Information's Coding Standards in Healthcare

Close attention has been recently given to the need for interoperability in health information systems. Interoperability - defined as the ability to communicate between software and hardware of different systems - is necessary to provide complete and accurate patient information. The need for interoperable systems is evident in every aspect of our healthcare organisations. For example, a physician treating a patient in the emergency room needs to know the patient’s medical history, current medications, and recent lab results in order to deal with patients in a proper way. Similarly,the emergency room physician is supposed to be able to communicate test results to the patient’s primary care physician. This is the reason why standards are required. Analysing resources published by the various SDOs and previous academic articles on the subject, the purpose of this article is to examine the major healthcare coding systems, illustrate them with examples, and relate them to each other. The first chapter is dedicated to standards used for coding healthcare terms while the second one mainly describes standards for coding healthcare documents and clinical summaries; the latter focuses on standards related to data transmission and messaging.