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Sign In. Access provided by: anon Sign Out. Theory and practice on development of medical informatics education Abstract: Medical informatics is a cross-cutting disciplines with medical science, informatics and management. It has been aroused the attention of professionals that how to realize the sustainable development of medical informatics education.

In this paper, we study the teaching objectives and curriculum system combined with the teaching practice, and come up with the characteristic and differentiation strategies which is suitable for the development of medical informatics. To be specific, by implementing differentiation strategies in the development process of medical informatics, combined with electronic information technology, medical knowledge and the practice of medical information.

It will be helpful to make health information talents more adapt to the future development, and help to realize development of medical informatics discipline. Article :. Common data standards are essential to simplify and streamline data requirements and allow the information systems that carry the data to function as an integrated enterprise. This section provides a detailed technical review of the three primary areas in which standards for health care data need to be developed: data interchange, terminologies, and knowledge representation.

The final subsection addresses the implementation of these data standards. In the area of data interchange, standards are needed for message format, document architecture, clinical templates, user interface, and patient data linkage. Message format standards facilitate interoperability through the use of common encoding specifications, information models for defining relationships between data elements, document architectures, and clinical templates for structuring data as they are exchanged. In March , the Consolidated Health Informatics CHI initiative announced its requirement that all federal health care services agencies adopt the primary clinical messaging format standards i.

Numerous acronyms appear in the discussion in this section. We follow the convention of defining each upon its first appearance and using the acronym thereafter. All acronyms used here are defined in Appendix B. It is worth noting that HL7, through its Laboratory Automated Point-of-Care Special Interest Group, has also developed messaging standards for the devices used in laboratory automation e. The HL7 V2. However, there have been a number of technical problems with the standard that have been difficult to resolve.

Also, although V2. However, V2. Resolving these issues would be time consuming and labor intensive and could easily be accomplished by completion and implementation of HL7 Version 3. Currently, the scope of the V3 standard remains the same as that of V2. To move forward, the first step is to accelerate the completion of V3 and develop implementation guides for the use of both V2. Both V2. Additionally, since V2. For example,. Ensuring interoperability between these two standards is necessary for high-functioning systems. HL7 V3 differs from V2. The RIM is based on object-oriented modeling, expressing the classes of information required and the properties of those classes, including attributes, relationships, and states Health Level Seven, The structured specifications of the information requirements minimize optionality by clearly defining each aspect of the RIM Van Hentenryck, Data fields are populated with explicit controlled vocabulary, increasing semantic interoperability among various code sets Van Hentenryck, XML is used to exchange the data quickly and simply, but the RIM is needed to provide the necessary semantic interoperability.

At the core of the RIM are four high-level classes from which all other classes are derived—entity, role, participation, and act. Figure is a simplified depiction of the structural relationships encompassed by the RIM that should aid in understanding the basis of the model. Information modeling facilitates recognition of high-risk procedures having a direct impact on patient safety Russler, Both safe active patient care and retrospective analysis for a patient safety event depend on proper information relationships Russler, To this end, the information model must facilitate the process of care such that the link from entities to their intentional actions can support the information relationships used in analyzing patient safety issues, as well as larger issues of cost and quality improvement Russler, Using an analogy from aviation, examination of the link between a precipitating event and an adverse event is as important as comparing the data from a flight data recorder with the data from the voice recording in the cockpit in the case of an airline accident Russler, HL7 V3 and the RIM are particularly important to the advancement of integrated clinical systems because they provide the backbone for the next set of standards needed for the EHR including those required for the use of concept-oriented terminologies, document architectures, clinical templates, alerts and reminders, and automated clinical guidelines, all of which would result in improved interoperability and structuring of clinical and patient data.

A method for representing electronically clinical data such as discharge summaries or progress notes and patient safety reports requires a standardized document architecture. This need stems from the desire to access the considerable content currently stored in free-text clinical notes and to enable comparison of content from documents created on information systems of widely varying characteristics Dolin et al.

