MEDICAL INFORMATICS |
|
Standard |
Organization |
Domains |
Remarks |
| Electronic Data Interchange for Administration, Commerce and Transport (EDIFACT) |
ISO |
- |
Messages are generally used for communications with systems outside the organization. Example: lab message sent from hospital to physician |
|
Health Level 7 (HL-7) |
- |
order entry, observation reporting, ADT, financial transactions, master file exchange, appointment scheduling, problem list maintenance, nursing goal maintenance, referral notices, US UB92, capture of clinical data from automated bed-side instruments, clinical trial management, immunization reporting, adverse product experience reporting |
Messages are used for communications between systems inside the organization. Example: lab exam result sent from lab to patient data repository |
|
American College of Radiology/National Electrical Manufacturers Association (ACR-NEMA) |
image and non-image information |
The non-image portion is like an HL-7 message. It is compatible with the CEN WG4 MEDICOM standard and the Japanese JIRA standard. It supports the JPEG compression standard |
|
|
American Society of Testing and Materials (ASTM) |
American Society of Testing and Materials |
laboratory orders and reports |
- |
|
Abstract Syntax Notation One (ASN.1) (tutorial here) |
International Standards Organization (ISO) and the Consultative Committee of the International Telegraph and Telephone (CCITT) |
- |
ASN.1 is a meta-standard for providing mechanisms for defining standards. ASN.1 is a standard way to describe a message (a unit of application data) that can be sent or received in a network. ASN.1 is divided into two parts: (1) the rules of syntax for describing the contents of a message in terms of data types and content sequence or structure and (2) how you actually encode each data item in a message. |
| System Name | Initials / Versions | Maintaining Organization |
Domains | Remarks |
| International Classification of Diseases | ICD-9-CM, ICD-9-CM, ICD-10 (1992) | World Health Organization | diagnostic terms, RFE, external causes of death, medical procedures (ICD-9-CM), other medical terms for ICD-9 and ICD-10 | ICD-10 is a larger and more extensible kin of ICD-9 |
| International Classification of Primary Care | ICHPPC-2-Defined, IC-Process-PC, ICPC | WONCA (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians) | diagnosis, RFE, therapy, lab tests | Granularity is less than ICD-9. It is used to code clinical encounters in SOAP format. |
| Diagnostic and Statistical Manual for Mental Disorders (development coordinated with ICD system) | DSM-II, DSM-III-R, DSM-IV | American Psychiatric Organization | diagnosis | DSM-IV diagnostic codes are valid ICD-9-CM codes. It also contains a cross-reference between DSM codes and ICD-10 codes. |
| Systematized Nomenclature of Human and Veterinary Medicine | SNOMED, SNOMED II | American College of Pathologists | clinical information | multiaxial coded medical nomenclature |
| International Classification of Diseases for Oncology (based on ICD-9 and draft neoplasm chapter of ICD-10) | ICD-O (first edition) | World Health Organization | diagnosis | Morphology code includes neoplasm behavior code and a code for histologic grading and differentiation |
| Current Procedural Terminology | CPT-4 | American Medical Association | medical services, diagnostic and therapeutic procedures (codes based on cost) | usually required by most payers for physician and technical billing |
| International Classification of Procedures in Medicine | ICPM | World Health Organization | diagnostic, laboratory, preventive, surgical, other therapeutic and ancillary procedures | - |
| Read Clinical Classification | RCC, or Read codes | British National Health Service | diseases, occupations, history/symptoms, examinations/signs, diagnostic procedures, radiology/diagnostic imaging, preventive procedures, operative procedures, other therapeutic procedures, administration, drugs/appliances, health status measurements, diagnosis-related groups (DRGs) | Read Codes has specifically been developed for computerized patient records and aims to cover all the terms that can be written for a patient record |
| Anatomic Therapeutic Chemical Code | ATC | World Health Organization Collaborating Center for Drug Statistics Methodology | drugs | Identifies drug product, active substance, route of administration, dose |
| Medical Subject Headings | MeSH | National Library of Medicine | medical terms | Used to index medical literature and features concepts with broader and narrower terms. |
| Diagnosis-Related Groups | DRG | - | diagnoses and procedures coded in ICD-9-CM, patient-related data (age, sex, length of stay, and other factors) | Describes hospital stay in terms of what was wrong with and what was done for a patient; determines the amount of money that will be reimbursed, independently of the charges that the hospital may have incurred |
| Unified Medical Language System | UMLS | National Library of Medicine | - | The UMLS is not a standard but a cross-referenced collection of standards and other data and knowledge sources.Metathesaurus contains references from the following classifications and nomenclatures: SNOMED, Read Thesaurus, ICD-9-CM, Universal Medical Device Nomenclature System, WHO Adverse Drug Reaction Terminology, Classification of Nursing Diagnoses (NANDA), Home Health Care Classification, of Nursing Diagnoses and Intervention, CPT, MeSH, DSM-IV, Thesaurus of Psychological Index Terms |
| North American Nursing Diagnosis Assocation Codes | NANDA Codes | NANDA | nursing diagnoses | NANDA nursing diagnoses describe a patient's reactions to the disease |
| Logical Observation Identifiers, Names and Codes (LOINC™) | LOINC version 10J-A | Regenstrief Institute | laboratory and clinical observations | Facilitates the exchange and pooling of clinical laboratory results, such as blood hemoglobin or serum potassium, for clinical care, outcomes management, and research |
| Universal Medical Device Nomenclature System | UMDNS | ECRI | medical equipment | - |
| National Drug Codes | NDC | US Federal Drug Administration | pharmaceuticals (including packaging) | no reliable means of crosslinking trade with generic names, or even different packages of the same medication |