at the point of entry prior to being forwarded electronically for the targeted medical action (First Consulting Group, 2003).
Elements of the terminology are coded concepts, with possibly multiple synonymous text representations and hierarchical or definitional relationships to other coded concepts. No redundant, ambiguous, or vague concepts exist (Sujansky, 2003).
The meaning of each coded concept in a terminology remains forever unchanged. If the meaning of a concept needs to be changed or refined, a new coded concept is introduced. No retired codes are deleted or reused (Sujansky, 2003).
A model of the main concepts of a domain and their relationships (van Bemmel, 1997).
Consistency of views.
Consistency of views says that concepts in multiple classes have the same appearance in each context (e.g., corticosteroid as hormone or antiinflammatory agent has the same attributes and descendant concepts).
The input of data into a computer system through direct data entry, collection from a medical device, or other means (Shortliffe et al., 2001).
The basic unit of information having a unique meaning and subcategories of distinct units or values (van Bemmel, 1997).
Data interchange standards.
Syntactic and semantic rules for defining data elements and which govern the seamless communication between computer systems while preserving the meaning of the data and intended functions.
The use of a basic set of tools to extract patterns from the data in a data warehouse (van Bemmel, 1997).
A group of data elements specifically selected for a particular clinical purpose, such as clinical quality measurement, patient safety reporting, etc.
Defines how a data element is formatted or expressed. Simple data types include date, time, numeric, string, blob (large binary objects, such as images), currency, or coded element; complex data types include a structure for names, addresses, etc. (Hammond, 2002).
Database optimized for long-term storage, retrieval, and analysis of records aggregated across patient populations, often serving the longer term business and clinical analysis needs of an organization. (Shortliffe et al., 2001).