Relevant Tools for Tackling Interoperability Problems on Heterogeneous Electronic Health Record Systems: An Exploratory Research / Herramientas Relevantes para Abordar Problemas de Interoperabilidad en Sistemas de Expedientes Clínicos Electrónicos Heterogéneos: una Investigación Exploratoria

Abstract: Patients' medical records have been originally based on paper and since 1865 the medical field recognized the need to improve the means for storing and retrieving disperse information. Electronic Health Records (EHR) systems face similar problems, with interoperability being one of them, it defined by IEEE standard glossary of software engineering terminology as: the ability among information systems to exchange data. Mainly, two perspectives of interoperability emerge: a) syntactic, which refers to the ability of an information system to import and validate grammar, as well as a set of construction rules utterances created by another system; and b) semantic, the ability to exchange data among systems and understand it in the same way, regardless of the source system, also called Semantic Interoperability on Information and Communication Technologies or SIICT. The use of standards, vocabularies and terminologies is a common practice for sharing data among heterogeneous EHR systems in order to face interoperability problems. This heterogeneity starts with the manner to collect and store data. This paper presents to e-health practitioners and researches relevant tools used to achieve interoperability in heterogeneous EHR systems, as well as challenges and future trends to manage EHRs with the intention to achieve SIICT.

Resumen: Los registros clínicos de pacientes se basaron en papel originalmente, desde el año de 1865 se reconoció en el entorno medico la necesidad de mejorar los medios para el almacenamiento y recuperación de información dispersa. Los Sistemas de Expediente Clínicos Electrónicos (ECE) enfrentan problemas similares, siendo uno de estos problemas, la interoperabilidad. La cual es definida por "IEEE standard glossary of software engineering terminology" como: la habilidad de intercambiar datos entre sistemas de información, donde dos perspectivas de interoperabilidad emergen: a) sintáctica, la cual se refiere a la habilidad de un sistema de información de importar y validar la gramática de datos, así como de un conjunto de reglas de expresiones creadas por otro sistema; y b) semántica, como la habilidad de intercambiar datos entre sistemas y de entenderlos de la misma forma, independientemente del sistema fuente, llamando a esto como Interoperabilidad Semántica sobre Tecnologías De La Información y Comunicación (ISTIC). El uso de estándares, vocabularios y terminologías es una práctica común para poder compartir datos entre sistemas ECE con el fin de enfrentar problemas de interoperabilidad. Esta heterogeneidad se da desde la forma en cómo se colecta y almacenan los datos. Este artículo presenta a los profesionales de salud e investigadores de e-salud acerca de herramientas relevantes utilizadas para lograr la interoperabilidad de sistemas ECE heterogéneos, así como retos y futuras tendencias para administrar sistemas ECE con la intención de lograr ISTIC.

Application of Standards for Semantic Interoperability in the Clinical Decision Support System / 医学信息学杂志

The paper introduces the basic situation of research on interoperability of the Clinical Decision Support System (CDSS),based on the types of standards for semantic interoperability and functional requirements for the development and arrangement of the CDSS,classifies the standards in the CDSS,and discusses the application of various standards in the CDSS.

Arquetipos, terminologías e interoperabilidad semántica en salud / Archetypes, terminologies and semantic interoperability in health

La falta de aplicación de estándares repercute en lo negativo en la calidad de la prestación de servicios de salud, lo cual se ve reflejado en un alto porcentaje de errores médicos prevenibles, que son causados por la falta de acceso inmediato a la información de salud. Es por esto que en la actualidad, existe una necesidad hacia sistemas distribuidos e interconectados, que favorezcan la representación y comunicación de los sistemas de historia clínica electrónica, de tal forma que permitan la interoperabilidad. Es aquí donde la arquitectura de modelo dual surge como una solución a los problemas clásicos de evolución y mantenimiento de los sistemas de información y por consiguiente, como la piedra angular para alcanzar la llamada interoperabilidad semántica. La interoperabilidad es la clave para la atención efectiva en el ámbito de la salud ya que aumenta la calidad de la atención, reduce los costos, y mejora los servicios, lo que se traduce en una atención más segura y eficiente. En la presente revisión, se pretende como objetivo, describir los elementos más importantes a la hora de expresar la información clínica, como son las terminologías para codificar la información, un modelo de referencia para expresar las características generales de los componentes de un registro clínico, y de unos arquetipos que definen los conceptos clínicos presentes; todos estos como componentes indispensables para alcanzar dicha interoperabilidad.

The lack of application of standards has a negative effect on the quality of health service provision which is shown in the high percentage of preventable medical errors that are caused by lack of immediate access to health information. That is the reason why it is necessary today to move towards distributed and interconnected systems favoring representation and communication of electronic health record systems so that they allow interoperability. This is the moment when the dual model architecture emerges as a solution to the clasic problems of evolution and maintenance of the information systems and consequently, as a milestone to reach the so called semantic interoperability. Interoperability is the key to effective care in health since it increases the quality of care, reduces costs and improves services. All the above-mentioned brings more efficient and safer care. The present literature review was aimed at describing the most important elements to express clinical information such as terminologies to coding information, a reference model to express the general characteristics of the clinical register components and those of archetypes that define the present clinical concepts. All of them are indispensable elements to reach interoperability.

Use of clinical terminology for semantic interoperability of electronic health records

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.

Establishing semantic interoperability in the course of clinical document exchange using international standard for metadata registry

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.

Evaluation of the Clinical Data Dictionary (CiDD) / 대한의료정보학회지

OBJECTIVES: The purpose of the study was to evaluate content coverage and data quality of the Clinical Data Dictionary (CiDD) developed by the Center for Interoperable EHR (CiEHR). METHODS: A total of 12,994 terms were collected from 98 clinical forms of a tertiary cancer center hospital with 500 beds. After data cleaning, 9,418 terms were mapped with the data items of the CiDD by the research team, and validated by 30 doctors and nurses at the research hospital. RESULTS: Mapping results were classified into five categories: lexically mapped; semantically mapped; mapped to either a broader term or a narrower term; mapped to more than one term and not mapped. In terms of coverage, out of 9,418 terms, 6,750 (71.7%) terms were mapped; 4,319 (45.9%) terms were lexically mapped; 2,431 (25.8%) were semantically mapped; 281 (3.0%) terms were mapped to a broader term; 43 (0.5%) were mapped to a narrower term; and 550 (5.8%) were mapped to more than one term. In terms of data quality, the CiDD has problems such as errors in concept namingand representation, redundancy in synonyms, inadequate synonyms, and ambiguity in meaning. CONCLUSIONS: Although the CiDD has terms covering 72% of local clinical terms, the CiDD can be improved by cleaning up errors and redundancies, adding textual definitions or use cases of the concept, and arranging the concepts in a hierarchy.

Clinical Terminologies: A Solution for Semantic Interoperability / 대한의료정보학회지

To realize the benefits of electronic health records, electronic health record information needs to be shared seamlessly and meaningfully. Clinical terminology systems, one of the current semantic interoperability solutions, were reviewed in this article. Definition, types, brief history, and examples of clinical terminologieswere introduced along with phases of clinical terminology use and issues on clinical terminology use in electronic health records. Other attempts to standardize the capture, representation and communication of clinical data were also discussed briefly with future needs.