The architecture should be designed as a markup standard Dolin et al. It should also be able to accommodate the desire for rich narrative text that makes up a significant portion of patient safety information from voluntary and mandatory reports. One example is the HL7 Clinical Document Architecture CDA , a defined, complete information object that can include text, images, sounds, and other multimedia content Dolin et al. The CDA provides a hierarchical set of specifications for the structure of clinical documents and derives its semantic content from the RIM Dolin et al. Initial specifications define the document header in detail i.

This structure minimizes technical barriers to the adoption of the standard in that it intentionally lacks some of the complex semantics used in HL7 V3 messages. The initial specifications lay the foundation for future specifications that will incorporate clinical templates and additional RIM-derived markup, enabling the clinical content to be expressed more formally to the extent that it can be encompassed fully in the RIM or V3 message Dolin et al.

Again, because both HL7 V2. HL7 V3 provides the mechanism to specify further constraints on the optionality of the data elements through the use of templates that can be applied against a V3 message or document.


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For greater precision in standardization of clinical data, more targeted specifications of the allowable values for the data elements must be applied. A tem-. For example, an HL7 message format for laboratory observations may specify that the data elements for a complete blood count test must include measurements for hemoglobin, hematocrit, and platelets. The design of constraints will be left to the discretion of health care organizations and providers, as HL7 provides the mechanisms and technical specifications for their use.

Clinical templates will be important in the development of electronic structure for the collection and analysis of clinical and patient safety data, particularly those related to the 20 priority areas identified by the Institute of Medicine The medical device industry is well versed in developing user interfaces that make devices safer, more effective, and easier to use by employing a voluntary standard for human factors design established by the Association for the Advancement of Medical Instrumentation AAMI and approved by the American National Standards Institute ANSI Association for the Advancement of Medical Instrumentation, Consideration of the HE74 standard may provide insight into the processes employed for designing and developing user-friendly clinical information systems, including electronic patient safety reporting systems.

An overview of the human factors engineering process that governs HE74 is provided in Figure The specific activities at each step in the cycle vary with the particular development effort Association for the Advancement of Medical Instrumentation, The cycle in Figure emphasizes the iterative nature of the development process, whereby the outcomes i. Although entry into the cycle can begin at any step, involving users at the early stages of development is critical.

The hardware and software designers can then craft the necessary technical requirements and specifications. Whether this model or another is developed, the committee urges further research on the development of user interfaces for integrated systems. HL7 has taken an approach to data integration at the visual level by way of the user interface. These applications and standards facilitate the integration of multiple independent applications from many different systems through interface standards Van Hentenryck, The context manager standard establishes the primary architecture, a core set of data definitions, rules for application user interfaces, security specifications, and translation of the architecture for interoperability with applications in a way that is technology neutral Van Hentenryck, With the Context Manager, an organization can give providers a single sign-on capability so they do not have to log on for each separate clinical application program they need Seliger, Likewise, the Context Manager provides a single patient selection that, similar to a single clinician sign-on, allows all patient data in multiple applications to be readily available for use as needed by the clinician Seliger, This context management gives users the experience of using a single system, when in fact they are accessing multiple applications simultaneously Seliger and Royer, For example, to review patients of immediate importance, a physician might inspect a patient list in a scheduling application.

To further the understanding of each patient, the physician might also wish to view laboratory test results via a laboratory application, view computed axial tomography CAT scans via a picture archiving and communications system PACS application, and order new tests or medications via an order entry application Seliger and Royer, Along with identifying users and patients, the Context Manager can identify concepts for unifying the availability of clinical data across applications.

Two concepts for which the Context Manager specifications have been developed are the clinical encounter and clinical observation Seliger, Thus a clinician can use an encounter or observation identifier to access multiple applications for information related to that encounter or observation.

User interface standards such as the Context Manager provide a mechanism to begin the process of achieving interoperability at the level of the user interface. Data linkage allows the users to create tiles of the different applications and compose them into a single visual window utilizing the.

