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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.
Publications/Tools: 
Vreeman DJ, McDonald C, Huff SM. LOINC® - A Universal Catalog of Individual Clinical Observations and Uniform Representation of Enumerated Collections. Int J Funct Inform Personal Med. 2010;3(4):273-291. Epub 2011 May 23.
Pontet F, Magdal Petersen U, Fuentes-Arderiu X, Nordin G, Bruunshuus I, Ihalainen J, Karlsson D, Forsum U, Dybkaer R, Schadow G, Kuelpmann W, Ferard G, Kang D, McDonald C, Hill G. Clinical laboratory sciences data transmission: the NPU coding system. Stud Health Technol Inform. 2009;150:265-9.
Wei D, Wang Y, Perl Y, Xu J, Halper M, Spackman KA. Complexity measures to track the evolution of a SNOMED hierarchy. AMIA Annu Symp Proc. 2008 Nov 6:778-82.
Kho AN, Lemmon L, Commiskey M, Wilson SJ, McDonald C. Use of a Regional Health Information Exchange to Detect Crossover of Patients with MRSA between Urban Hospitals J Am Med Inform Assoc. 2008 Mar-Apr;15(2):212-6. Epub 2007 Dec 20.
McDonald C. Dataset: LOINC Panels and Forms file
Drake TA, Braun J, Marchevsky A, Kohan IS, Fletcher C, Chueh H, Beckwith B, Berkowicz D, Kuo F, Zeng QT, Balis U, Holzbach A, McMurry A, Gee CE, McDonald C, Schadow G, Davis M, Hattab EM, Blevins L, Hook J, Becich M, Crowley RS, Taube SE, Berman J. A System for Sharing Routine Surgical Pathology Specimens Across Institutions: The Shared Pathology Informatics Network Hum Pathol. 2007 Aug;38(8):1212-25. Epub 2007 May 8

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