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https://www.readbyqxmd.com/read/27435084/standardizing-physiologic-assessment-data-to-enable-big-data-analytics
#1
Susan A Matney, Theresa Tess Settergren, Jane M Carrington, Rachel L Richesson, Amy Sheide, Bonnie L Westra
Disparate data must be represented in a common format to enable comparison across multiple institutions and facilitate big data science. Nursing assessments represent a rich source of information. However, a lack of agreement regarding essential concepts and standardized terminology prevent their use for big data science in the current state. The purpose of this study was to align a minimum set of physiological nursing assessment data elements with national standardized coding systems. Six institutions shared their 100 most common electronic health record nursing assessment data elements...
July 18, 2016: Western Journal of Nursing Research
https://www.readbyqxmd.com/read/27332495/developing-standardized-physiologic-assessments
#2
Susan A Matney, Theresa Tess Settergren, Bonnie Westra, Lisiane Pruinelli
A terminology for nursing assessments does not exist to support exchange of information and research. A team of nurse informaticts collaborated to create a standard for medical/surgical assessment terms coded in LOINC and SNOMED CT. Nursing assessments represented 106 observation (50% new LOINC), and 348 Values (20% New SNOMED CT) organized into fifteen panels (86% new LOINC).
2016: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/27332328/milestones-and-experiences-of-standardized-documentation
#3
Kaija Saranto, Virginia Saba, Patricia Dykes, Ulla-Mari Kinnunen, Minna Mykkänen
The purpose of this panel is to discuss milestones and experiences of a standardized nursing terminology for the documentation of nursing practice using Clinical Care Classification as an example. The aim is to describe the value of using the CCC as the standardized nursing terminology and framework for the multidisciplinary care plans and how its interoperability with SNOMED CT, LOINC, and other required terminologies can be used for the electronic health record systems. Further the aim is to discuss the advantages a multidisciplinary documentation system and how it impacts on nursing practice, management, and research as well as highlight the monitoring of nursing documentation...
2016: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/27178985/patient-crossover-and-potentially-avoidable-repeat-computed-tomography-exams-across-a-health-information-exchange
#4
Benjamin H Slovis, Tina Lowry, Bradley N Delman, Anton Oscar Beitia, Gilad Kuperman, Charles DiMaggio, Jason S Shapiro
OBJECTIVE: The purpose of this study was to measure the number of repeat computed tomography (CT) scans performed across an established health information exchange (HIE) in New York City. The long-term objective is to build an HIE-based duplicate CT alerting system to reduce potentially avoidable duplicate CTs. METHODS: This retrospective cohort analysis was based on HIE CT study records performed between March 2009 and July 2012. The number of CTs performed, the total number of patients receiving CTs, and the hospital locations where CTs were performed for each unique patient were calculated...
May 13, 2016: Journal of the American Medical Informatics Association: JAMIA
https://www.readbyqxmd.com/read/27081756/mapping-perinatal-nursing-process-measurement-concepts-to-standard-terminologies
#5
Catherine H Ivory
The use of standard terminologies is an essential component for using data to inform practice and conduct research; perinatal nursing data standardization is needed. This study explored whether 76 distinct process elements important for perinatal nursing were present in four American Nurses Association-recognized standard terminologies. The 76 process elements were taken from a valid paper-based perinatal nursing process measurement tool. Using terminology-supported browsers, the elements were manually mapped to the selected terminologies by the researcher...
July 2016: Computers, Informatics, Nursing: CIN
https://www.readbyqxmd.com/read/26765657/communicating-nursing-care-using-the-health-level-seven-consolidated-clinical-document-architecture-release-2-care-plan
#6
Susan A Matney, Gay Dolin, Lindy Buhl, Amy Sheide
A care plan provides a patient, family, or community picture and outlines the care to be provided. The Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document is used to structure care plan data when sharing the care plan between systems and/or settings. The American Nurses Association has recommended the use of two terminologies, Logical Observation Identifiers Names and Codes (LOINC) for assessments and outcomes and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for problems, procedures (interventions), outcomes, and observation findings within the C-CDA...
March 2016: Computers, Informatics, Nursing: CIN
https://www.readbyqxmd.com/read/26392850/coding-of-electronic-laboratory-reports-for-biosurveillance-selected-united-states-hospitals-2011
#7
Sanjaya Dhakal, Sherry L Burrer, Carla A Winston, Achintya Dey, Umed Ajani, Samuel L Groseclose
Objective Electronic laboratory reporting has been promoted as a public health priority. The Office of the U.S. National Coordinator for Health Information Technology has endorsed two coding systems: Logical Observation Identifiers Names and Codes (LOINC) for laboratory test orders and Systemized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for test results. Materials and Methods We examined LOINC and SNOMED CT code use in electronic laboratory data reported in 2011 by 63 non-federal hospitals to BioSense electronic syndromic surveillance system...
