Highlights of Moving Toward International Standards in Primary Care Informatics: Clinical Vocabulary Key PersonnelConference Chair H. C. Moon Mullins, M.D.Conference Co-Chair Robert D. Price, Ph.D.Conference Consultants and Facilitators Nancy M. Lorenzi, Ph.D. Robert T. Riley, Ph.D.Organizing Committee Robert M. Bernstein (Canada) Nick S. Booth (U.K.) Robert Elson (U.S.) Michael Kidd (Australia) H.C. Mullins (U.S.) Robert D. Price (U.S.)Consensus Panel Robert Elson (U.S.) Michael D. Hagen (U.S.) Philip T. Hagen (U.S.) Stephen Kay (U.K.) Michael Kidd (Australia)Telecommunications Officer Rob WilsonTranscriber Suzanne SpiersReturn to Contents AgendaMoving Toward International Standards in Primary Care Informatics: Clinical Vocabulary AMIA Family Practice/Primary Care Working Group IMIA Working Group V New Orleans, November 1-2, 1995November 13:30 p.m. Introduction: Henry C. Mullins, M.D.Conference Overview: Nancy M. Lorenzi, Ph.D., Conference Facilitator Robert T. Riley, Ph.D.3:45 Keynote Address Christopher Chute, M.D., Dr.P.H.4:30Presentation on UMLS General Overview: Charles A. Sneiderman, M.D. Expert Comments: Stuart J. Nelson, M.D. Application to Primary Care: Michael J. Lincoln, M.D.5:15 Report on Successful Global Programs Ian Purves, M.D. Rob Wilson, B.Sc.5:30 Light MealCoding Summary Panels6:30 SNOMED General Overview: Yves A. Lussier, M.D., P.Eng. Expert Comments: David J. Rothwell, M.D. Application to Primary Care: Yves A. Lussier, M.D., P.Eng.7:10 ICPC General Overview: Robert M. Bernstein,Ph.D., M.D. Expert Comments : Maurice Wood, M.D. Application to Primary Care: Michael S. Klinkman, M.D., M.S.7:50 Read Codes General Overview: Nick S. Booth, M.D. Expert Comments: Charles Stuart-Buttle, M.D. Application to Primary Care: Neill Jones, M.D.8:30 Break8:45 Participant Questions, Discussion, and Testimony9:30 Adjournment and Social HourNovember 2 (Glyn M. Hayes, M.D., Moderator)7:00 a.m. Breakfast7:30 Distribution and Overview of Consensus Report Consensus Panel Members7:45 Discussion Groups9:00 Break9:15 Development of Consensus Nancy M. Lorenzi, Ph.D. Robert T. Riley, Ph.D.11:30 Planning for the Future12:00 AdjournmentReturn to Contents Introductory LettersUniversity of South Alabama College of Medicine Department of Family Practice and Community Medicine 1504 Springhill Avenue Mobile, Alabama 36604-3273 Telephone: (334) 434-3480Moving Toward International Standards in Primary Care Informatics: Clinical VocabularyThe purpose of this conference was to begin a process of moving toward international standards in primary care informatics. It succeeded far beyond our expectations, and we believe it to be a "breakthrough" conference for shaping the future. The proceedings that follow were carefully recorded and developed to accurately reflect the conference process, discussions, and outcomes. We suggest that readers focus on the Report of Consensus, which documents the outcomes and is the most valuable and important section of these proceedings.Among the papers included in this publication, we recommend A View From the Consensus Panel, by Stephen Kay, for an appreciation of the spirit and feel of the meeting. A list of the participants and Process Overview are also included.The keynote address and the 12 intensive 15-minute presentations covering the International Classification of Primary Care (ICPC), the Read Codes, the Systematized Nomenclature of Human and Veterinary Medicine (SNOMED), and the Unified Medical Language System (UMLS) are not included in this summary but will be published elsewhere.We would like to share some of our own thoughts on future actions and direction. To be effective, our efforts must be staged. We suggest the following:Stage I:Work with national and international agencies as soon as possible.Give testimony about what occurred at this conference.Develop a glossary.Stage II:Work to accomplish all conference action items.Continue to enhance and broaden group activity through electronic communications.Plan and conduct a followup and expanded conference.Stage III:Identify potential stakeholders.Seek funding from stakeholders for future efforts.Develop methodologies for moving forward.Link with other interested agencies, activities, and professional groups.It is essential to work with national agencies. We recommend that immediate steps be taken to establish an ongoing working relationship with the Agency for Health Care Policy and Research (AHCPR), the National Library of Medicine, the National Committee on Vital and Health Statistics, and other appropriate U.S. agencies as well as agencies in other countries.We express our appreciation to the 80 attendees who traveled from 9 countries to contribute to the deliberations, to the 12 presenters who provided key information, to Nancy Lorenzi for developing and then facilitating the process, and to the American Medical Informatics Association (AMIA) and AHCPR for financial support.This conference was a beginning. A followup conference will be held in Washington, D.C., in October 1996 immediately after the Symposium of Computer Applications in Medical Care (SCAMC), and we invite you and others who are interested to attend and participate as we move closer to the goal of international standards.H. C. Mullins, M.D. Conference Chair Past Chair, Family Practice/ Primary Care