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Sachi: DQ 1 reply
These terminologies address a fundamental requirement for effective communication, the ability to represent concepts unambiguously between a sender and receiver of information. Most communication between health information systems relies on structured vocabularies, terminologies, code sets, and classification systems to represent health concepts.
Standard terminology provides a foundation for interoperability by improving the effectiveness of information exchange. Using everyday language should be a simple and logical step in health IT. Structured terms provide a means for organizing information and defining the semantics of information using consistent and computable mechanisms. The institutional entry terminology is composed of concepts and descriptions (Shapiro JS et al.,2005). We use SNOMED definition of these terms, where concepts represent distinct clinical meanings and descriptions are a phrase used to name a concept. Our institutional entry terminology can be divided into several subsets such as Problems list terminology, Procedures terminology, Findings in chest radiography, Administration routes for drugs, State of consciousness description, Physical examination subset, and Liver failure diagnosis
Here are the few sample terminologies used in the health care industry such as MEDCIN, ICD-10, Logical Observation Identifiers Names and Codes (LOINC®), The Unified Code for Units of Measure (UCUM), Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT)National Drug File Reference Terminology (NDF-RT), Radiological Society of North America (RadLex), Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS), Centers for Disease Control and Prevention (CDC) and National Drug Code (NDC). These terminologies standards facilitate decision support, consistent reporting, and analytics in addition to interoperability (Bates DVV et al., 2003).There is a lot of potentials, but it also comes at a cost. Implementation is complex and generally requires a lot of tedious mapping work.
Examples with descriptions:
MEDCIN
MEDCIN is medical terminology maintained by Medicomp Systems that encompasses symptoms, history, physical examination, tests, diagnoses, and therapies.
ICD-10
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems(ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs, and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
CPT®
Current Procedural Terminology (CPT®) is a code set maintained by the American Medical Association (AMA) to bill outpatient and office procedures.
Reference:
Bates DVV, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. Journal of the American Medical Informatics Association [Internet]. 2003;10
Shapiro JS, Bakken S, Hyun S, Melton GB, Schlegel C, Johnson SB. Document ontology: Supporting narrative documents in electronic health records. AMIAAnnua1 Symposium,Proceedings [Internet]. 2005;2005:684-688.
Evans DA, Cimino JJ, Hersh WR, Huff Bell DS, Group C. Toward a Medical Concept Representation Language. The Canon Group. Journal of the American Medical Informatics Association. 1994;1(3):207-217
Carrie: DQ 1reply
In Healthcare the exchange of information often involves very specific, detailed information that is essential to convey to the other party. This requires a very specialized terminology in order for the meaning to be clear (Wager, et al., 2017). In the attempt to exchange information not only between offices locally, but across the country and even the world, there needs to be a common language, an agreed-upon way to identify and describe things that transcends local terms and language. To do this, health care technology has devised many different specialized terminology types.
One type of international terminology is Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT). SNOMED-CT allows the users to use these codes to give clear clinical details, that are easy to store and to retrieve in EHR systems (Wager, et al., 2017).
Another type of terminology used is to identify laboratory tests is Logical Observation Identifiers Names and Codes (LOINC). These are able to convey the exact test done by abbreviated codes that explain not only what is being tested for, but also the method and exact details (Wager, et al., 2017). This allows any lab familiar with this terminology to understand exactly what type of testing was done.
Similar to the Lab terminology, there is a medication terminology as well. This is called RxNorm, and it identifies the medications not only by the generic name, but also creates a unique identifier for each medication (Wager, et al., 2017).
These types of terminologies allow health care practitioners to be able to exchange and understand health information despite different languages across the world, where they are adopted and understood.
Wager, K. A., Wickham-Lee, F., & Glaser, J. P. (2017). Health care information systems: A practical approach for health care management (4th ed.). Jossey-Bass. ISBN-13: 9781119337188
Sachi: DQ 2 reply
The consolidated clinical document architecture (CCDA) is one of the robust messaging frameworks. It is an XML-based standard for encoding documents for easy data exchange. It specifies the syntax and offers a framework specifying the full semantics of a clinical document and making it easy to read by humans and processed by machines (Dolin RH et al.,2001). This enables the display of the entire patient’s medical history in compressed one document.
This eliminates the issue of the message variability that the HL7 V2 generally faces. Thus it makes it possible to interoperate (Muller ML et al., 2003). The challenges include the reluctance of the staff to adapt to this framework, cost, and the time consumed is also a barrier. The advantage of this document is that it is a flexible standard that can be read by both humans and processed by a machine. It can also be reused in multiple applications. The challenge of the clinical document architecture is that different customers will have different validation methods, which often won’t match the publicly available ones. The other challenge is that having an incomplete data set can make it challenging to create valid documents. While we talk about consolidated clinical document Architecture, we should mention CDA also. As we know, the Consolidated Clinical Document Architecture issued for an implementation specifies a library of templates and is used for a set of specific document types. CCDA is technically specified in the laws and contains more information than a CCD. CCD keeps on changing to meet government regulations and fixing the errors in the old version.
Few critical benefits of CDA:
- It is a flexible standard that can be read and processed by humans and machines.
- It can be reused in multiple applications.
- It allows displaying a patient’s medical history in one document.
- It aims to eliminate message variability that HL7 V2 is prone to.
- It does not identify a specific method for sharing the data in a document. Options can include MIME (multi-purpose Internet Mail Extensions), HyperText Transfer Protocol (HTTP), DICOM (Digital Imaging and Communication in Medicine). Along with the continuity of care record (CCR) standard, CDA forms the CCD and patient document information exchange basis.
Reference
Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer SL,Essin D, Kimber E, Lincoln T, and Mattison JE. The HL7Clinical Document Architecture. J Am Med Inform Assoc;2001: 8(6): 552-569.
Muller ML, Butta R, and Prokosch HU. Electronic Discharge Letters Using the Clinical Document Architecture(CDA). Stud Health Technol Inform 2003: 95: 824-828.
Ueckert F, Goerz M, Ataian M, Tessmann S, and ProkoschHU. Empowerment of patients and communication with health care professionals through an electronic health record. Int J Med Inf 2003: 70(2-3): 99-108.
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