Gardner, Reed M.

Stead, William W.

English

The University of Utah: J. Willard Marriott Digital Library

Letters to the Editor Letter Standardized Coding of’ the Medical Problem List To the Editor:-We strongly support the position that many of the potential benefits of computerized med- ical records will not be achieved unless standard cod- ing schemes are used to represent the medical con- cepts therein, as presented in JAMIA’s first issue.’ We believe that pointing out reasonable options for standard coding schemes will assist developers and will promote consensus development. Also, pointing out where reasonable options are not yet available will help direct research efforts. We were surprised that, of the many categories of medical concepts listed, the medical problem list was not mentioned as a domain suitable for standardiza- tion. We feel that this represents an important omis- sion. A problem list is a key aspect of both inpatient and outpatient medical records (computerized as well as paper-based). Projects that have demonstrated the benefits of computerized patient record2 have made explicit use of coded problem lists, and these data are fundamentally important to health services re- search. However, developing codes to use in a com- puterized problem list remains a nontrivial effort. An institution wishing to add a coded list of problems to its information system has no easy options from which to choose. At the 1993 Spring AMIA Meeting, a panel on on-line problem lists underscored the many diverse schemes in current use. Some institutions are using one of a number of existing coding schemes (e.g., ICD-9, SNOMED), while others have created their own proprietary schemes. While many of the items on medical problem lists are common to other domains (e.g., diagnoses, procedures, symptoms, etc.), it is not clear that even the union of existing schemes will suffice to describe all of the items that may appear on a problem list (e.g., social situations).” Developing proprietary schemes involves enormous effort, runs counter to the need for standards, and precludes the possibility of data sharing in the future. We urge the AMIA Board of Directors to acknowl- edge the need for a standardized scheme to represent medical problems in the computerized medical rec- ord. We further encourage the organization to review existing candidate coding schemes and to endorse one if appropriate or to state that none of the cur- rently available schemes is suitable. Progress in this area will speed the realization of benefits from com- puterized medical records. GIL KUPERMAN, MD, PHD DAVID W. BATES, MD, MSc Center for Applied Medical Information Systems Research Brigham and Women’s Hospital Boston, MA 02115 Board of Directors of the American Medical Informatics Asso- ciation. Standards for medical identifiers, codes, and messages needed to create an efficient computer-stored medical record. J Am Med Informatics Assoc. 1994;1:1-7. Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA. 1993;269:379-83. Chueh HC, Barnett GO. Client-server distributed database strategies in a healthcare record system for a homeless popu- lation. Proc Annu Symp Comput Appl Med Care (SCAMC). 1993;17:119-24. In reply: Drs. Kuperman and Bates are correct in identifying the need to develop consensus standards for coding schemes for the medical problem list as a high priority. The problem list is a “table of contents and an index combined” of the medical record.’ It is a summari- zation of information about the patient’s medical and psychosocial history. As such, its coding scheme must permit representation of any concept that can be rep- resented within the medical record itself. It is thus unlikely that a new set of codes will be needed just to represent the problem list. An alternative course would be to develop consensus on a framework of the types of information that should be included in the problem list. A code system could then be selected for each type of information. For  group.bmj.com on April 15, 2012 - Published by jamia.bmj.comDownloaded from Journal of the American Medical Informatics Association Volume 1 Number 5 Sep / Oct 1994 415 example, a patient’s allergy to penicillin should be included in his or her problem list. Rather than de- veloping a code for allergy to penicillin, a code for allergy could be combined with the World Health Organization (WHO) or National Drug Code (NDC) code for penicillin. The code systems identified in Table 1 of the AMIA position paper on standards2 should be taken as a starting point in developing a code scheme for the problem list. The AMIA position paper on standards was a call to embrace existing standards and approaches in an ef- fort to progress quickly. Kuperman and Bates point out one of the many areas where we need to build on and to move beyond those approaches. The “stra- tegic plan” of AMIA3 contains two very powerful statements supporting AMIA’s concern about and commitment to further development of standards: Goal B.7. Promote adoption of consensus standards. Example: Promote published consensus standards about medical records, messages, vocabularies. (p 266) AMIA should take an activist role in promoting stan- dardization efforts. (p 270) It is heartening to see members of AMIA coming together around the Board of Directors’ strong state- ment on standards. Standard development is a long and tedious process. The work of standard devel- opment cannot be delegated to the uninitiated. Standard development is generally carried out by “volunteers” who seldom get paid for their work, either in dollars or in professional recognition. We support the needs outlined by Kuperman and Bates. We must move forward as an organization and as volunteers to develop better standards, including those for the patient problem list. REED M. GARDNER, PHD WILLIAM W. STEAD, MD For the AMIA Board of Directors References Weed LL. Medical Records, Medical Education, and Patient Care. Cleveland, OH: Case Western Reserve University, 1969:25. Board of Directors of the American Medical Informatics Asso- ciation. Standards for medical identifiers, codes, and messages needed to create an efficient computer-stored medical record. J Am Med Informatics ASSOC. 1994;1:1-7. Greenes RA, Board of Directors of the American Medical In- formatics Association. Strategic planning activities of the Amer- ican Medical Informatics Association. J Am Med Informatics Assoc. 1994;1:263-71.  group.bmj.com on April 15, 2012 - Published by jamia.bmj.comDownloaded from doi: 10.1136/jamia.1994.95153430 1994 1: 414-415J Am Med Inform Assoc Gil Kuperman and David W Bates problem listStandardized coding of the medical http://jamia.bmj.com/content/1/5/414.citationUpdated information and services can be found at: These include:serviceEmail alertingthe box at the top right corner of the online article.Receive free email alerts when new articles cite this article. 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Standardized Coding of the Medical Problem List (Letter)

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Standardized Coding of the Medical Problem List (Letter)

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