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|Requirement ID:||Req-715: Standard Terminologies and Terminology Models||Req-1013: Standard terminology for medications and treatments|
|Release Package:||2013 Format||2013 Format|
|Title:||Standard Terminologies and Terminology Models||Standard terminology for medications and treatments|
|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 the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use existing terminologies that represent clinical medications, such as MediSpan, First Data Bank or Multum to support this function. However, EHR systems may also maintain their own proprietary medication terminology. In either case, the scope of the functionality for EHR systems relates to their ability to allow users to encode medications according to a standard representation.
|Topic Area(s):||Medication Management, Special Terminology and Information||Medication Management, 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 medication names: Children may receive medications or immunizations specifically targeted to treat or prevent diseases particular or common to that population. For example, the vaccine used to prevent infection with Haemophilus Influenzae Type B is given to children under the age of 1 year. Terminologies designed to represent medications and immunizations can include concepts covering these child-specific medications and immunizations. A number of drug terminologies exist, including Rx-Norm, NDF-RT (National Drug File - Reference Terminology), and FDB (First DataBank). There are currently no studies evaluating their coverage for medications or vaccinations common to pediatrics. However, these terminologies are likely to cover most such concepts, and developers should consider starting with these resources.|