2. Support Clinical Decision Making

The ability of an automated system to support clinical decision making depends largely on how well the data available to it are structured. The nomenclature used to record information is one aspect of that structure. Consider, for example, the desire to have the system advise the nurse when a particular patient is at high risk for falling, or to propose appropriate measures to prevent pressure ulcers, or to recommend the most cost-effective wound treatment given a description of the wound. None of this can be done without assessment data that are recorded using a nomenclature that is quite granular. Furthermore, the data must be coded in such a way that they are easily retrievable and able to be manipulated by the computer. This requires that each term in the nomenclature have a unique identifier that can be used for coding.

Experience with the maintenance of large nomenclatures has shown that the unique identifiers must be context-free, that is, the code should not indicate that the term belongs in one section of the taxonomy or another. This is because knowledge evolves, and using context-dependent codes creates serious problems when a code has to be moved to a different section of the taxonomy, or when the same term can logically belong in more than one section of a taxonomy (that is, when it can have multiple parents). It's extremely difficult to design decision support systems when the data required for a decision can exist under multiple codes. Of course, the quality of the data used for decision support is paramount, so the attributes of clarity and non-redundancy in the nomenclature will be key, along with the need to have clear definitions of each term so that clinicians use the terms accurately and consistently.

3. Billing/Costing/Accounting

It has long been advocated that atomic-level data captured in the course of clinical care should be able to be used for multiple purposes, including billing, costing, and/or accounting (Dick & Steen, 1991; Zielstorff, Hudgings & Grobe, 1993). In order to accomplish this, it must be possible to map the terms used in the clinical nomenclature to other nomenclatures that are used for billing, such as Current Procedural Terminology (CPT) (American Medical Association, 1993), or HCFA Common Procedure Coding System (HCPCS). Medical diagnoses may also be required for billing purposes, so terms for recording diagnoses must be able to be mapped to such nomenclatures as International Classification of Diseases — Clinical Modification (ICD9-CM) (National Center for Health Statistics, 1980).