Information Technology Reference
In-Depth Information
Fig. 3.4
An Example of Mapping between ICD-10 and SNOMED
(SNOMED). Today, SNOMED CT, the clinical terminology subset of SNOMED, is
a standard accepted by the US government and is increasingly seen as a key tool for
the advancement of clinical health informatics. ICD-10 has many similar hierarchi-
cal structures and a mapping between it and SNOMED CT has been developed. [
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]
There is talk of merging the two into a single common international standard, some-
thing that will probably happen in the future.
As shown in
Fig. 3.4
, ICD-10 requires additional specification that might affect
reimbursement. SNOMED is more focused on describing clinical detail. In fact,
SNOMED CT “understands” that the operative morphology of “fracture of shaft of
ulna” is a fracture and that the shaft is a part of the Ulna. These are intentionally
simple examples to give you a feel for the information that is contained in the hierar-
chical structure and the more generalized research and clinical decision support capa-
bilities that it could support. That is best appreciated by using an online SNOMED-CT
browser. [
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] I encourage readers with a serious interest in the topic to do this.
Interoperability Standards:
Whether the data is structured or free text it should
ideally be wrapped for transport in some standard electronic document format so
that a computer understands what each section of the data is and what it represents
(i.e. where the lab results and the medication orders are and how they have been
coded). This format has been standardized. The HL7 Clinical Document Architecture
(CDA) uses XML for encoding of the structure of the documents, but not their infor-
mational contents, dividing the document into generic, unnamed, and sections with-
out a defined template. Stated another way, CDA is an XML-based markup standard
intended to specify the encoding, structure and semantics of
clinical documents
for
health information exchange but it does not specify the format of the contents of
these documents.
Extensible Markup Language (XML) is used in virtually all domains to which
computing is applied. It defines a set of rules for encoding documents in a format
