Chapter 17 – Ontologies, Vocabularies and Data Models

The purpose of this chapter is to describe current vocabulary and terminology issues and challenges related specifically to the successful implementation of clinical decision support (CDS) systems. The chapter discusses: why standard coded data are essential for accurate and reliable execution of decision logic; how to unambiguously reference data in the electronic health record (EHR) from CDS expressions; alternatives for pre- and post-coordinated representations of data; representation of patient data as name-value pairs; the relationship between terms and information/data models which provide the context of use; terminology in the life cycle of CDS; the next steps that are needed in standardizing models and terminology for use in CDS.

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