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Dominik Brammen, Heike Dewenter, Kai U Heitmann, Volker Thiemann, Raphael W Majeed, Felix Walcher, Rainer Röhrig, Sylvia Thun
INTRODUCTION: The German Emergency Department Medical Record (GEDMR) was created by medical domain experts and healthcare providers providing a dataset as well as a form. The trauma module of GEDMR was syntactically standardized using HL7 CDA and semantically standardized using different terminologies including SNOMED CT, LOINC and proprietary coding systems. This study depicts the mapping accuracy with aforementioned syntactical and semantical standards in general and especially the content coverage of SNOMED CT...
2017: Studies in Health Technology and Informatics
Dominik Brammen, Heike Dewenter, Volker Thiemann, Raphael W Majeed, Tingyan Xu, Kai U Heitmann, Felix Walcher, Sylvia Thun, Rainer Röhrig
A standardized medical record for the emergency department (GEDMR) was released in Germany, but only sparsely and randomly implemented by emergency department (ED) electronic health record (EHR) vendors. A reason for this may be a lacking common language between the medical and the Health Information Technology (HIT) domain. HL7 clinical document architecture (CDA) may leverage this communication gap. This paper reports on the effects of a professional medical association record standard on EHR vendors and the German ED-EHR market...
2017: Studies in Health Technology and Informatics
Ranjit S Sandhu, James Shin, Kenneth C Wang, George Shih
The LOINC-RSNA Radiology Playbook represents the future direction of standardization for radiology procedure names. We developed a software solution ("RadMatch") utilizing Python 2.7 and FuzzyWuzzy, an open-source fuzzy string matching algorithm created by SeatGeek, to implement the LOINC-RSNA Radiology Playbook for adult abdomen and pelvis CT and MR procedures performed at our institution. Execution of this semi-automated method resulted in the assignment of appropriate LOINC numbers to 86% of local CT procedures...
August 25, 2017: Journal of Digital Imaging: the Official Journal of the Society for Computer Applications in Radiology
M Diane Lougheed, Nicola J Thomas, Nastasia V Wasilewski, Alison H Morra, Janice P Minard
OBJECTIVES: The burden of asthma ranks among the highest for chronic diseases. Interoperable EHRs can improve the management of chronic diseases such as asthma by facilitating sharing of data between health care settings along the continuum of care. Terminology such as SNOMED CT® (Systematized Nomenclature of Medicine-Clinical Terms) and LOINC® (Logistical Observation Identifier Names and Codes) are prerequisites for interoperability of electronic health records (EHRs). We sought to determine the extent to which data elements in a validated asthma care map (ACM) are congruent with these terminologies...
August 11, 2017: Journal of Asthma: Official Journal of the Association for the Care of Asthma
Ronald G Hauser, Douglas B Quine, Alex Ryder, Sheldon Campbell
Logical Observation Identifiers Names and Codes (LOINC) is the most widely used controlled vocabulary to identify laboratory tests. A given laboratory test can often be reported in more than 1 unit of measure (eg, grams or moles), and LOINC defines unique codes for each unit. Consequently, an identical laboratory test performed by 2 different clinical laboratories may have different LOINC codes. The absence of unit conversions between compatible LOINC codes impedes data aggregation and analysis of laboratory results...
June 19, 2017: Journal of the American Medical Informatics Association: JAMIA
Jozef Aerts
BACKGROUND: RESTful web services nowadays are state-of-the-art in business transactions over the internet. They are however not very much used in medical informatics and in clinical research, especially not in Europe. OBJECTIVES: To make an inventory of RESTful web services that can be used in medical informatics and clinical research, including those that can help in patient empowerment in the DACH region and in Europe, and to develop some new RESTful web services for use in clinical research and regulatory review...
2017: Studies in Health Technology and Informatics
Barbara Giannini, Niccolò Riccardi, Antonio Di Biagio, Giovanni Cenderello, Mauro Giacomini
Tuberculosis (TB) is responsible for a global epidemic. TB treatment requires long-term therapy usually with multiple drugs, which have potential side effects and interactions that may influence patients' adherence to treatment. The TB Ge network is a multi-centric web based platform that collects clinical information of TB affected patients to increase their support and retention in care. The system stores the list of all tuberculosis episodes for each patient with the related data, starting from the first visit including follow-ups clinical evaluations, laboratory tests, imaging and therapies...
2017: Studies in Health Technology and Informatics
Karel Zvára, Marie Tomečková, Jan Peleška, Vojtěch Svátek, Jana Zvárová
OBJECTIVES: Our main objective is to design a method of, and supporting software for, interactive correction and semantic annotation of narrative clinical reports, which would allow for their easier and less erroneous processing outside their original context: first, by physicians unfamiliar with the original language (and possibly also the source specialty), and second, by tools requiring structured information, such as decision-support systems. Our additional goal is to gain insights into the process of narrative report creation, including the errors and ambiguities arising therein, and also into the process of report annotation by clinical terms...
April 28, 2017: Methods of Information in Medicine
Bo Kyeung Jung, Jeeyong Kim, Chi Hyun Cho, Ju Yeon Kim, Myung Hyun Nam, Bong Kyung Shin, Eun Youn Rho, Sollip Kim, Heungsup Sung, Shinyoung Kim, Chang Seok Ki, Min Jung Park, Kap No Lee, Soo Young Yoon
The National Health Information Standards Committee was established in 2004 in Korea. The practical subcommittee for laboratory test terminology was placed in charge of standardizing laboratory medicine terminology in Korean. We aimed to establish a standardized Korean laboratory terminology database, Korea-Logical Observation Identifier Names and Codes (K-LOINC) based on former products sponsored by this committee. The primary product was revised based on the opinions of specialists. Next, we mapped the electronic data interchange (EDI) codes that were revised in 2014, to the corresponding K-LOINC...
April 2017: Journal of Korean Medical Science
Wilfred Bonney, James Galloway, Christopher Hall, Mikhail Ghattas, Leandro Tramma, Thomas Nind, Louise Donnelly, Emily Jefferson, Alexander Doney
Background & Objectives: Legacy laboratory test codes make it difficult to use clinical datasets for meaningful translational research, where populations are followed for disease risk and outcomes over many years. The Health Informatics Centre (HIC) at the University of Dundee hosts continuous biochemistry data from the clinical laboratories in Tayside and Fife dating back as far as 1987. However, the HIC-managed biochemistry dataset is coupled with incoherent sample types and unstandardised legacy local test codes, which increases the complexity of using the dataset for reasonable population health outcomes...
2017: Studies in Health Technology and Informatics
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
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
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
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...
January 2017: Journal of the American Medical Informatics Association: JAMIA
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
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
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
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
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
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
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