Standards & Terminologies | Joint Commission
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Standards & Terminologies

April 28, 2016

Pioneers in Quality Portal - Articles and Publications

  • Harmonizing and extending standards from a domain-specific and bottom-up approach:  an example from development through use in clinical applications. J Am Med Inform Assoc.  2015 May;22(3):545-52

    • Structured nursing documentation addressing skin and wound assessments with a primary emphasis on pressure ulcer documentation from 6 large organizations was analyzed to generate a common information model and terminologies that fully expressed documentation across all systems. The objective was to use this bottom-up approach to harmonize and extend standards by leveraging the knowledge within local documentation artifacts.  Results:  Significant gaps in existing standards were identified. The models and terminologies were submitted to and incorporated by standards development organizations and are published, implemented, and now serving as a foundation for an eMeasure.

      While this article does not specifically address eCQM’s it describes how the documentation can and should feed the standards development process and ultimately emeasure reporting. 

  • Design, Development, and Initial Evaluation of a Terminology for Clinical Decision Support and Electronic Clinical Quality Measurement. AMIA Annu Symp Proc. 2015 Nov 5;2015:843-51. eCollection 2015.

    • When coupled with a common information model, a common terminology for clinical decision support (CDS) and electronic clinical quality measurement (eCQM) could greatly facilitate the distributed development and sharing of CDS and eCQM knowledge resources. To enable such scalable knowledge authoring and sharing, we systematically developed an extensible and standards-based terminology for CDS and eCQM in the context of the HL7 Virtual Medical Record (vMR) information model. The development of this terminology entailed three steps: (1) systematic, physician-curated concept identification from sources such as the Health Information Technology Standards Panel (HITSP) and the SNOMED-CT CORE problem list; (2) concept de-duplication leveraging the Unified Medical Language System (UMLS) MetaMap and Metathesaurus; and (3) systematic concept naming using standard terminologies and heuristic algorithms. This process generated 3,046 concepts spanning 68 domains. Evaluation against representative CDS and eCQM resources revealed approximately 50–70% concept coverage, indicating the need for continued expansion of the terminology.

 
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