There are many implementation solutions for primary, assisted and secondary

In assisted coding what you mention is one way.

The best solution IMO that I saw implemented is free text search, matching
to an interface terminology that internally maps to SNOMED. The interface
terminology is controlled, and based on real terms gathered from users, so
this methodology adapts to the location and usage. And what the wizard
provides are alternative and suggested terms from the interface
terminology. Everything is a tree here but no tree is shown to the end
user, they just see free text suggestions for his/her input. A team of
experts maintains the interface terminology and mappings to SNOMED.
Mappings to other terminologies can be done, for instance with LOINC, or
even ICD for statistics.

This is the approach of a health provider in Argentina and is the way the
national EHR strategy is being implemented in Uruguay. I think Chile will
also follow those steps.

On Tue, Mar 13, 2018 at 3:55 PM, Thomas Beale <>

> I would put it the other way around: it can only be done with structured,
> controlled subsets, that retain hierarchy from the original terminology,
> remove unneeded codes, and do a few other tricks (adding non-coding 'group'
> concepts to help guide the user). This has to be done using smart tree
> controls, or anything that logically works as a tree-based choosing tool.
> No flat lists ;)
> - thomas
> On 13/03/2018 18:33, Pablo Pazos wrote:
> It is a very very very bad practice to ask clinicians to code!
> Standardizing diagnosis is a very different thing than asking clinicians
> to code, the first is the strategy, the second is one possible, and bad,
> implementation.
> There are 3 ways of "coding" that I know of: 1. primary coding (ask
> clinicians and other clinical users to code directly), 2. secondary coding
> (users record information, a team of specialists do the coding later), 3.
> assisted coding (software helps users to code, and there are many ways of
> doing this, from NLP to GUI wizards).
> But I'm not sure if Karsten was talking about this, let's wait :)
> --
> Thomas Beale
> Principal, Ars Semantica <>
> Consultant, ABD Team, Intermountain Healthcare
> <>
> Management Board, Specifications Program Lead, openEHR Foundation
> <>
> Chartered IT Professional Fellow, BCS, British Computer Society
> <>
> Health IT blog <> | Culture blog
> <>
> _______________________________________________
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Ing. Pablo Pazos Gutiérrez
+598 99 043 145
skype: cabolabs
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