Data are viewed in an integrated manner while the organization progressively builds a truly integrated, comprehensive clinical information system at the back end.

A/PROF Kathleen Gray - The University of Melbourne

The administrative simplification provisions of the Health Insurance Portability and Accountability Act HIPAA originally mandated the implementation of a unique health identifier for individuals. However, Congress withheld funding of the implementation pending adequate federal privacy protection.

Now that the HIPAA privacy rules have been implemented nationwide, means to link patient data across organizations should be revisited. In the meantime, pragmatic approaches to linking patient data have been emerging within the provider community. One approach used by many health care systems is the enterprise master patient index, which essentially creates a local unique patient identifier for persons cared for within a single health care system.

Since most health care is local, and relationships among patients, physicians, and specific hospitals are ongoing, this approach has served as a viable interim solution; however, it is costly to maintain, does not address the issue of data coming from other systems of care, and requires the development of matching algorithims to solve such problems as patients with similar names. Because no algorithm is perfect, a small percentage of attempted matches will result in errors that can be recognized and reconciled only through human intervention. All medical data are retained by the health care organizations behind secure firewalls.

Initially, authentication was accomplished through established hospital procedures. A three-key approach to authentication is in the process of being implemented: card and password for patient, digital certificate and password for physician, and permission key for the hospital or clinic.

As of. Patients voluntarily opt into the program to allow their physicians access to past diagnoses, laboratory results, medications, allergies, and immunizations Carper, Sensitive medical data e. The committee believes that the careful examination and development of innovative methods for patient data linkage should be undertaken against a background of changing technology, illness patterns, and consumer attitudes.

In particular, changing demographics have resulted in the growth of chronic care conditions that involve multiple providers and data sources, making it more difficult to maintain and integrate relevant patient information. Consumers will be more involved in their self-care and disease management and will require the capability to utilize a personal health record and engage in electronic communication with their provider s. Likewise, as they continue to become more savvy in accessing and understanding health information on the Internet, the demand for tools to incorporate this information into their care protocols and personal health records will likely increase.

With HIPAA security rules in place, it is also possible to create patient data linkages in a manner that empowers patients to permit access to some of their data while restricting access to other, more sensitive data e. Standardized terminologies facilitate electronic data collection at the point of care; retrieval of relevant data, information, and knowledge i. To promote patient safety and enable quality management, standardized terminologies that represent the focus e.

Significant efforts during the last quarter-century have resulted in the development of standardized terminologies for the core phenomena of clinical practice: 1 diagnoses, symptoms, and observations e. Although standardized measures for health outcomes have been developed, the incorporation of such measures into standardized terminologies has lagged behind that of measures for problems and interventions. Additionally, standardized terms for patient goals i. Standardized terminologies vary along many dimensions; most important is the primary purpose of the terminology, as well as the extent to which it is concept oriented and possesses the semantic structures that enable computer algorithmic processing Ingenerf, ; Rossi et al.

To achieve the integrated approach to patient safety envisioned by the committee, the terminology must serve the purposes of decision support tools, the EHR, and knowledge resources Chute et al. Terminology efforts for the EHR have focused on how to represent the history, findings, diagnoses, management, and outcomes of patients in a way that can preserve clinical detail and identify characteristics that enable improved risk adjustment, the development of common guidelines, aggregate outcome analyses, and shared decision support rules.

While a number of diverse terminologies are required for clinical care, patient safety, and other aspects of biomedicine, a central group of terminologies can serve as the backbone of clinical information systems.

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A number of technical criteria must be met for terminologies to function in a way. The most basic criteria for a controlled medical vocabulary are identified by Cimino ; they include domain completeness, nonredundancy, synonymy, nonambiguity, multiple classification, consistency of views, and explicit relationships. In , the ANSI Health Informatics Standards Board went a step further and created a detailed framework of informatics criteria for the development and evolution of terminologies with high functionality Chute et al.

