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Clinical Vocabulary Standards

Multiple projects in this area continue to promote the development, enhancement, and adoption of clinical vocabulary standards. Inter-terminology mapping promotes the use of standard terminologies by creating maps to administrative terminologies, which allows re-use of encoded clinical data.

  • CORE Subset of SNOMED CT: The CORE Problem List Subset is derived from real clinical data from eight large-scale healthcare institutions. It identifies the most frequently used SNOMED CT terms in the problem list.
  • Newborn Screening, Coding, & Terminology Guide: The NLM Newborn Screening Coding and Terminology Guide and HRSA/NLM Guidance for Exchanging Electronic Newborn Screening Orders and Results Web site facilitates the use of electronic health data standards (LOINC, SNOMED CT, UCUM, and HL7) in recording and transmitting newborn screening test results. The Guide includes standard codes and terminology for newborn tests and conditions.
  • RxNav: RxNav is an interface to the RxNorm database, designed for displaying relations among drug entities. In addition to the browser, we created SOAP-based and RESTful application programming interfaces (APIs) enabling users to integrate RxNorm in their applications.
  • RxTerms: RxTerms is a drug interface terminology derived from RxNorm for prescription writing or medication history recording (e.g. in e-prescribing systems, PHRs). The advantages of RxTerms are: Free to use. Directly links to RxNorm, the U.S. drug terminology standard, and facilitates inclusion of RxNorm identifiers in electronic health records. Efficient data entry - RxTerms separates the full names in RxNorm into two parts: drug name + route.
  • Top LOINC Laboratory Codes – Orders and Observations: This list is for laboratories, practices, researchers, and others who wish to map their laboratory test codes to universal LOINC codes.


Publications/Tools: 
McDonald CJ, Maglott D, Abhyankar S, Goodwin RM, Kanduru A, Lu S, Lynch P, Vreeman D, Wang Y, Wood G. US Realm, Chapter 5, Use Case – Clinical Genomics Results Reporting in HL7 Version 2.5.1 Implementation Guide: Lab Results Interface (LRI), DTSU3. HL7 International (Ann Arbor).
McDonald CJ, Maglott D, Abhyankar S, Goodwin RM, Kanduru A, Lu S, Lynch P, Vreeman D, Wang Y, Wood G. US Realm, Chapter 14, Use Case – Clinical Genomics Code Systems. in HL7 Version 2.5.1 Implementation Guide: Lab Results Interface (LRI), DTSU3. HL7 International (Ann Arbor).
McDonald CJ. Logical Observation Identifiers Names and Codes for In Vitro Diagnostic Test; Guidance for Industry and Food and Drug Administration Staff. Silver Spring, Md: Center for Devices and Radiological Health, FDA, 2018.
Vreeman DJ, Abhyankar S, McDonald CJ. Re: Unit conversions between LOINC codes Published June 19, 2017 [Letter]. J Am Med Inform Assoc. 2018 May 1;25(5):614-615. doi: 10.1093/jamia/ocx087.
Fung K, Xue Z, Ameye F, Gutierrez AR, D'Have A. Achieving Logical Equivalence between SNOMED CT and ICD-10-PCS Surgical Procedures. AMIA Annu Symp Proc. 2018 Apr 16;2017:724-733. eCollection 2017.
Tang P, McDonald CJ. Computer-Based Patient-Record Systems - Chapter 9. In Shortliffe E, Perreault L, eds. Medical Informatics. New York: springer. 2001:327-358. DOI: 10.1007/978-0-387-21721-5_9.
McDonald CJ. FHIR Overview Presentation by Clement J. McDonald, MD
McDonald CJ. Top LOINC Codes – Orders and Observations
McDonald CJ, Vreeman D, Wang K, Carr C, Colins B, Abhyankar S, Deckard J, Rubin D, Langlotz C. The LOINC/RSNA Radiology Playbook: A unified terminology for radiology procedures. . In 2017 AMIA Symposium. Washington DC.
Abhyankar S, Schluter P, Bennett K, Vreeman D, McDonald CJ. Enabling Interoperability between Healthcare Devices and EHR Systems. In 2017 AMIA Symposium. Wasington DC: IEEE.

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