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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: 
Tierney VM, Overhage JM, Murray MD, Harris LE, Zhou XH, Eckert GJ, Smith FE, Nienaber N, McDonald CJ, Wolinsky FD. Effects of computerized guidelines for managing heart disease in primary care. J Gen Intern Med. 2003 Dec;18(12):967-76.
Weiner M, Stump TE, Callahan CM, Lewis JN, McDonald CJ. A practical method of linking data from Medicare claims and a comprehensive electronic medical records system. Int J Med Inform. 2003 Aug;71(1):57-69.
Murray MD, Smith FE, Fox J, Teal EY, Kesterson JG, Stiffler TA, Ambuehl RJ, Wang J, Dibble M, Benge DO, Betley LJ, Tierney WM, McDonald CJ. Structure, functions, and activities of a research support informatics section. J Am Med Inform Assoc. 2003 Jul-Aug;10(4):389-98. Epub 2003 Mar 28.
McDonald CJ, Huff SM, Suico JG, Hill G, Leavelle D, Aller R, Forrey A, Mercer K, DeMoor G, Hook J, Williams W, Case J, Maloney P. LOINC, a universal standard for identifying laboratory observations: a 5-year update. Clin Chem. 2003 Apr;49(4):624-33.
Thomas SM, Mamlin B, Schadow G, McDonald CJ. A successful technique for removing names in pathology reports using an augmented search and replace method. Proc AMIA Symp. 2002:777-81.
Schadow G, Grannis S, McDonald CJ. Privacy-Preserving Distributed Queries for a Clinical Case Research Network. IEEE International Conference on Data Mining Workshop on Privacy, Security, and Data Mining City: Maebashi City, Japan 2002 vol: 14 pp: 55-65.
Overhage JM, Dexter PR, Perkins SM, Cordell WH, McGoff J, McGrath R, McDonald CJ. A randomized, controlled trial of clinical information shared from another institution. Ann Emerg Med. 2002 Jan;39(1):14-23.
McDonald CJ, Schadow G, Suico J, Overhage JM. Data standards in health care. Ann Emerg Med. 2001 Sep;38(3):303-11.
Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med. 2001 Sep 27;345(13):965-70.
Schadow G, Russler DC, Mead CN, McDonald CJ. Integrating medical information and knowledge in the HL7 RIM. Proc AMIA Symp. 2000:764-8.

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