Clinical Terminology and Clinical Classification Systems: A Critique Using AHIMA's Data Quality Management Model
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. The two sets of systems were designed to serve different purposes and therefore are intended to satisfy different user requirements. However, essential elements distinguish a clinical terminology from a classification system. Rather than concluding which system is "best" to accommodate healthcare needs and data structure, a critique of both systems will be presented in this article using AHIMA's Data Quality Management Model. SNOMED CT and ICD 10 CM/PCS will be utilized as examples of clinical terminologies and clinical classification systems, respectively.