Establishing semantic interoperability in the course of clinical document exchange using international standard for metadata registry.
10.5124/jkma.2012.55.8.729
- Author:
Yu Rang PARK
1
;
Hyehyeon KIM
;
Eun Yang AN
;
Hyung Hoi KIM
;
Ju Han KIM
;
Rae Woong PARK
;
Dong Kyun PARK
;
Eun Young JUNG
;
Ju Han KIM
Author Information
1. Seoul National University Biomedical Informatics (SNUBI), Division of Biomedical Informatics, Seoul National University College of Medicine, Seoul, Korea. juhan@snu.ac.kr
- Publication Type:Original Article
- Keywords:
Metadata;
Semantic interoperability;
Metadata registry;
ISO/IEC 11179;
Clinical document exchange
- MeSH:
Dietary Sucrose;
Electronic Health Records;
Health Personnel;
Humans;
Patient Care;
Policy Making;
Public Health;
Semantics
- From:Journal of the Korean Medical Association
2012;55(8):729-740
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
Around the world electronic health records data are being shared and exchanged between two different systems for direct patient care, as well as for research, reimbursement, quality assurance, epidemiology, public health, and policy development. It is important to communicate the semantic meaning of the clinical data when exchanging electronic health records data. In order to achieve semantic interoperability of clinical data, it is important not only to specify clinical entries and documents and the structure of data in electronic health records, but also to use clinical terminology to describe clinical data. There are three types of clinical terminology: interface terminology to support a user-friendly structured data entry; reference terminology to store, retrieve, and analyze clinical data; and classification to aggregate clinical data for secondary use. In order to use electronic health records data in an efficient way, healthcare providers first need to record clinical content using a systematic and controlled interface terminology, then clinical content needs to be stored with reference terminology in a clinical data repository or data warehouse, and finally, the clinical content can be converted into a classification for reimbursement and statistical reporting. For electronic health records data collected at the point of care to be used for secondary purposes, it is necessary to map reference terminology with interface terminology and classification. It is necessary to adopt clinical terminology in electronic health records systems to ensure a high level of semantic interoperability.
