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Related Concept Videos

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Determining Pain Detection and Tolerance Thresholds Using an Integrated, Multi-Modal Pain Task Battery
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Pain Documentation: Validation of a Reference Model.

Emily Gesner1, Sarah A Collins1, Roberto Rocha1

  • 1Clinical Informatics, Partners eCare, Partners Healthcare Systems, Boston, MA.

Studies in Health Technology and Informatics
|August 12, 2015
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Summary
This summary is machine-generated.

Electronic Health Record (EHR) interoperability faces documentation inconsistencies. A validated reference model, using standards like HL7 and LOINC, addresses pain documentation challenges, proving effective for diverse sub-domains.

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Area of Science:

  • Health Informatics
  • Clinical Documentation Standards

Background:

  • Electronic Health Record (EHR) interoperability is a growing trend.
  • Inconsistent clinical documentation, particularly for concepts like pain, hinders EHR interoperability.
  • Standardized reference models are crucial for consistent data representation.

Purpose of the Study:

  • To validate a reference model for clinical documentation using established standards.
  • To assess the model's ability to handle complex and inconsistent data, using pain as a case study.

Main Methods:

  • Developed a reference model based on Health Level 7 (HL7), Logical Names and Codes (LOINC), and Intermountain Clinical Element Model requirements.
  • Validated the model using external published sources and guidelines.
  • Evaluated the model's applicability to the domain of pain documentation.

Main Results:

  • The reference model, designed with broad data elements, demonstrates validity.
  • The identified data elements are sufficiently comprehensive to meet the needs of various pain sub-domains.
  • The model effectively addresses inconsistencies in pain documentation.

Conclusions:

  • The validated reference model is suitable for improving EHR interoperability.
  • Standardized models can overcome documentation barriers in complex clinical domains like pain.
  • This approach supports more consistent and reliable health data exchange.