The National Committee on Vital and Health Statistics NCVHS used these informatics criteria to evaluate and select a core set of well-integrated, nonredundant clinical terminologies that will serve as the national standard for medical terminology for the EHR Sujansky, Table Minimization of overlap in domain representation was another important criterion for selection of the NCVHS core terminology group. The CHI initiative is also evaluating the terminologies in this regard, as well as assessing their ability to meet the extensive data representation requirements for the common clinical domains that cut across the three dimensions of the NHII i.

Issues related to data collection, sharing, and reuse are being addressed during the evaluations, as well as identification of the overlap and gaps in clinical representation. Table provides an overview of the cross-cutting domains identified by CHI to date.

The terminologies determined by CHI to best represent requirements of the clinical domain areas, after consultation with NCVHS, will be accepted for federal government—wide implementation. Additional areas within the clinical domains, including those relevant to patient safety, will be added as the process proceeds.

CHI is working rapidly and expects to make recommendations on terminologies to represent many, if not all, of the domain areas identified in Table by late The first round of terminology evaluations includes laboratory results content, medications, demographics, immunizations, and interventions and procedures.

Initially, CHI identified many of the domain areas that support the corresponding domains needed for patient safety reporting systems; however, the list is not comprehensive, and there will likely be a need to expand or extend the domains. For example, in the domain area for medications, CHI identifies clinical drugs, warnings, allergic reactions, and adverse drug events ADEs as primary areas for clinical representation. For patient safety, representation is also needed for subcategories, such as nutritional supplements and alternative medicines.

Expansion of the domain areas for comprehensive clinical and patient safety data is a subject for additional work. Appendix F provides a compre-. Elements of the terminology are coded concepts, possibly with multiple synonymous text representations, and hierarchical or definitional relationships to other coded concepts. No redundant, ambiguous, or vague concepts are included Sujansky, The meaning of each coded concept in a terminology remains forever unchanged. If the meaning of a concept needs to be changed or refined, a new coded concept is introduced. No retired codes are deleted or reused Sujansky, Concepts must have exactly one meaning.

When a common term has two or more associated meanings, it must be separated into distinct concepts Cimino, Each version of the terminology is designated by a unique identifier, such that parties exchanging data can readily determine whether they are using the same set of terms Sujansky, Unique codes attached to concepts are not tied to hierarchal position or other contexts and do not carry any meaning Chute et al. Concepts are accessible through all reasonable hierarchical paths i. A mechanism must exist that can help prevent multiple terms for the same concept from being added to the terminology as unique concepts Cimino, Software tools support and enforce a collaborative terminology development process Sujansky, Mappings to other terminologies should be algorithmic and derive from mapping tables or hierarchies within the classification or should be treated commonly Chute et al.

In cases where domain coverage of a terminology is inadequate, the best sources of data for the development of new terms to represent clinical and patient safety information are the clinical measures within standardized datasets for a health condition derived from evidence-based guidelines, documentation of physical findings, and narrative text of patient safety reports. Once comprehensive datasets have been identified, it may be possible to develop extensions of existing terminologies for those areas that are insufficient in representing clinical or safety data.

In other cases, it may be necessary to develop new terminologies. Each data element e. This approach takes into consideration the conceptual model for data integration discussed in Chapter 2. For the 20 priority areas identified by the IOM in its report Priority Areas for National Action , efforts to extend and create complete terminologies for clinical and safety data should follow a process that:. Clearly defines the condition in terms of clinical measurements and actions, and define safety in terms of what could go wrong with those measures or actions.

Evaluates datasets to determine whether they truly represent data elements necessary to measure outcomes, including safety. Continues refining the taxonomy for safety by asking about the reasons for errors of omission and commission e. Determines precursors to potential adverse events e. The need for multiple levels of granularity and cross-organizational terminologies means that a dataset will need to be either initially represented by or mapped to a concept-oriented clinical reference terminology and further mapped to high-level taxonomies for comparative analysis and research.

