Structuring clinical information in healthcare records

Area of Science:

• Health Informatics
• Electronic Health Records (EHR) Standardization

Background:

• Current electronic health record systems lack interoperability.
• Disparate patient records hinder homogeneous data transmission and browsing.
• Need for a standardized domain termlist for clinical information exchange.

Purpose of the Study:

• To prepare the European Prestandard CEN ENV13606-2 Domain Termlist.
• To facilitate transmission and homogeneous browsing of clinical information from disparate patient records.
• To enable data exchange without preliminary agreement on coding systems or record organization.

Main Methods:

• Analytical study of clinical document names, section titles, and data element names.
• Definition of a three-layer structure for clinical information: records into complexes, complexes into statements, statements into details.
• Preparation of lists representing coarse-grained information for defined constructs.

Main Results:

• Development of a domain termlist for CEN ENV13606-2.
• Establishment of a three-layer model for structuring clinical information.
• Creation of lists for representing coarse-grained clinical information.

Conclusions:

• The developed domain termlist supports the standardization of electronic health records.
• The three-layer structure provides a framework for organizing clinical information.
• The standard aims to improve interoperability and data accessibility in healthcare informatics.