Clinical coding constitutes one of the fundamental functions in the field of health information management. Clinical classification systems and clinical terminologies represent two distinct sets of coding schemes that are used in healthcare. In this context, it is critical to distinguish between clinical terminologies and clinical classification systems, identify how both sets of systems are utilized in healthcare settings, and acknowledge individual contributions of each system to providing data infrastructure for clinical as well as administrative data uses in the healthcare delivery system.
A standard electronic health record (EHR) and interoperable national health information infrastructure require the use of uniform health information standards, including a common medical language. Data must be collected and maintained in a standardized format, using uniform definitions, in order to link data within an EHR system or share health information between systems.
A descriptive study of health information technology (HIT) vendors was conducted to identify which EMR/EHR vendors currently work or anticipate working with SNOMED CT, determine the prevalence of SNOMED CT integration in electronic medical record (EMR) and electronic health record (EHR) products, identify the available and potential future applications for SNOMED CT in EMR/EHR systems