Multilingual documentation and classification

Abstract

Health care providers around the world have used classification systems for decades as a basis for documentation, communications, statistical reporting, reimbursement and research. In more recent years machine-readable medical terminologies have taken on greater importance with the adoption of electronic health records and the need for greater granularity of data in clinical systems. Use of a clinical terminology harmonised with classifications, implemented within a clinical information system, will enable the delivery of many patient health benefits including electronic clinical decision support, disease screening and enhanced patient safety. In order to be usable these systems must be translated into the language of use, without losing meaning. It is evident that today one system cannot meet all requirements which call for collaboration and harmonisation in order to achieve true interoperability on a multilingual basis.