The committee encourages further work on developing standardized datasets with the capability to represent patient safety information in all clinical areas. The NCVHS core terminology group comprises a core set of medical terminologies that together are sufficiently comprehensive, technically sound, mutually consistent, and readily available to deliver most of the envisioned functionality of a national standard medical terminology for the EHR Sujansky, Having a common clinical reference terminology is expected to reduce the cost, increase the efficiency, and improve the quality of data exchange, clinical research, patient safety, sharing of computer guidelines, and public health monitoring.

Terminologies to be included in the core group must have sufficient clinical granularity and serve multiple functions, including decision support, interoperability, aggregation and reporting, EHR data entry, order entry, indexing for data retrieval, and domain ontology. Supplemental terminologies should be mapped to the core terminologies to provide the functionalities associated with the use of data standards and information systems. Box provides a brief overview of these terminologies.

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NCVHS continues to study additional terminologies that it may recommend for adoption at a later date. A concept-oriented reference terminology can be defined as one that has such characteristics as a grammar that defines the rules for automated generation and classification of new concepts, as well as the combining of atomic concepts to form molecular expressions Spackman et al. SNOMED CT is based on a formal terminology model that provides nonambiguous definitions of health care concepts and contains the most granular concepts for representing clinical and patient safety information.

SNOMED CT is designed to be the primary support for knowledge-based systems, the expression of clinical guidelines and datasets for the IOM priority conditions, and a key source for the development of new concepts for clinical and patient safety data. Laboratory LOINC Even with its comprehensiveness, SNOMED CT requires the support of additional terminologies to capture certain clinical data not currently available in the terminology with sufficient granularity or scope, namely laboratory, medication, and medical device data. LOINC is the available terminology that most fully represents laboratory data in terms of naming for tests e.

Many nursing codes have been incorporated into the terminology. It is a comprehensive medical vocabulary and classification system with over , fully specified concepts and , supporting descriptions. Logical Observation Identifiers, Names, and Codes LOINC —developed by the Regenstrief Institute, LOINC provides a set of universal names and numeric identifier codes for laboratory and clinical observations and measurements in a database structure without hierarchies whereby the records appear as line items.

Universal Medical Device Nomenclature System UMDNS —developed by the Emergency Care Research Institute as a multihierarchical terminology for identifying, processing, filing, storing, retrieving, transferring, and communicating data about medical devices. UMDNS contains 17, terms. Medical Dictionary for Drug Regulatory Affairs MedDRA —developed by the International Conference on Harmonization to harmonize international regulatory requirements for the drug development, marketing approval, and safety monitoring process.

It provides a comprehensive vocabulary and coding system of 70, terms for safety-related events and adverse drug reactions. Medicomp Systems Incorporated MEDCIN —a proprietary medical vocabulary designed as a controlled vocabulary of precorrelated clinical concepts from its nomenclature and associated knowledge base containing , clinical findings and diagnoses and , synonyms.

It was designed to capture additional and more complex information regarding the identification and content of blood and blood products on the label and to make that information universally accessible to the international blood banking community. Pharmacy knowledge bases —developed by the vendor community, including FirstDatabank, Medi-Span, and Multum.

These systems provide information about drug interactions, allergies, contraindications, drug—laboratory inferences, toxicology, and the like. The U.

Strategies and Technologies for Healthcare Information: Theory into Practice (Health Informatics)

ICD CM contains about 50, terms. The codes also are used for reimbursement of medicines. NDCs are employed for the approximately 10, drugs approved for use in the United States. CPT is the official code set for physician services in outpatient office practices. Current Dental Terminology —developed by the American Dental Association to represent data related to dentistry. International Classification of Functioning, Disability and Health ICF —developed by WHO to provide a scientific basis for understanding information on health outcomes, determinants, and functional capacity that is complementary to the ICD.

LOINC also contains information for clinical observations that is not included in the core terminology group at this time, since it may be possible to represent many of the observations with SNOMED CT, and one of the criteria for selection is to minimize overlap in terminology representation. Varying degrees of precoordination for an observation are also provided for e.

