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Standardizing Clinical Document Names Using the HL7/LOINC Document Ontology and LOINC Codes.
Elizabeth S Chen1, Genevieve B Melton, Mark E Engelstad
1Center for Clinical & Translational Science.
AMIA ... Annual Symposium Proceedings. AMIA Symposium
|February 25, 2011
Summary
Standardizing clinical document names using the HL7/LOINC Document Ontology (DO) is crucial for data exchange. Mapping local names revealed the DO
Area of Science:
- Health Informatics
- Clinical Documentation
- Data Standardization
Background:
- Effective use, management, and exchange of clinical documents require standardized naming conventions.
- The HL7/LOINC Document Ontology (DO) provides a framework for consistent clinical document naming and LOINC code creation.
Purpose of the Study:
- To assess the feasibility and challenges of mapping local clinical document names from two institutions to the HL7/LOINC Document Ontology (DO).
- To utilize the mapping to identify appropriate LOINC codes for clinical notes.
Main Methods:
- Mapping local clinical document names from two distinct healthcare institutions to the five axes of the HL7/LOINC Document Ontology (DO).
- Leveraging the established mapping to identify and assign specific LOINC codes.
Main Results:
- The HL7/LOINC Document Ontology (DO) was found to be adequate or overly broad for most local document names.
- LOINC codes were identified for approximately one- to two-thirds of the mapped document names.
- The mapping process highlighted issues related to granularity and nomenclature.
Conclusions:
- The HL7/LOINC Document Ontology (DO) is a valuable tool but requires refinement for optimal clinical document name standardization.
- Further work is needed to address granularity and other identified issues to enhance the effectiveness of clinical document name standardization.
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