title: Standard Information Models for Representing Adverse Sensitivity Information in Clinical Documents.
abstract: BACKGROUND
  Adverse sensitivity (e.g., allergy and intolerance) information is a critical component of any electronic health record system. While several standards exist for structured entry of adverse sensitivity information, many clinicians record this data as free text.
  
  
  OBJECTIVE
  This study aimed to 1) identify and compare the existing common adverse sensitivity information models, and 2) to evaluate the coverage of the adverse sensitivity information models for representing allergy information on a subset of inpatient and outpatient adverse sensitivity clinical notes.
  
  
  METHODS
  We compared four common adverse sensitivity information models: Health Level 7 Allergy and Intolerance Domain Analysis Model, HL7-DAM; the Fast Healthcare Interoperability Resources, FHIR; the Consolidated Continuity of Care Document, C-CDA; and OpenEHR, and evaluated their coverage on a corpus of inpatient and outpatient notes (n = 120).
  
  
  RESULTS
  We found that allergy specialists' notes had the highest frequency of adverse sensitivity attributes per note, whereas emergency department notes had the fewest attributes. Overall, the models had many similarities in the central attributes which covered between 75% and 95% of adverse sensitivity information contained within the notes. However, representations of some attributes (especially the value-sets) were not well aligned between the models, which is likely to present an obstacle for achieving data interoperability. Also, adverse sensitivity exceptions were not well represented among the information models.
  
  
  CONCLUSIONS
  Although we found that common adverse sensitivity models cover a significant portion of relevant information in the clinical notes, our results highlight areas needed to be reconciled between the standards for data interoperability.
authors.affiliation: Maxim Topaz PhD, RN, MA, 93 Worcester St., Wellesley Gateway, Suite 2030I, Wellesley, MA, 02481, USA, E mail: mtopaz80@gmail.com.
authors.forename: M
authors.initials: M
authors.lastname: Topaz
authors.forename: D L
authors.initials: DL
authors.lastname: Seger
authors.forename: F
authors.initials: F
authors.lastname: Goss
authors.forename: K
authors.initials: K
authors.lastname: Lai
authors.forename: S P
authors.initials: SP
authors.lastname: Slight
authors.forename: J J
authors.initials: JJ
authors.lastname: Lau
authors.forename: H
authors.initials: H
authors.lastname: Nandigam
authors.forename: L
authors.initials: L
authors.lastname: Zhou
mesh_terms: D004282:Documentation; D057286:Electronic Health Records; D008962:Models, Theoretical; D012015:Reference Standards
keywords: Allergy; Health Level 7; electronic health records; health information systems; hypersensitivity