Læknablaðið - 15.03.1983, Side 42

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LÆKNABLAÐIÐ
I. The patient: Age, sex, referral mode (acute/pro-
grammed)
II. The examination: Area, organ, special type,
date, allocation
III. The report: Description of interpretation, dia-
gnosis, further examinations/other information.
IV. The work-load: Of physicians, other groups,
department in general, individual exam. Rooms,
duration, time of the day.
The goals set in designing the registrations system
were, that they should
1. be simple to use
2. have reliable personal identification
3. be generally useful for all roentgen departments
.4. have registration of examinations and their
results in a logical and precise way
5. have logical correspondence between registra-
tion and archives/filing practice
6. be easily extendable
7. have easy and economical dataprocessing.
Most of these objectives were taken into considera-
tion by Koivisto (1969), in his thesis on Roentgen
Diagnostic Classifications.
In Iceland there was at this time some uncertainty
as to the choice of a universally useful personal
indentification system. For census and fiscal pur-
poses a numerical system based on pre- and
surname has been in use since the early fifties.
Careful study of this system led the author to
believe that it would be impractical as a universal
identification system within the health services, as
changes of names and various other factors influen-
ce that coding, and changes are not infrequent. At
the inception of this study trials were being made by
the national health insurance services with an
earlier introduced personal-linked identification ba-
sed on the 6 ciphers of the individual’s birthday-
month-year in that order, with a 3-digit check
number added.
After studying this type of identification and
comparing the theoretical possibilities of failures
and misinterpretations as opposed to the afore
mentioned »name-number«, it was decided to adopt
the 9 ciphered »birth-number« as the basic personal
identification data in the registration system. This
decision was further motivated by the fact, that this
type of identification was at the same time intro-
duced for an extensive population-and health survey
initiated by the Icelandic Heart Association.
Furthermore, it seemed at the time the logical
»integration key« for further linkage of various
medical data.
The logic in the choice of other basic statistical
data is discussed. The value of the elementary data
regarding the patient, the examination, the report
and the work-load is obvious for general statistical
purposes, as well as for planning and management.
The linkage of these data for specific medical
research purposes is equally necessary, including or
omitting the personal identification data. It is
equally obvious, that these data may for special
purposes also serve as »integration keys«.
(Literature references in this chapter: 8-10, 18, 20,
22, 27, 28, 57-66.)
Chapter 6. Registration system and diagnostic code,
their construction and use
This chapter is a description of the principles
involved in the construction of a logical system for
the registration and classification of examinations
on the one hand, and the systematic registration of
examination findings or diagnosis, on the other.
The main objectives of the registration code for
various examinations are to provide an easily
manageable method of retrieval for various adminis-
trative and scientific purposes. The considerations
involved in this study led to the construction of an
examination code which would be examination- and
finding- oriented, that is referring to the examina-
tion area as well as to the result.
In principle, codes for grouping of various organ
systems and also other systems can be designed
according to two methods. On the one hand, there is
a simple list of species and concepts where the units
are named and arranged together in a numerical
row, and each number has its definition (monoaxial
coding). On the other hand, there are codes which
may be defined as hierachic, which actutally is a
subspecies arrangement, where the definition of the
lower branches is a part of the name or concept in a
higher branch, (cfr. figures 6.4.1. and 6.4.2.).
The final codes used here are a simplification of
the diagnostic coding system earlier recommended
by the American College of Radiologists (ACR) and
Deutsche Röntgengesellschaft, linked to the exami-
nation code recommended originally by the Swedish
Health Authorities and now in use in all the Nordic
countries.
The difficulties of the construction of a Roentgen
Diagnostic Code are discussed at some length:
The complicated function of interpretation and
communication is one of the causes of difficulties in
construction of logical diagnostic codes or keys for
roentgen diagnostic examination. One very seldom
is able to give a report of findings in values to which
relatively standardized criteria of normality are
attached in the same way as for instance a clinical
chemistry report. The report and thus the findings
frequently and inevitably will bear some personal
mark of the examiner, the receiver, and even the
patient.
By using computer assisted reporting systems
these individual variations may be greatly reduced.
But the fact must be borne in mind that even in such
systems there are several topics which can not be
interpreted according to predefined categories in all
cases. In such computer systems one may try to
eliminate these difficulties in objectivity i.a. by