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The Virtual Medical Record (vMR) is a simplified, standardised electronic health record data model designed to support interfacing to clinical decision support (CDS) systems. [1] vMR is compatible with Service-oriented Architecture (SOA) of CDS.
Health informatics is information engineering applied to the field of health care, essentially the management and use of patient health care information. It is a multidisciplinary field that uses health information technology (HIT) to improve health care via any combination of higher quality, higher efficiency, and new opportunities. The disciplines involved include information science, computer science, social science, behavioral science, management science, and others. The United States National Library of Medicine (NLM) defines health informatics as "the interdisciplinary study of the design, development, adoption and application of IT-based innovations in health care services delivery, management and planning".
Health Level Seven or HL7 refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is "layer 7" in the OSI model. The HL7 standards are produced by Health Level Seven International, an international standards organization, and are adopted by other standards issuing bodies such as American National Standards Institute and International Organization for Standardization.
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.
A clinical decision support system (CDSS) is a health information technology system that is designed to provide physicians and other health professionals with clinical decision support (CDS), that is, assistance with clinical decision-making tasks. A working definition has been proposed by Robert Hayward of the Centre for Health Evidence: "Clinical decision support systems link health observations with health knowledge to influence health choices by clinicians for improved health care". CDSSs constitute a major topic in artificial intelligence in medicine.
Arden syntax is a markup language used for representing and sharing medical knowledge. This clinical and scientific knowledge language is used in an executable format by clinical decision support systems to generate alerts, interpretations, and to screen and manage messages to clinicians. This syntax is used to share medical knowledge within and across many health service institutions. Rule sets, called Medical Logic Modules, comprise enough logic to make a single medical decision. Medical logic modules are written in Arden syntax, and are called by a program – an event monitor – when the condition they are written to help with occurs.
A guideline execution engine is a computer program which can interpret a clinical guideline represented in a computerized format and perform actions towards the user of an electronic medical record.
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.
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.
The term virtual patient is used to describe interactive computer simulations used in health care education. The special focus is targeted on the simulation of clinical processes with virtual patients. Virtual patients combine scientific excellence, modern technologies and the innovative concept of game-based learning. Virtual patients allow the learner to take the role of a health care professional and develop clinical skills such as making diagnoses and therapeutic decisions. Virtual patients have also been considered computer-based simulations designed to complement clinical training. The use of virtual patient programmes is increasing in healthcare, partly in response to increasing demands on health care professionals and education of students but also because they allow opportunity for students to practice in a safe environment. There are many different formats a virtual patient may take. However the overarching principle is that of interactivity—a virtual patient will have mechanisms for the learner to interact with the case and material or information is made available to the learner as they complete a range of learning activities. Interactivity is often included with questions, specific decision-making tasks, text-composition etc. and is non-sequential. Most systems provide quantitative and qualitative feedback.
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."
MEDCIN, a system of standardized medical terminology, is a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.
First Databank (FDB) is a major provider of drug and medical device databases that help inform healthcare professionals to make decisions. FDB partners with information system developers to deliver useful medication- and medical device-related information to clinicians, business associates, and patients. FDB is part of Hearst and the Hearst Health network.
The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange.
The GELLO Expression Language was started in 2001 and introduced in 2002; in 2005, GELLO was adopted as an international standard by Health Level Seven International and ANSI for a decision support language. GELLO Release 2 was completed and approved by ANSI in June 2010. The GELLO specifications have been developed in coordination with the HL7 Clinical Decision Support TC (CDSTC)
International HL7 implementations is a collection of known implementations of the HL7 Interoperability standard. These do not necessarily refer to cross-border health information systems.
Fast Healthcare Interoperability Resources is a standard describing data formats and elements and an application programming interface (API) for exchanging electronic health records (EHR). The standard was created by the Health Level Seven International (HL7) health-care standards organization.
In silico medicine is the application of in silico research to problems involving health and medicine. It is the direct use of computer simulation in the diagnosis, treatment, or prevention of a disease. More specifically, in silico medicine is characterized by modeling, simulation, and visualization of biological and medical processes in computers with the goal of simulating real biological processes in a virtual environment.
Health Level Seven International (HL7) is a non-profit ANSI-accredited standards development organization dedicated to providing standards and solutions that empower global health data interoperability.
Dipak Kalra is President of the European Institute for Health Records and of the European Institute for Innovation through Health Data. He undertakes international research and standards development, and advises on adoption strategies, relating to Electronic Health Records.
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