Structuring clinical information in healthcare records.

We carried out an analytical study about names of clinical documents, titles of generic sections, names of data elements, to prepare the European Prestandard CEN ENV13606-2 on "Health Informatics--Communication of Electronic Health Care Record--Part 2: Domain Termlist". The goal of the standard is to facilitate transmission and/or homogeneous browsing of clinical information from disparate patient records, without any preliminary agreement on coding systems, data elements, record organization. With the assistance of the members of CEN/TC251/PT27 and under the control of CEN/TC251/WG I and WG II, we defined three layers to structure clinical information (structuring records into complexes, complexes into statements, statements into details) and we prepared many lists suitable to represent coarse-grained information about the different constructs used in the above layers.