Table 1.
Common data categories and how they are represented in electronic health records (EHRs)
| EHR data category | Structured/unstructured/mixed | Common data standarda |
|---|---|---|
| Demographics (age, gender) | Structured | |
| Demographics (race/ethnicity) | Mixed | Office of management and budget categories (ref. 40) |
| Diagnoses | Structured | ICD9/10 (ref. 41) or SNOMED-CT (ref. 42) |
| Procedures | Structured | Common Procedural Terminology (CPT) (ref. 43) |
| Medications | Mixed | RxNorm (ref. 44) |
| Vital signs (e.g., blood pressure, heart rate) | Structured (numeric) | SNOMED-CT |
| Laboratory tests | Structured | LOINC (ref. 45) |
| Laboratory results/reports | Mixed/unstructured | SNOMED-CT |
| Family history | Mixed | Under development |
| Radiology images | Structured | DICOM (ref. 46) |
| Radiology reports | Semistructured (unstructured text organized into consistent sections) | SNOMED-CT or RadLex (ref. 47) |
a
These are not exclusive, and there can be overlap of available standards across data categories (e.g., LOINC codes can represent radiology report titles).
DICOM, Digital Imaging and Communications in Medicine; ICD-9/ICD-10, International Classification of Diseases, Ninth Revision/Tenth Revision; LOINC, Logical Observation Identifiers Names and Codes; SNOMED-CT, Systematized Nomenclature of Medicine–Clinical Terms