storing patient history via HL7 / LOINC

By: Johnathon Wright on: January 04, 2013

In addition to storing data about a patient's current visit, my clients want to store a patient history. Thus, I need to store fields like:

  • history of breast cancer? y/n
  • history of lung cancer? y/n
  • history of x cancer? y/n

and then: - if yes, any evidence of cancer in the last 5 years?

What medicines are you taking?

Have you been hospitalized for a stroke?

etc.

My initial visit to "the LOINC search engine":http://search.loinc.org/ did not reveal any codes for "history of breast cancer" etc. Perhaps there is some other term medical professionals use?

h2. HL7 to the rescue, sort of.

"Evaluation of family history information .... ":http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995709/ shows that there is quite a bit of work being done to solve this problem. ( Apparently much of it involves HL7 v3, which I have read is a big tangled mess. ) This paper mentions three standards for modeling family history, listed in order from least to most helpful (according to the authors):

  • HL7 Clinical Statement Model
  • HL7 Clinical Genomics Family History Model
  • Merged Family History Model ( not HL7; created by the document's authors.)

They also mention the "My Family History Portrait" program, which (apparently) does something similar to what we're considering.

h2. American Health Information Community Family Health History Workgroup

According to the Family History report I cited above, "the American Health Information Community Family Health History Workgroup recently outlined a core family history dataset for future EHR systems."





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