Drug terminologies Drug terminologies are an important part of the core group. NCVHS has been evaluating which drug and device terminologies best represent these areas. The process for determining drug terminologies is more complex than that for identifying a comprehensive reference terminology and laboratory terminology.

Representation of drug information involves both definitional and knowledge-based information National Committee on Vital and Health Statistics, a.


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  7. Definitional information serves the purpose of interoperability by providing standardized terms to represent clinical drugs in clinical information systems. Knowledge-based information provides terminology for such phenomena as drug interactions, allergies, and contraindications, thus supporting greater functionality of clinical systems National Committee on Vital and Health Statistics, a. For purposes of standardizing data elements for patient medical records information, the core terminology group will be focused on definitional terms. NLM has developed a normalized i.

    RxNORM assigns a standardized name for the active ingredient i. The semantic form provides.

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    Preliminary research on incorporating RxNORM into actual systems indicates that some refinements are needed e. Medical device terminologies A medical device terminology is also a must for the core terminology group. The terminology selected should be comprehensive in scope to cover the range of devices and their functions; capable of representing adverse events and malfunctions related to the devices; inclusive of emerging technologies used in investigative settings; sufficiently granular to capture essential data without losing critical information; and capable of being continuously maintained at a high level of technical quality, being mapped to other terms in use, and supporting high-quality translation to other languages for international use Coates, a.

    Although the GMDN consortium initiated its activities using international standards and collaborated with six primary device terminology developers, the FDA found that the final resulting terminology did not meet the above criteria. UMDNS provides a formal hierarchical system for representing complex medical device concepts, with content expressed in preferred terms. The process for maintaining the terminology is well developed at ECRI.

    For international regulatory purposes, subsequent modifications and enhancements of the GMDN by the FDA may render it mappable to the terminologies in the core terminology group. Mapping terminologies Mapping terminologies is a challenging task. The detailed terminologies of the core group and less granular classifications can be thought of as existing along a continuum of detail; for example, patient information can be expressed in a detailed nomenclature, such as SNOMED CT, funneling into a classification rubric, such as an ICD-9, Clinical Modification CM code Chute, This is a limited one-way process in that once patient data have been expressed solely in the form of classifications, the original detail is lost and generally cannot be recovered.

    In many cases, this funneling process can be accomplished satisfactorily through a simple mapping or table that indicates which classification code subsumes a detailed description. However, such code-to-code mappings often fail since some terminologies incorporate complex criteria that can be reliably achieved only with rules for aggregating several patient details Chute, It is also critical that the integration and mapping of the terminologies be based on the same information model as that of the data interchange standards—the HL7 RIM—to ensure optimum system functionality and interoperability National Committee on Vital and Health Statistics, a.

    The committee believes that several supplemental terminologies are necessary to support the requirements for an integrated information infrastructure that supports multiple methods of collecting, analyzing, disseminating,. As noted earlier, the terminologies must support system functionality and knowledge-based activities such as automated chart reviews and surveillance, voluntary reporting, natural language processing of narrative text, decision support tools e.

    The supplemental terminologies outlined in Box would be mapped through aggregation logic to the NCVHS core terminology group. Terminologies for further investigation and research The NCVHS core terminology group and the supplemental terminologies support the basic functionalities of the conceptual model for integrated systems presented in Chapter 2.

    However, the committee has determined that two additional terminologies are also needed and warrant further investigation and research—the International Classification of Functioning, Disability and Health ICF to represent outcomes data, and the International Classification of Primary Care ICPC to represent the data needs of the office practice clinician. Functional status can be regarded as the demonstrated or anticipated capacity of an individual to perform or undertake actions or activities deemed essential for independent living and physiological sustenance Ruggieri et al.

    Computer formats for clinical data describing the functional status of patients will be in increasing demand for measuring the impact of health care interventions and gauging quality of life Ruggieri et al. Information on functioning as a. The Mayo Clinic is undertaking a study to determine how well ICF can represent functional status data as they emerge traditionally within the health care setting Ruggieri et al.

