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Children's EHR Format Requirement Comparison

(No Match) Requirement ID: Req-715: Standard Terminologies and Terminology Models Req-1014: Standard terminology for signs, systems, and development
(Matches) Release Package: 2013 Format 2013 Format
(No Match) Title: Standard Terminologies and Terminology Models Standard terminology for signs, systems, and development
(No Match) 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 pediatric signs, symptoms and development using a terminology identified as a standard for documenting signs and symptoms.
(No Match) Topic Area(s): Medication Management, Special Terminology and Information Special Terminology and Information
(No Match) Provenance: HL7 EHR FM R1 SME
(No Match) Achievability: Moderate
(No Match) Requirement Type: Function Normative Statements
(No Match) Shall/Should/May: SHOULD
(Matches) Critical/Core: no no
(Matches) Status: Released Released
(No Match) 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.htmBright Futures: The Bright Futures toolset published by the American Academy of Pediatrics contains standard assessment content for many pediatric signs, symptoms, and developmental findings. This is a general link to the full set of Bright Futures information. [Last accessed 27 September 2012]http://brightfutures.aap.org/
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(Matches) Comments:
(No Match) Additional Information: Terminologies for signs and symptoms: Healthcare providers evaluating children often assess the presence of signs or symptoms to gauge developmental status, basic childhood growth, or to determine the presence of child-specific clinical findings. For example, it is common to evaluate and document whether a six month old baby is able to crawl, or whether a freshly cut umbilical cord has three blood vessels when an infant is admitted to the neonatal intensive care unit. Terminologies designed to support clinical assessments of signs, symptoms and development of children can accommodate this content. The Bright Futures toolset published by the American Academy of Pediatrics contains standard assessment content for many pediatric signs, symptoms and developmental findings.
(Matches) Implementation Notes:
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