Background on Standardized Coding and Classification
Why Standardize Coding and Classification?
- Reliability of the current community-based health service encounter databases regarding diagnoses is dreadful and has always been recognized as such. This is well-iterated in Graham C. Scott’s 1991 report of the Task Force on Use and Provision of Medical Services to the Minister of Health for Ontario:
"The quality of most health care information systems is abysmal when examined from the perspective of system planning. While there is an almost unlimited amount of information on paper, most of it is of very limited use. The result is that we simply do not know enough about what is happening in doctors' offices, hospitals, laboratories and community health centres to assess these trends, motivations, incentives, practice patterns and health outcomes.
"Without the development of this kind of basic management information, we are doomed to continue making policy decisions without an adequate appreciation of the possible downstream implications. This weakness has contributed to the system becoming more costly. In the shadow of ever growing cost pressures, the common response has been to contain them with the blunt instruments of supply management, an approach that often increases distortions and thereby indirectly contributes to lower quality health care.
"It is the experience of the Task Force that much of the data are simply not of a quality to provide the desirable support for planning and research initiatives, and are too often in such a form as to be of limited value in making judgments on system management.... There must be a major thrust to address management information systems, and this undertaking should meaningfully involve the major stakeholders and potential users in the system."
Suffice it to say that little has changed since 1991.
- To obtain analyzable information from health service encounter data requires an acceptable standard vocabulary to be used by care providers for recording the process of care.
- This vocabulary, to be acceptable to providers, must reflect the current usage of clinical terms. Because the majority of visits have no definitive diagnosis, it must enable effective capture of symptoms and reasons for encounter.
- CIHI (Canadian Institute of Health Information) has declared that ICD-10 (International Classification of Diseases revision 10) will be Canada's standard by 2001. Unfortunately ICD-10 is not by itself suitable for use in an electronic record and is inadequate for capturing most symptoms.