    Preliminary findings suggest that in their current state, ICF terms lack unambiguous clarity, fidelity, and hence usability across the ranges of clinical data and granularity required for the varied and extensive use cases that rely on the representation of functional status data Ruggieri et al. However, ICF provides an important foundation from which clinical modifications and extensions can be developed to support robust functional status descriptions and representations in a broad spectrum of clinical domains and use cases Ruggieri et al.

    Further study and development of outcome terminologies for patient safety applications, including nursing terminologies, are recommended. More specifically, ICPC provides for simultaneous classification of the three elements of an encounter: the process of care, the reason for the encounter, and the health problem diagnosed WONCA, Although ICPC is not widely used in the United States, it is the primary classification system used by much of the international community for electronic documentation of clinical practice in primary care or for reporting to national governments Marshall, A study in Finland found repeatedly that ICPC permits coding of 95 percent or more of primary care visits episodes of care , compared with 50 percent for ICD-9 diagnosis Jamoulle, The ability to monitor episodes of care would support concurrent surveillance efforts by permitting a longitudinal look at patient symptoms, encounters including diagnoses and treatments , and outcomes.

    Because ICPC captures episodes of care, it has also been used to produce probability tables for presenting symptoms and diagnoses. This function could support the development of triggers in data monitoring or data mining systems and could be the basis for a much more robust decision.

    The ability of U. With regard to patient safety, the University of Colorado Department of Family Medicine and numerous other organizations are involved in a collaborative project entitled Applied Strategies for Improving Patient Safety. This project, sponsored by AHRQ to analyze the causes and effects of adverse events in primary care and reduce the incidence of errors, is using ICPC as its classification system Pace, Preliminary results are not available at this time.

    A conceptual diagram of the core terminology group and associated mappings to supplemental terminologies is presented in Figure , which shows the possible relationships among the terminologies and the use of aggregation logic for mapping through various levels of granularity.

    This figure was developed as a modification of a presentation in August to. James R. Biomedical literature knowledge bases are powerful tools for clinical reference. These knowledge bases hold the vast body of medical research findings from both a historical perspective and the perspective of current best evidence-based practice. At present, most digital sources of evidence are operating as stand alone systems without the ability to link to clinical information systems.

    With the development and use of common data standards, this linkage for enhanced access to medical knowledge bases can occur. An earlier IOM report defines practice guidelines as systematically developed statements to assist practitioners and patients in making decisions about health care for specific circumstances Institute of Medicine, The National Guideline Clearinghouse alone contains nearly 1, publicly accessible guidelines Maviglia et al. There are gaps and inconsistencies in the medical literature supporting one practice versus another, as well as biases based on the perspective of the authors, who may be specialists, general practitioners, payers, marketers, or public health officials Maviglia et al.

    Few national guidelines can be implemented in clinical information systems because of the lack of a way to represent the knowledge in machine-executable formats. Automating guidelines requires a computer-readable format that is unambiguous and makes use of stored patient data. A number of computational models and tools for extracting, organizing, presenting, and sharing clinical guidelines are currently in developmental use. Box lists the most common of these. Few guidelines have been successfully translated and incorporated into real clinical settings Advandi et al.

    Eligibility criteria and severity of disease or symptoms often are not explicitly defined, and when they are defined, they may not map to computable data within an EHR Maviglia et al. The multitude of guideline models are dissimilar—they capture different features of a guideline and were created for different purposes. For example, guidelines can be used to support clinical work flow, to foster background utilization review and monitoring, to drive consultations, or to capture the process flow in a clinical protocol.

    As a consequence, no single model enables all of the features of the various models to be fully encoded. One potential approach to data sharing is a model known as Guideline Interchange Format GLIF , developed by the InterMed Collaboratory comprising Harvard, Stanford, and Columbia universities , that encodes the essential features of guidelines common to all models i.

