Skip to main content
Article thumbnail
Location of Repository

Vocabulary Requirements for Implementing Clinical Guidelines in an Electronic Medical Record: A Case Study

By Frank A. Sonnenberg, C. Greg Hagerty, Janaki Acharya, David S. Pickens and Casimir A. Kulikowski


As part of a larger effort to automate guidelines we determined the number and types of clinical variables required to implement two complex clinical guidelines and the adequacy of the electronic medical record (EMR) to capture them. 178 unique variables were required by both guidelines. Variables were classified as simple (existing observation terms in the EMR), calculated (transformations of simple variables), and complex (requiring multiple simple variables and logical rules for combining them). Many variables are unlikely to be instantiated in an EMR without focused efforts to collect them. In addition, many variables required knowledge that was neither provided in the guideline nor referenced. We conclude that, although the EMR contains the necessary variables to implement these guidelines, successful automated implementation requires unambiguous definition of required terms, incorporation of additional knowledge not provided in the guideline and modification of workflow to collect variables not normally captured in routine clinical care

Topics: Article
Publisher: American Medical Informatics Association
OAI identifier:
Provided by: PubMed Central
Download PDF:
Sorry, we are unable to provide the full text but you may find it at the following location(s):
  • http://www.pubmedcentral.nih.g... (external link)
  • Suggested articles

    To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.