations between ICD-10 and SNOMED Int. As 9...