CIA Principle 6: Approved vocabularies will be consistently adopted wherever appropriate in all regional Clinical Systems.
“Approved vocabularies will be consistently adopted wherever appropriate in all regional Clinical Systems.”
One of the benefits of using Clinical Systems is that passive data, previously found in paper charts, can become active and actionable. It can be reused to display in different contexts and it can be used to support Clinical Decision Support (such as proactive care delivery) and Health Planning (at multiple levels). In order to achieve this level of activity, information needs to be coded in a way that can be consistently interpreted both by users and by the information systems. Thus, standardized vocabularies are desired to provide that consistency. There are three levels of vocabularies that can be considered.
Reference Vocabularies are designed to have maximum details in to support the information needs of clinical care. SNOMED CT is recommended as one of the primary clinical coding terminologies. It is supported by provincial and national standards and is actively developing on an international level. Additional reference vocabularies will be included where SNOMED CT does not have sufficient clinical coverage.
For Health Planning and Reporting activities, Classification Vocabularies and Group Vocabularies will be used, as they are today. ICD 10 is currently used for chart abstraction functions and various reporting as a Classification Vocabulary. The level of detail in ICD-10 is not truly sufficient for clinical documentation but provides useful data at an aggregate level. Mapping from reference vocabularies to classification vocabularies is possible and recommended to reduce manual re-coding of information.
Here, the focus is on the need to develop a nomenclature approach and leverage the right detail level of existing standards for their purposes. This principle relates to Principle 3 in that data should be captured at a granularity level for appropriate clinical purposes and then can be mapped up to the higher level reporting needs.
SNOMED CT is called out explicitly in this principle to ensure that energy and resources are applied to gaining knowledge about this powerful – but complex – terminology.