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Item The LOINC RSNA radiology playbook - a unified terminology for radiology procedures(Oxford Academic, 2018-07-01) Vreeman, Daniel J.; Abhyankar, Swapna; Wang, Kenneth C.; Carr, Christopher; Collins, Beverly; Rubin, Daniel L.; Langlotz, Curtis P.; Medicine, School of MedicineObjective: This paper describes the unified LOINC/RSNA Radiology Playbook and the process by which it was produced. Methods: The Regenstrief Institute and the Radiological Society of North America (RSNA) developed a unification plan consisting of six objectives 1) develop a unified model for radiology procedure names that represents the attributes with an extensible set of values, 2) transform existing LOINC procedure codes into the unified model representation, 3) create a mapping between all the attribute values used in the unified model as coded in LOINC (ie, LOINC Parts) and their equivalent concepts in RadLex, 4) create a mapping between the existing procedure codes in the RadLex Core Playbook and the corresponding codes in LOINC, 5) develop a single integrated governance process for managing the unified terminology, and 6) publicly distribute the terminology artifacts. Results: We developed a unified model and instantiated it in a new LOINC release artifact that contains the LOINC codes and display name (ie LONG_COMMON_NAME) for each procedure, mappings between LOINC and the RSNA Playbook at the procedure code level, and connections between procedure terms and their attribute values that are expressed as LOINC Parts and RadLex IDs. We transformed all the existing LOINC content into the new model and publicly distributed it in standard releases. The organizations have also developed a joint governance process for ongoing maintenance of the terminology. Conclusions: The LOINC/RSNA Radiology Playbook provides a universal terminology standard for radiology orders and results.Item Possibilities and implications of using the ICF and other vocabulary standards in electronic health records(Wiley, 2015-12) Vreeman, Daniel J.; Richoz, Christophe; Department of Medicine, IU School of MedicineThere is now widespread recognition of the powerful potential of electronic health record (EHR) systems to improve the health-care delivery system. The benefits of EHRs grow even larger when the health data within their purview are seamlessly shared, aggregated and processed across different providers, settings and institutions. Yet, the plethora of idiosyncratic conventions for identifying the same clinical content in different information systems is a fundamental barrier to fully leveraging the potential of EHRs. Only by adopting vocabulary standards that provide the lingua franca across these local dialects can computers efficiently move, aggregate and use health data for decision support, outcomes management, quality reporting, research and many other purposes. In this regard, the International Classification of Functioning, Disability, and Health (ICF) is an important standard for physiotherapists because it provides a framework and standard language for describing health and health-related states. However, physiotherapists and other health-care professionals capture a wide range of data such as patient histories, clinical findings, tests and measurements, procedures, and so on, for which other vocabulary standards such as Logical Observation Identifiers Names and Codes and Systematized Nomenclature Of Medicine Clinical Terms are crucial for interoperable communication between different electronic systems. In this paper, we describe how the ICF and other internationally accepted vocabulary standards could advance physiotherapy practise and research by enabling data sharing and reuse by EHRs. We highlight how these different vocabulary standards fit together within a comprehensive record system, and how EHRs can make use of them, with a particular focus on enhancing decision-making. By incorporating the ICF and other internationally accepted vocabulary standards into our clinical information systems, physiotherapists will be able to leverage the potent capabilities of EHRs and contribute our unique clinical perspective to other health-care providers within the emerging electronic health information infrastructure.