2015: Online Journal of Public Health Informatics
https://www.readbyqxmd.com/read/26305513/an-alternative-database-approach-for-management-of-snomed-ct-and-improved-patient-data-queries
#8
W Scott Campbell, Jay Pedersen, James C McClay, Praveen Rao, Dhundy Bastola, James R Campbell
OBJECTIVE: SNOMED CT is the international lingua franca of terminologies for human health. Based in Description Logics (DL), the terminology enables data queries that incorporate inferences between data elements, as well as, those relationships that are explicitly stated. However, the ontologic and polyhierarchical nature of the SNOMED CT concept model make it difficult to implement in its entirety within electronic health record systems that largely employ object oriented or relational database architectures...
October 2015: Journal of Biomedical Informatics
https://www.readbyqxmd.com/read/26262349/development-of-unified-lab-test-result-master-for-multiple-facilities
#9
Naoto Kume, Kenji Suzuki, Shinji Kobayashi, Kenji Araki, Hiroyuki Yoshihara
A clinical study requires massive amounts of of lab test data, especially for rare diseases. Before creating a protocol, the hypothesis if the protocol will work with enough amount of patients' dataset has to be proved. However, a single facility, such as a university hospital, often faces a lack of number of patients for specific target diseases. Even if collecting datasets from several facilities, there is no active master table that can merge lab test results between the facility datasets. Therefore, the authors develop a unified lab test result master...
2015: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/26262166/analyzing-operative-note-structure-in-development-of-a-section-header-resource
#10
Genevieve B Melton, Yan Wang, Elliot Arsoniadis, Serguei V S Pakhomov, Terrence J Adam, Mary R Kwaan, David A Rothenberger, Elizabeth S Chen
Operative notes contain essential details of surgical procedures and are an important form of clinical documentation. Sections within operative notes segment provide high level note structure. We evaluated the HL7 Implementation Guide for Clinical Document Architecture Release 2.0 Operative Note Draft Standard for Trial Use (HL7-ON DSTU) Release 1 as well as Logical Observation Identifiers Names and Codes (LOINC®) section names on 384 unique section headers from 362,311 operative notes. Overall, HL7-ON DSTU alone and HL7-ON DSTU with LOINC® section headers covered 66% and 79% of sections headers (93% and 98% of header instances), respectively...
2015: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/26262163/pain-documentation-validation-of-a-reference-model
#11
Emily Gesner, Sarah A Collins, Roberto Rocha
Over the last decade, interoperability of the Electronic Health Record (EHR) is becoming more of a reality. However, inconsistencies in documentation such as pain are considered a barrier to obtaining this goal. In order to be able to remedy this issue, it is necessary to validate reference models that have been created based upon requirements defined by Health Level 7 (HL7), Logical Names and Codes (LOINC) and the Intermountain Clinical Element Model using external published sources and guidelines. Using pain as an example of complex and inconsistent documentation, it was found that the reference model based upon these standards is valid because the data elements identified are broad and can meet the needs of each sub-domain within the primary domain of pain...
2015: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/26224334/learning-from-the-crowd-while-mapping-to-loinc
#12
Daniel J Vreeman, John Hook, Brian E Dixon
OBJECTIVE: To describe the perspectives of Regenstrief LOINC Mapping Assistant (RELMA) users before and after the deployment of Community Mapping features, characterize the usage of these new features, and analyze the quality of mappings submitted to the community mapping repository. METHODS: We evaluated Logical Observation Identifiers Names and Codes (LOINC) community members' perceptions about new "wisdom of the crowd" information and how they used the new RELMA features...
November 2015: Journal of the American Medical Informatics Association: JAMIA
https://www.readbyqxmd.com/read/25991170/mapping-russian-laboratory-terms-to-loinc
#13
Georgy Kopanitsa
The paper presents the results of semiautomatic mapping of Russian laboratory terms to LOINC. Two clinics (A and B) and a laboratory service participated in the project. We were able to map 86% (Clinic A) and 87% (Clinic B) of laboratory terms. The required effort was reasonable and the price of mapping and maintenance was considered as relatively low. We established LOINC as a canonical coding method for a laboratory data exchange. This provided semantic interoperability for the data exchange process.
2015: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/25954591/application-of-hl7-loinc-document-ontology-to-a-university-affiliated-integrated-health-system-research-clinical-data-repository
#14
Yan Wang, Serguei Pakhomov, Justin L Dale, Elizabeth S Chen, Genevieve B Melton
Fairview Health Services is an affiliated integrated health system partnering with the University of Minnesota to establish a secure research-oriented clinical data repository that includes large numbers of clinical documents. Standardization of clinical document names and associated attributes is essential for their exchange and secondary use. The HL7/LOINC Document Ontology (DO) was developed to provide a standard representation of clinical document attributes with a multi-axis structure. In this study, we evaluated the adequacy of DO to represent documents in the clinical data repository from legacy and current EHR systems across community and academic practice sites...