    The goal of GLIF is to be able to 1 encode different requirements of clinicians during decision making, 2 support automatic verification and validation of guidelines, 3 facilitate standard approaches to guideline dissemination and local adaptation, and 4 be used as a template for the integration of automated clinical guidelines with clinical information systems Wang et al. Following a workshop hosted by InterMed in March , the collaboratory decided to develop a standard model for representing guidelines with HL7. Rather than pursue agreement on one model, the group decided to focus on the building-block components that all guideline mod-.

    GELLO includes an object-oriented query language—that is, syntax for querying the EHR—thus specifying how one retrieves elements to be used in the logic expressions Sordo et al. GELLO depends on the existence of an object-oriented data model i. Another aspect to consider with GLIF is recognition that guidelines most often are not executed in their entirety Greenes, Instead, certain steps of a guideline may be implemented within different parts of a clinical information system Greenes, For example, some steps may bear upon evaluation of clinical findings and may offer suggestions for diagnostic assessment or workup strategy; some may bear on the choice of particular medications or other procedures and may be implemented as order entry suggestions or templates; some may relate to the interpretation to be made and the action to be taken when an abnormal laboratory result is obtained and might be implemented as alerts; and some may trigger reminders or scheduling events Sordo et al.

    Thus a guideline should be considered in terms of the application services or functions required by its various steps to be most effective Sordo et al. These requirements will differ from one clinical information system to another based on functionality supported by the system e. Thus work is proceeding on developing a taxonomy for application services that might be invoked by guidelines, as well as ways of marking up particular steps with the details of how the action is to be carried out in a specific clinical information system implementation Greenes, The volume of medical information continues to grow exponentially, leaving some clinicians feeling that it has become unmanageable Jerome et al.

    Yet the value of having the most recent medical literature for reference at the point of care is clear. Leveraging the efficiencies of information technology and expanding the services of medical libraries can facilitate this objective. Advances in communication technologies, application interface tools, and standardization in the representation of medical literature should allow such requests and retrievals to be completed through a fully automated system so that reliance on a librarian is not necessary, and information access is available to clinicians around the clock Humphreys, a. Since NLM holds the largest and most comprehensive database of medical literature, the development of application interface tools should initially be targeted to accessing the NLM databases.

    Automated data retrieval would require a direct connection to the various medical literature topics, rather than linkage through the NLM Web site as is now the case Humphreys, a. Such application interface tools would greatly enhance the usability of medical knowledge bases and capabilities for information seeking at the point of care Humphreys, a.

    The committee recommends further study into what characteristics of information and what design of the interface tools would be most useful to clinicians in this regard. MEDLINEplus identifies information that is easy to read for the consumer and makes more than interactive tutorials available in English, which include voice corresponding to the information printed on the screen Humphreys, b. The interactive tutorials are a popular feature in part because they are also suitable for those with low literacy Humphreys, b.

    NLM also encourages the institutes of the National Institutes of Health and producers of patient and consumer health materials to both convert their existing materials to electronic form and produce more of these materials. The Cochrane Collaboration—an international effort for preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions—is another important source of medical knowledge. Other types of knowledge bases are highly important to patient safety and decision support tools.

    Disease registries are special databases that contain information about people diagnosed with a specific disease. Most registries are either hospital or population based and are used for a number of purposes, such as patient outcome tracking, support for self-care, epidemiological research, and public health surveillance New York State Department of Health, They are also used for direct patient care, such as providing reminders for follow-up visits.

    Knowledge bases, such as those for pharmacology and pharmacokinetics, hold a vast amount of medical knowledge critical to the accurate prescription drugs and surveillance of drug reactions. These knowledge bases provide information on drug—body interactions to support decisions about what drugs to prescribe; drug—drug comparisons; advice on administration Duclos-Cartolano and Venot, ; information on contraindications, interactions, or therapeutic strategies related to the physiological conditions of a particular disease; and listings of drugs according to some of their properties Duclos-Cartolano and Venot,