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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.

Schadow G, Russler DC, Mead CN, McDonald CJ. Integrating medical information and knowledge in the HL7 RIM. Proc AMIA Symp. 2000:764-8.
McDonald CJ, Schadow G, Suico J, Heilmann K. Sprechen Sie LOINC. HL7 Mitteilugen, Germany. 2000. P 6-11.
Olesen H, Ibsen I, Bruunshuus I, Kenny D, Dybkaer R, Fuentes-Arderiu X, Hill G, Soares de Araujo P, McDonald CJ. Properties and Units in the Clinical Laboratory Sciences. Part X. Pure Appl Chem 2000 vol: 72 (5) pp: 889-962.
Russler DC, Schadow G, Mead C, Snyder T, Quade LM, McDonald CJ. Influences of the Unified Service Action Model on the HL7 Reference Information Model. Proc AMIA Symp. 1999:930-4.
McDonald CJ, Overhage JM, Tierney WM, Dexter PR, Martin DK, Suico JG, Zafar A, Schadow G, Blevins L, Glazener T, Meeks-Johnson J, Lemmon L, Warvel J, Porterfield B, Cassidy P, Lindbergh D, Belsito A, Tucker M, Williams B, Wodniak C. The Regenstrief Medical Record System: a quarter century experience. Int J Med Inform. 1999 Jun;54(3):225-53.
Schadow G, McDonald CJ, Suico JG, Fohring U, Tolxdorff T. Units of measure in clinical information systems. J Am Med Inform Assoc. 1999 Mar-Apr;6(2):151-62.
Huff SM, Rocha RA, McDonald CJ, De Moor GJ, Fiers T, Bidgood WD Jr, Forrey AW, Francis WG, Tracy WR, Leavelle D, Stalling f, Griffin B, Maloney P, Leland D, Charles L, Hutchins K, Baenziger J. Development of the Logical Observation Identifier Names and Codes (LOINC) vocabulary. J Am Med Inform Assoc. 1998 May-Jun;5(3):276-92.
McDonald CJ, Overhage JM, Dexter P, Takesue B, Suico JG. What is done, what is needed and what is realistic to expect from medical informatics standards. Int J Med Inform. 1998 Feb;48(1-3):5-12.