The Value of Clinical Information Models and Terminology for Sharing Clinical Information (original) (raw)
Related papers
Standardized headings as a foundation for semantic interoperability in EHR
The new Swedish Patient Act, which allows patients to choose health care in county councils other than their own, creates the need to be able to share health-related information contained in electronic health records [EHRs) across county councils. This demands interoperability in terms of structured and standardized data. Headings in EHR could also be a part of structured and standardized data. The aim was to study to what extent terminology is shared and standardized across county councils in Sweden. Headings from three county councils were analyzed to see to what extent they were shared and to what extent they corresponded to concepts in SNOMED CT and the National Board of Health and Welfare's term dictionary [NBHW's TD). In total 41% of the headings were shared across two or three county councils. A third of the shared headings corresponded to concepts in SNOMED CT. Further, an eighth of the shared headings corresponded to concepts in NBHW's TD. The results showed that the extent of shared and standardized terminology in terms of headings across the studied three county councils were negligible.
Towards Semantic Interoperability for Electronic Health Records
Methods of Information in Medicine, 2007
Objectives: In the fieldofopenelectronic health records(EHRs), openEHRasanarchetype-based approach is beingincreasingly recognised. It is theobjectiveofthispapertoshortly describe this approach, andtoanalyse how openEHR archetypesimpacton healthprofessionals andsemantic interoperability. Methods: Analysis of current approaches to EHRsystems, terminology and standards developments. In additiontoliterature reviews,weorganised face-to-face and additionaltelephone interviews andtele-conferences with membersofrelevant organisationsand committees. Results: The openEHR archetypesapproach enables syntactic interoperability andsemantic interpretability -bothimportantprerequisites forsemantic interoperability.Archetypesenable theformal definition of clinical contentbyclinicians.Toenable comprehensive semanticinteroperability, the developmentand maintenance of archetypesneedstobecoordinated internationally andacross healthprofessions. Domain knowledge governance comprises aset of processesthatenable thecreation,development, organisation,sharing, dissemination,use andcontinuous maintenance of archetypes. It needstobesupported by information technology. Conclusions: To enable EHRs,semantic interoperability is essential. The openEHR archetypesapproach enables syntactic interoperability andsemantic interpretability. However,without coordinated archetype development andmaintenance, 'rankgrowth' of archetypeswould jeopardizesemantic interoperability.Wetherefore believe that openEHR archetypesand domain knowledge governance together createthe knowledge environment requiredtoadopt EHRs.
2008
Findings related to developing implementation specifications for the use of SNOMED Clinical Terms (SNOMED CT) in both HL7 and openEHR information models are summarized and compared. Common themes from this work, including overlaps between the expressivity of structure and terminology, are identified and discussed. Distinctions are made between aspects of meaning that are most readily represented by distinct structures, others where terminology offers greater flexibility and a 'gray-area' in which the relative merits are more balanced. Focusing on particular stages in the clinical information life cycle may suggest different points of balance and may lead to different approaches to integration. However, greater consistency is essential if clinical information is to be used effectively in electronic record systems. Consensus guidance documents of the type developed by the work described are only a first step. Mutually aware evolutionary refinement of structural and terminology...
European Journal for Biomedical Informatics
The purpose of this paper is to present and discuss the adoption and use of medical terminologies and coding systems in Italy, focusing on their management and integration for guaranteeing semantic interoperability among Electronic Health Records (EHRs). Semantic interoperability guarantees meaningful exchange of data between two or more healthcare information systems, ensuring that data content is not only understandable within its original context, but also in the destination one, and is capable of supporting health service management, clinical decision-making care collaboration, as well as public health reporting, and improving clinical research. Methods: The approach used for the coding systems management and integration in the Italian Fascicolo Sanitario Elettronico (FSE) 1 use case is presented according to the current Italian regulations on federated EHRs. Results: Results show the need to promote an advanced approach, in conformance to the literature best cases, which takes care about a better integration and maintenance of medical terminologies and coding systems through the use of standardized models of terminology services. Conclusion: The paper presents terminology interoperability issues arisen from the described approach and related requirements to propose a solution that could allow, through sophisticated terminology services framework, to achieve also in Italy semantic interoperability.
Clinical Terminologies: A Solution for Semantic Interoperability
Journal of Korean Society of Medical Informatics, 2009
To realize the benefits of electronic health records, electronic health record information needs to be shared seamlessly and meaningfully. Clinical terminology systems, one of the current semantic interoperability solutions, were reviewed in this article. Definition, types, brief history, and examples of clinical terminologies were introduced along with phases of clinical terminology use and issues on clinical terminology use in electronic health records. Other attempts to standardize the capture, representation and communication of clinical data were also discussed briefly with future needs.
Semantic interoperability is essential for advanced Electronic Health Records (EHRs) functionality, and in particular for data exchanges, and efficient communication among clinicians. Integrated terminology services offer the chance to manage clinical code systems, both standard and local, and value sets, through a series of functionalities such as searching, querying, cross mapping, etc. The main standard in the domain is Clinical Terminology Service Release 2 (CTS2) by Health Level 7 (HL7). This paper describes the approach used for designing and developing an integrated terminology service based on the CTS2 standard, namely Servizio Terminologico Integrato (STI), which aims to support domain experts and healthcare organizations in ensuring semantic interoperability in the Italian Federated EHR.
2021
BACKGROUND This study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations. OBJECTIVE The aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable...
Archetype-Based Knowledge Management for Semantic Interoperability of Electronic Health Records
2009
Formal modeling of clinical content that can be made available internationally is one of the most promising pathways to semantic interoperability of health information. Drawing on the extensive experience from openEHR archetype research and implementation work, we present the latest research and development in this area to improve semantic interoperability of Electronic Health Records (EHRs) using openEHR (ISO 13606) archetypes. Archetypes as the formal definition of clinical content need to be of high technical and clinical quality. We will start with a brief introduction of the openEHR architecture followed by presentations on specific topics related to the management of a wide range of clinical knowledge artefacts. We will describe a web-based review process for archetypes that enables international involvement and ensures that released archetypes are technically and clinically correct. Tools for validation of archetypes will be presented, along with templates and compliance templates. All this in combination enables the openEHR computing platform to be the foundation for safely sharing the information clinicians need, using this information within computerized clinical guidelines, for decision support as well as migrating legacy data.
Journal of the American Medical Informatics Association
Health care in the United States has become an information-intensive industry, yet electronic health records represent patient data inconsistently for lack of clinical data standards. Classifications that have achieved common acceptance, such as the ICD-9-CM or ICD, aggregate heterogeneous patients into broad categories, which preclude their practical use in decision support, development of refined guidelines, or detailed comparison of patient outcomes or benchmarks. This document proposes a framework for the integration and maturation of clinical terminologies that would have practical applications in patient care, process management, outcome analysis, and decision support. Arising from the two working groups within the standards community--the ANSI (American National Standards Institute) Healthcare Informatics Standards Board Working Group and the Computer-based Patient Records Institute Working Group on Codes and Structures--it outlines policies regarding 1) functional characteri...