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Relationship of Classifications and Terminologies

Purposes of Classifications and Terminologies

Classifications and terminologies are designed for distinctly different purposes and satisfy diverse user data requirements. They should be considered complementary, as neither a clinical terminology nor a classification can, by itself, serve all of the purposes for which health information is currently used or will be used in the future. Classifications are a necessary adjunct to terminologies for standardized summarization for statistical and external reporting purposes.

Classification systems such as ICD-9-CM, ICD-10-CM, and ICD-10-PCS are considered “output” systems and are not intended or designed for the primary documentation of clinical care. They are typically used for external reporting requirements or other uses where data aggregation is advantageous. They can be used in either paper-based or EHR systems. A classification system arranges or organizes like or related entities for easy retrieval. It aggregates granular clinical concepts into manageable categories for secondary data purposes. The uses being made today of data derived from classification systems go well beyond the purposes for which these data were used in the 1970s when ICD-9-CM was designed and implemented.

The purposes for which this data are used today include:

• Measuring the quality, safety (or medical errors), and efficacy of care
• Making clinical decisions based on output from multiple systems
• Enabling the connectivity of information systems for continuity of care
• Designing payment systems and processing claims for reimbursement
• Conducting research, epidemiological studies, and clinical trials
• Setting health policy
• Designing healthcare delivery systems
• Monitoring resource utilization
• Improving clinical, financial, and administrative performance
• Identifying fraudulent or abusive practices
• Managing care and disease processes
• Tracking public health and risks
• Providing data to consumers regarding costs and outcomes of treatment options.

Clinical terminologies such as SNOMED-CT® are “input” systems and are designed for the primary documentation of clinical care. Since they codify the clinical information captured during the course of patient care, terminologies can only be used in electronic health record (EHR) systems.

Mapping Between Terminologies and Classifications

Together, standard clinical terminologies and classifications represent a common medical language that allows data to be shared between EHR systems. Therefore, standard, modern clinical terminologies and classifications must be incorporated into EHR systems in order to achieve system interoperability and the benefits of a national health information infrastructure.

The expanded availability of SNOMED-CT® made possible by the federal government licensing agreement increases the urgency of replacing ICD-9-CM with ICD-10-CM/PCS so the development of mapping tools to the ICD-10-CM and ICD-10-PCS can be initiated. Mapping is the process of linking content from one terminology to another or to a classification.

The use of a map from SNOMED-CT to ICD-10-CM and ICD-10-PCS will allow clinical information captured at a very granular level to be aggregated for reporting and statistical analysis purposes. Mapping a terminology to modern classification systems:

• Decreases administrative costs,
• Decreases time in revenue cycle,
• Increases data specificity and accuracy, and
• Maintains comparable data.

For more information, read:

Coordinating SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems (July/August 2005)

Implementation of SNOMED-CT Needed to Facilitate Interoperable Exchange of Health Information (AHIMA position statement) (July 2005)

SNOMED CT Helps Drive EHR Success (April 2005)

Avoiding a War of Words (and Numbers): The Uncertain Future of Terminologies and Classifications (October 2004)

Essentials for Mapping Clinical Terminology (October 2004)

Mapping from a Clinical Terminology to a Classification (October 2003)

AHIMA Project Offers Insights into SNOMED, ICD-9-CM Mapping Process (July/August 2003)

A Closer Look: The SNOMED Clinical Terms to ICD-9-CM Mapping (June 2003)

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