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The records show up as columns, fields show up as columns and each data in the table is called a cell. Forms are designed by database designers to enable users to enter data in the database.
The human body comprises numerous interrelated systems and each system is critical for having a healthy body. Furthermore, a doctor diagnoses ailments concerning each system by assessing the medical data associated with that particular system, hence there is a range of medical data that is assessed. Key forms of medical data include (Szolovitz, 2002):
- Numerical data about various laboratory data, and bedside measurements.
- Physiological data like ECG, EEG, EMG, etc.
- Imaging data like X-Ray, MRI, CT, Ultrasound, and Pathology.
- Genetic data.
- Historic and family data.
- Narrative data prepared by doctors and paramedical personnel.
Information records about this data include patient records and medical records. Electronic forms of these records are relevant to this project.
Healthcare is a safety and security-critical domain. The safety and security of medical data can only be maintained if it is acquired, processed, stored and shared in a systematic and structured manner. Hence it calls for proper nomenclature, coding and standardization of the medical data. Systems like clinical vocabularies, and coding systems are structured formats that enable error-free unambiguous care and treatment of the patient (Rogers, 2005). These terminologies (like SNOMED CT) and coding and standardization systems (like International Classification of Diseases) are facilitating the development of healthcare IT standards like Heath Level 7 (HL7) at the global level and such standards are leading to the development of interoperable information systems in healthcare.
Various forms of health information standards that may be applicable pertain to classifications, guides, practices, and terminology. Furthermore, there are identifier standards that enable flawless identification of patients, products, providers, Sites of care etc. Communications standards pertain to message formats, these include DICOM (Digital Imaging and Communication in Medicine) and HL7, National Electrical Manufacturers Association (NEMA) is responsible for DICOM and ANSI is the organization that has accredited HL7. IEEE has been working on Medical Data Interchange Standard (MEDIX) and Medical Information Bus. Standards on content and structure are also underway, ASTM is the agency that is working on these standards. As far as clinical data representation is concerned, ICD-10 is the standard that has been developed by World Health Organisation. Laboratory Observation Identifier Name and Codes (LOINC) has been developed by a group of pathologists and these codes are being incorporated into the Unified Medical Language System (UMLS) that is being maintained by the National Library of Medicine (Blair, 1999). Similarly, some standards about confidentiality, data security, authentication, quality indicators, data sets and guidelines.
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