2014: AMIA Summits on Translational Science Proceedings
https://www.readbyqxmd.com/read/25954408/extending-the-hl7-loinc-document-ontology-settings-of-care
#15
Sripriya Rajamani, Elizabeth S Chen, Yan Wang, Genevieve B Melton
Given federal mandates recommending document standards, increasing numbers of electronic clinical documents being created, and local initiatives/projects using clinical documents, there is a growing need to better represent clinical document metadata. The HL7/LOINC Document Ontology (DO) was developed to provide a standard representation of clinical document attributes with a multi-axis structure. Prior studies have demonstrated the need for extension of DO axes values and proposed new values for some axes, but significant gaps remain for representing the DO "Setting" axis...
2014: AMIA ... Annual Symposium Proceedings
https://www.readbyqxmd.com/read/25935354/an-update-on-the-use-of-health-information-technology-in-newborn-screening
#16
REVIEW
Swapna Abhyankar, Rebecca M Goodwin, Marci Sontag, Careema Yusuf, Jelili Ojodu, Clement J McDonald
Newborn screening (NBS) has high-stakes health implications and requires rapid and effective communication between many people and organizations. Multiple NBS stakeholders worked together to create national guidance for reporting NBS results with HL7 (Health Level 7) messages that contain LOINC (Logical Observation Identifiers Names and Codes) and SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms) codes, report quantitative test results, and use standardized computer-readable UCUM units of measure...
April 2015: Seminars in Perinatology
https://www.readbyqxmd.com/read/25918199/learning-from-the-crowd-in-terminology-mapping-the-loinc-experience
#17
Brian E Dixon, John Hook, Daniel J Vreeman
National policies in the United States require the use of standard terminology for data exchange between clinical information systems. However, most electronic health record systems continue to use local and idiosyncratic ways of representing clinical observations. To improve mappings between local terms and standard vocabularies, we sought to make existing mappings (wisdom) from healt care organizations (the Crowd) available to individuals engaged in mapping processes. We developed new functionality to display counts of local terms and organizations that had previously mapped to a given Logical Observation Identifiers Names and Codes (LOINC) code...
2015: Laboratory Medicine
https://www.readbyqxmd.com/read/25769684/standard-for-improving-emergency-information-interoperability-the-hl7-data-elements-for-emergency-department-systems
#18
James C McClay, Peter J Park, Mark G Janczewski, Laura Heermann Langford
BACKGROUND: Emergency departments in the United States service over 130 million visits per year. The demands for information from these visits require interoperable data exchange standards. While multiple data exchange specifications are in use, none have undergone rigorous standards review. This paper describes the creation and balloting of the Health Level Seven (HL7) Data Elements for Emergency Department Systems (DEEDS). METHODS: Existing data exchange specifications were collected and organized into categories reflecting the workflow of emergency care...
May 2015: Journal of the American Medical Informatics Association: JAMIA
https://www.readbyqxmd.com/read/25717392/ehr-based-phenome-wide-association-study-in-pancreatic-cancer
#19
Tomasz Adamusiak, Mary Shimoyama
BACKGROUND: Pancreatic cancer is one of the most common causes of cancer-related deaths in the United States, it is difficult to detect early and typically has a very poor prognosis. We present a novel method of large-scale clinical hypothesis generation based on phenome wide association study performed using Electronic Health Records (EHR) in a pancreatic cancer cohort. METHODS: The study population consisted of 1,154 patients diagnosed with malignant neoplasm of pancreas seen at The Froedtert & The Medical College of Wisconsin academic medical center between the years 2004 and 2013...
2014: AMIA Summits on Translational Science Proceedings
https://www.readbyqxmd.com/read/25682737/enabling-semantic-interoperability-in-multi-centric-clinical-trials-on-breast-cancer
#20
Raul Alonso-Calvo, David Perez-Rey, Sergio Paraiso-Medina, Brecht Claerhout, Philippe Hennebert, Anca Bucur
BACKGROUND AND OBJECTIVES: Post-genomic clinical trials require the participation of multiple institutions, and collecting data from several hospitals, laboratories and research facilities. This paper presents a standard-based solution to provide a uniform access endpoint to patient data involved in current clinical research. METHODS: The proposed approach exploits well-established standards such as HL7 v3 or SPARQL and medical vocabularies such as SNOMED CT, LOINC and HGNC...
March 2015: Computer Methods and Programs in Biomedicine
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