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|Requirement ID:||Req-715: Standard Terminologies and Terminology Models||Req-1012: Standard terminology for diagnoses|
|Release Package:||2013 Format||2013 Format|
|Title:||Standard Terminologies and Terminology Models||Standard terminology for diagnoses|
|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 diagnoses using a terminology identified as an adequate standard for documenting diagnoses common in childhood.|
|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|
|Additional Information:||Terminologies for diagnoses in children: Particular diseases are more commonly diagnosed in children, as compared to adults, such as roseola or rare genetic syndromes. Numerous terminologies exist but may not cover pediatric diagnoses well. Certain terminologies may have relatively good coverage for pediatric diagnostic concepts, and are recognized as standards by stakeholders. The terminology SNOMED CT may have acceptable coverage for many common pediatric diagnostic concepts. When ICD-9 CM is employed as a diagnostic terminology it may fail to adequately support diagnoses common in children. ICD-10 CM similarly may not be an effective choice for a diagnostic terminology. The United States National Committee on Vital and Health Statistics (NCVHS) recommended Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) as a standard to be used as a reference terminology for "the exchange, aggregation, and analysis of patient medical information."|