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Encode-Fm Code-Mf ENCODE-FM™ Electronic Nomenclature and Classification Of Disorders and Encounters for Family Medicine CODE-MF™ Codification Électronique pour la Médecine Familiale Developed by: Robert M. Bernstein PhD, MD,CM, CCFP, FCFP Gary R. Hollingworth MD, CCFP, FCFP Gary S. Viner BSc, MD, CCFP, FCFP ENCODE-FM™ Electronic Nomenclature and Classification Of Disorders and Encounters for Family Medicine CODE-MF™ Codification Électronique pour la Médecine Familiale Version 5.0 – November 2009 Developed by: Robert M. Bernstein PhD, MD, CM, CCFP Gary R. Hollingworth MD, CCFP, FCFP Gary S. Viner BSc, MD, CCFP The CLINICAL VOCABULARY contained in this publication is copyrighted and all rights are reserved. It may not be copied, reproduced or translated to any electronic medium or machine-readable form without prior consent in writing from INSITE-Family Medicine Inc. Copyright © 1997, 2001, 2004, 2006, 2009 INSITE-Family Medicine Inc. INSightful Information TEchnologies for Family Medicine 1943 Wembley Ave., Ottawa, Ontario, Canada K2A 1A8 ISBN 0-88927-296-4 Printed in Canada Acknowledgments INSITE-Family Medicine Inc. wishes to acknowledge The Centre for Information Technology Innovation (CITI) of Industry Canada and Clinidata Inc. for financial support of ENCODE-FM version 2.0 to provide for its use in The College of Family Physicians of Canada Clinical Practice Management Network. ♦ The authors are indebted to: The World Organization of Family Physicians (WONCA) Classification Committee and Professor Charles Bridges-Webb, it’s Retired Chairperson for leadership in classification in international primary care ♦ The authors would particularly like to thank: Dr. Maurice Wood for introducing us to ICPC, and Drs. Maurice Wood and Henk Lamberts for their outstanding contributions to research in standardized data collection in primary care, and for their many years of encouragement of our efforts. CONTENTS WHAT’S NEW IN VERSION 5.0 November 2009 ....................................................................................................iv WHAT’S NEW IN VERSION 4, build 7 2006 ............................................................................................................iv WHAT’S NEW IN VERSION 4 2004 .......................................................................................................................... v WHAT’S NEW IN VERSION 3 ................................................................................................................................... v AVAILABILITY & UPGRADES ...............................................................................................................................vi PREFACE ....................................................................................................................................................................vi DESCRIPTION .......................................................................................................................................................... vii STRUCTURE ............................................................................................................................................................ viii FUNCTIONAL GUIDELINES ....................................................................................................................................xi PLANS FOR FUTURE UPGRADES ..........................................................................................................................xi EVALUATION OF TERMINOLOGIES ................................................................................................................... xii RELIABILITY ...........................................................................................................................................................xiv STANDARDIZED DATA COLLECTION ................................................................................................................ xv REFERENCES AND BIBLIOGRAPHY ...................................................................................................................xvi ENCODE-FM 5.0 Section Title Page A General A 1 - 31 B Hematologic System B 1 - 6 D Digestive System D 1 - 18 F Eye and Adnexa F 1 - 12 H Ear H 1 - 4 I Perinatal or Infancy Period I 1 - 7 K Cardiovascular System K 1 - 11 L Musculoskeletal System L 1 - 24 N Neurological System N 1 - 16 P Psychology and Psychiatry P 1 - 18 R Respiratory System R 1 - 11 S Skin/Subcutaneous Tissue S 1 - 15 T Nutrition, Metabolism or the Endocrine System T 1 - 11 U Urinary System U 1 - 8 W Contraception and Obstetrics W1 - 16 X Female Breast and Genital System X 1 - 12 Y Male Breast and Genital System Y 1 - 6 Z Social Z 1 - 17 iii WHAT’S NEW IN VERSION 5.0 November 2009 • 144 new terms focussing