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|Requirement ID:||Req-715: Standard Terminologies and Terminology Models||Req-1015: Standard terminology for laboratory testing|
|Release Package:||2013 Format||2013 Format|
|Title:||Standard Terminologies and Terminology Models||Standard terminology for laboratory testing|
|Description:||STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally).
Support a formal standard terminology model.
DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc.). Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
|The system SHOULD provide the ability to encode laboratory and other testing names common to children using a terminology identified as a standard for documenting laboratory names .
Comment: In some cases, laboratory and other testing is managed by a laboratory information system that is either a component of or external to the EHR system. In those cases, the laboratory information system can use the terminology identified as a standard for documenting laboratory and testing names. In other cases, results from laboratory and other testing is entered directly into the EHR system by a healthcare provider. For example, office-based testing for streptococcus, pregnancy or infectious mononucleosis typically would not be documented in a laboratory information system. A user may prefer not to provide the terminology mapping to a specific vocabulary; however the EHR system may have this already linked in their system.
|Topic Area(s):||Medication Management, Special Terminology and Information||Special Terminology and Information|
|Provenance:||HL7 EHR FM R1||SME|
|Requirement Type:||Function||Normative Statements|
|Links:||http://www.ncvhs.hhs.gov/030820tr.htm: The United States National Committee on Vital and Health Statistics (NCVHS) and the United States government's multiagency consolidated health informatics (CHI) council recommended a core set of reference terminologies as standards for representing aspects of patient medical record information. The NCVHS selected the standard terminologies on the basis of those which "(1) are required to adequately cover the domain of patient medical record information and (2) meet essential technical criteria to serve as reference terminologies."http://www.ncvhs.hhs.gov/030820tr.htm|
|Comments:||Please see Comment within 'Description'|
|Additional Information:||Terminologies for laboratory tests: Certain laboratory or other tests are performed exclusively in the domain of pediatrics. Aspects of laboratory and other test names that may be unique to pediatrics include the name of the test, the specimen source, the required testing volume and characteristics about the test. All of these attributes may be encoded by a terminology. For example, a baby admitted to the neonatal intensive care unit may have an umbilical artery blood gas tested. Later, the baby will need to have several blood tests performed to screen for certain congenital diseases according to state newborn screening practices. The United States National Committee on Vital and Health Statistics (NCVHS) recommended LOINC as a standard to be used as a reference terminology for reporting and exchanging laboratory test concepts. The coverage by LOINC for pediatric laboratory and testing concepts has not been rigorously evaluated; however, this would be a good starting point for developers.|