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Logical Observation Identifiers Names And Codes
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization. LOINC was created in response to the demand for an electronic database for clinical care and management and is publicly available at no cost. It is endorsed by the American Clinical Laboratory Association. Since its inception, the database has expanded to include not just medical laboratory code names but also nursing diagnosis, nursing interventions, outcomes classification, and patient care data sets. Function ''LOINC'' applies universal code names and identifiers to medical terminology related to electronic health records. The purpose is to assist in the electronic exchange and gathering of clinical results (such as laboratory tests, clinical observations, outcomes management and research). LOINC has two ...
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Database
In computing, a database is an organized collection of data stored and accessed electronically. Small databases can be stored on a file system, while large databases are hosted on computer clusters or cloud storage. The design of databases spans formal techniques and practical considerations, including data modeling, efficient data representation and storage, query languages, security and privacy of sensitive data, and distributed computing issues, including supporting concurrent access and fault tolerance. A database management system (DBMS) is the software that interacts with end users, applications, and the database itself to capture and analyze the data. The DBMS software additionally encompasses the core facilities provided to administer the database. The sum total of the database, the DBMS and the associated applications can be referred to as a database system. Often the term "database" is also used loosely to refer to any of the DBMS, the database system or an appli ...
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SNOMED CT
SNOMED CT or SNOMED Clinical Terms is a systematically organized computer-processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens. SNOMED CT is maintained and distributed by SNOMED International, an international non-profit standards development organization, located in London, UK. SNOMED International is the trading name of the Inter ...
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Medical Classification
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including: * statistical analysis of diseases and therapeutic actions * reimbursement (e.g., to process claims in medical billing based on diagnosis-related groups) * knowledge-based and deci ...
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Computer File Formats
A computer is a machine that can be programmed to carry out sequences of arithmetic or logical operations ( computation) automatically. Modern digital electronic computers can perform generic sets of operations known as programs. These programs enable computers to perform a wide range of tasks. A computer system is a nominally complete computer that includes the hardware, operating system (main software), and peripheral equipment needed and used for full operation. This term may also refer to a group of computers that are linked and function together, such as a computer network or computer cluster. A broad range of industrial and consumer products use computers as control systems. Simple special-purpose devices like microwave ovens and remote controls are included, as are factory devices like industrial robots and computer-aided design, as well as general-purpose devices like personal computers and mobile devices like smartphones. Computers power the Internet, which links ...
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Controlled Vocabulary
Control may refer to: Basic meanings Economics and business * Control (management), an element of management * Control, an element of management accounting * Comptroller (or controller), a senior financial officer in an organization * Controlling interest, a percentage of voting stock shares sufficient to prevent opposition * Foreign exchange controls, regulations on trade * Internal control, a process to help achieve specific goals typically related to managing risk Mathematics and science * Control (optimal control theory), a variable for steering a controllable system of state variables toward a desired goal * Controlling for a variable in statistics * Scientific control, an experiment in which "confounding variables" are minimised to reduce error * Control variables, variables which are kept constant during an experiment * Biological pest control, a natural method of controlling pests * Control network in geodesy and surveying, a set of reference points of known geos ...
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UMLS
The Unified Medical Language System (UMLS) is a compendium of many controlled vocabularies in the biomedical sciences (created 1986). It provides a mapping structure among these vocabularies and thus allows one to translate among the various terminology systems; it may also be viewed as a comprehensive thesaurus and ontology of biomedical concepts. UMLS further provides facilities for natural language processing. It is intended to be used mainly by developers of systems in medical informatics. UMLS consists of Knowledge Sources (databases) and a set of software tools. The UMLS was designed and is maintained by the US National Library of Medicine, is updated quarterly and may be used for free. The project was initiated in 1986 by Donald A.B. Lindberg, M.D., then Director of the Library of Medicine, and directed by Betsy Humphreys. Purpose and applications The number of biomedical resources available to researchers is enormous. Often this is a problem due to the large volume o ...
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Public Health Information Network
The Public Health Information Network (PHIN) is a US national initiative, developed by the Centers for Disease Control and Prevention (CDC), for advancing fully capable and interoperable information systems in public health organizations. The initiative involves establishing and implementing a framework for public health information systems. Design PHIN is designed to do the following: * Enable the consistent exchange of health data * Protect the security of the health data exchanged * Ensure that the network will be available at all times Structure The five functional areas of PHIN: #Detection and Monitoring #Data Analysis #Knowledge Management #Alerting #Response PHIN's impact on public health PHIN attempts to provide the public health sector with continuous access to necessary health care information. Access to near real-time data attempts to improve community-based interventions that are implemented as a result of terrorism or disease outbreaks. PHIN provides suppo ...
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DOCLE
DOCLE (Doctor Command Language), is a non-numeric health coding and medical classification system. The DOCLE system is used in Health Communication Network's electronic medical record and patient management software package, Medical Director. Medical Director is the most widely used electronic medical record system by Australian primary health care providers. DOCLE has been modelled on the Linnaean biological classification system since 1995. DOCLE generates clinical codes from ubiquitous health language using an algorithm, hence it is a human readable clinical coding system. The design principles of DOCLE, as enumerated by the author in the DOCLE website include: * DOCLE codes being meaningful and intentional * DOCLE codes are derived from ubiquitous health language * DOCLE codes grew with evolving order and speciation of large scale structures in a linnean manner. * DOCLE codes are designed to strap together and form clinical structures using joiner codes * The author of DOCLE, ...
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DICOM
Digital Imaging and Communications in Medicine (DICOM) is the standard for the communication and management of medical imaging information and related data. DICOM is most commonly used for storing and transmitting medical images enabling the integration of medical imaging devices such as scanners, servers, workstations, printers, network hardware, and picture archiving and communication systems (PACS) from multiple manufacturers. It has been widely adopted by hospitals and is making inroads into smaller applications such as dentists' and doctors' offices. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The different devices come with DICOM Conformance Statements which state which DICOM classes they support. The standard includes a file format definition and a network communications protocol that uses TCP/IP to communicate between systems. The National Electrical Manufacturers Association (NEMA) holds the c ...
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Clinical Care Classification System
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings. Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions. The use of the CCC has expanded into other settings, and it is claimed to be appropriate for multidisciplinary documentation. The CCC, capturing the essence of patient c ...
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Clinical Data Interchange Standards Consortium
The Clinical Data Interchange Standards Consortium (CDISC) is a standards developing organization (SDO) dealing with medical research data linked with healthcare, to "enable information system interoperability to improve medical research and related areas of healthcare". The standards support medical research from protocol through analysis and reporting of results and have been shown to decrease resources needed by 60% overall and 70–90% in the start-up stages when they are implemented at the beginning of the research process. CDISC standards are harmonized through a model that is also a HL7 standard and is the process to becoming an ISO/ CEN standard. History * Late 1997 – Started as a Volunteer group * Summer 1998 – Invited to form DIA SIAC * 1999 – SDS v1.0; ODM v0.8 * 2000 – SDS v1.1 * Feb 2000 – Formed an Independent, non-profit organization * Dec 2001 – Global participation * 2001 – SDS v2.0; ODM v1.0 * 2002 – ODM v1.1; ADaM v1.0 * 2003 – LAB v1.0; SDTM ...
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Clinical Document Architecture
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0. The organization published Release 2.0 with its "2005 Normative Edition." Content CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document, defined by six characteristics: # Persistence # Stewardship # Potential for authentication # Context # Wholeness # Human readability CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: * Discharge summary (following inpatient care) * History & physical * Specialist reports, such as those for medical imaging or pathology An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. It was developed using the ...
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