mainly on interprofessional environments and the needs of social workers, occupational therapists, nursing and dietitians. • 34 terms were modified, mostly ICPC and ICD-10 mappings. • All versions are back compatible with previous versions. WHAT’S NEW IN VERSION 4, build 7 2006 • The main modifications maintain compatible mappings between the new changes in ICPC-2R (WONCA© 2005) and ICD-10. • Three new tables in addition to the standard complete file o A table in which all the Rubrics are combined into one column for easier import into an EHR. The embedded hierarchical numbering scheme still allows an indented hierarchical display. o A table of all key words in ENCODE with their related Unique numbers, and rubrics in English o A table of all key words in ENCODE with their related Unique numbers, and rubrics in French The latter 2 files allow rapid identification of a term based on a key word in a single step. Interfaces can then be designed to search for a second word within the list for the first. Both files allow easier development of clinical interfaces in French and English • 79 new terms including AVIAN influenza pneumonia and the newest Bethesda PAP naming conventions. • 236 terms were modified, mostly ICPC and ICD-210 mappings • All versions are back compatible with previous versions. iv WHAT’S NEW IN VERSION 4 2004 • 179 new terms including extensive additions to o social o dietary and o family history. • done in conjunction with the social workers and dietitians in the Ontario Community Health Centres to more accurately reflect those issues in primary care. • 17 terms were modified. • 2 terms were retired o 15 Hierarchy modifications WHAT’S NEW IN VERSION 3 • 343 new terms including extensive additions in the social and community issues areas, especially community health promotion and activism issues. Many of these terms have never appeared in any systematic terminology and have no corresponding maps to the standard classifications. • Social and psychiatric chapters have been revised in conjunction with social workers in the Ontario Community Health Centres to more accurately reflect those issues in primary care. • 1987 terms were modified, by wording changes, or mapping changes or both. These changes include the new standard classifications of diabetes, lung cancer and the Bethesda PAP system. o 6 terms were retired o 1585 ICPC map changes based on the new ICPC-ICD-10 conversion structure included in the electronic version of ICPC [reference] o 198 Map changes to ICD-10 o 29 Map changes to ICD-9 CM o 143 Hierarchy modifications o 246 non-standard maps • New term attributes for tracking version changes more accurately v AVAILABILITY & UPGRADES ENCODE-FM is also available in an electronic standard database format (English and French versions) for incorporation into electronic databases and electronic medical records, and as a stand-alone browser (ENCODE-R). INSITE-Family Medicine Inc. recognizes that distribution and acceptance of a standard nomenclature cannot be impeded by excessive cost. License and maintenance fees will therefore be structured with this in mind and will also be determined by the scope and use of specific applications. INSITE-Family Medicine Inc. has two separate licensing agreements for the electronic version based upon the purchaser's intended use for ENCODE-FM. 1. If it is to be used by a single individual in his/her own EMR and not for resale, there is a one time license fee with a small fee for updates, 2. If it is to be included in a vendor's EMR, licensing and yearly maintenance fees will be based upon specific arrangements with each vendor according to the number of users and the type of license that vendor has with its customers. The goal is to provide a quality family medicine terminology whose use is not hampered by cost. The maintenance fee covers all updates and changes based on feedback from users and changes to the standard international classifications to which ENCODE-FM maps. A maintenance fee is necessary due to the fact that the nomenclature is dynamic and updates are labour intensive. The costs to maintain the vocabulary increase based on the number of users because of the variations in personal terminology. INSITE does consider discounts for multiple users at any one site. ENCODE-FM will be updated on a regular basis (usually twice yearly) with relevant additional terms as deemed necessary by both the authors and users. In order to maintain the relevance and accuracy of ENCODE-FM, the authors would appreciate licensees to: 1) provide feedback regarding omissions, errors, and unnecessary terms, and 2) provide a “failed look-up" table of terms for possible inclusion into ENCODE-FM updates. Changes to the ICPC-ICD-10 correspondences continue to be made based on the work of
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