Working Group of AMIAR. D. Price, Ph.D. Conference Co-Chair Chair, Family Practice/ Primary Care Working Group of AMIAPrimary Health Care Specialist Group 3 Beech Avenue North Worcester United Kingdom WR3 8PX Telephone: (+44)(0) 905 454705 (home) Fax: (+44)(0)905 456817International Medical Informatics Association (IMIA) Working Group 5 Combined Coding Standards Workshop, New Orleans, November 1995 Conducted with the American Medical Informatics Association (AMIA) Family Practice/Primary Care Working GroupIMIA Working Group 5 is responsible for information dissemination and collaboration among workers in primary care computing around the world. Part of its specific remit is the development of coding standards for the effective recording of medical conditions in the electronic medical record in such a way as to allow international communication of medical information. It is therefore with great pleasure that the IMIA Working Group acts as cosponsor to this seminal workshop held in collaboration with the AMIA Family Practice/Primary Care Working Group.Electronic medical records are beginning to become effective vehicles for the delivery of patient care. They are also providing the data for better understanding of medicine and the delivery of health care services. These benefits will be realized only if the data stored within the electronic medical record are in a consistent and transportable form. This requires effective coding systems to provide the standardization required. These coding systems must not only be standardized but must be usable by clinicians when recording medical data.There have been many attempts to develop medical coding systems in various parts of the world. Sometimes they have been tailored to meet local needs. Sometimes they have been tailored to meet the needs of particular groups of users. There has also been a divergence between those concentrated on a scientifically valid classification structure, which is needed for epidemiological purposes, and those concentrated on developing a nomenclature that suits the needs of the recording clinician. These divergent aims between local and broader requirements and between classification and nomenclature have led to many polarized views about the most appropriate types of coding system, and this argument has been continuing for quite some time.In order to move the world forward, it is important to come to some overview of coding standards to see if there is such a thing as a potential international standard coding system and, if not, whether there can be some halfway house, some agreed collaboration and interchange between the protagonists of the various coding systems. This agreement would allow users and developers of the systems to know which coding systems are appropriate under which circumstances. It would also provide the basis for communication between the various coding systems in a scientifically valid manner, so that information can be communicated between the users of these various systems.The conundrum has halted or slowed the development of international medical informatics. The New Orleans conference was indeed an excellent beginning, and the suggested actions and directions reported in these proceedings provide useful material that workers around the world can use to move forward toward international standards.Dr. Glyn Hayes Chair IMIA Working Group 5Return to Contents ParticipantsAdams, Bill, M.D. Assistant Professor of Pediatrics Boston University School of Medicine Boston City Hospital Maternity 412 818 Harrison Avenue Boston, MA 02118 Phone: 617-534-4233 badams@bu.eduBainbridge, Mike, M.D. Telematics Officer Primary Health Care Specialist Group of the British Computer Society 49 Bondgate Castle Doninaton Derby DE74 2NS U.K. Fax: 44-1332-812609 mikebain@phcsg.demon.co.ukBernstein, Robert M., Ph.D., M.D., CM, CCFP Assistant Professor, Department of Family Medicine University of Ottawa 75 Bruyere Street Ottawa, Ontario K1N 5C8 Canada Phone: 613-241-3344 Fax: 613-241-1971 rmbernst@aix1.uottawa.caBird, David Legal/Commercial Director Computer Aided Medical Systems Tannery Buildings 58 Woodgate Loughborough Leicestershire LE11 2TQ U.K. Phone: 44-1509-611006 Fax: 44-1509-235560Bolinger, Robert E., M.D. Professor Emeritus Kansas University Medical Center 3901 Rainbow Boulevard Kansas City, KS 66160 Phone: 913-588-6063Booth, Nick S., M.D. General Practitioner and Research Fellow The Sowerby Unit University of Newcastle Upon Tyne 20 Springfield, Ovington Northumberland NE42 6EH U.K. Phone: 44-1661-835526 Fax: 44-1661-830316 n.s.booth@newcastle.ac.ukBormel, Joseph I., M.D, M.P.H.. Physician Executive Cerner Corporation 11121 Lakespray Way Reston, VA 22091 Phone: 703-904-1867, ext. 6479 Fax: 703-904-9575 jbormel@cerner.comBouhaddou, Omar, Ph.D. Vice President, Knowledge Engineering Applied Medical Informatics 2681 Parleys Way, Suite 101 Salt Lake City, UT 84109 Phone: 801-464-6209 (work) 801-582-6632 (home) Fax: 801-464-6201 omar@ami-med.com URL: http://www.ami-med.comBourque, Michael Director of Operations CUNIDATA Canada Phone: 514-392-1592Brantley, Mikel S., M.D. Project Coordinator Clinical Integrated Workstation Computer Data Systems, Inc. 375 Medical Group/SGSI 310 West Losey Street Scott Air Force Base, IL 62225-5252Buvig, Hakon, M.D. Consultant INFODOC Lifaret 7 N-1410 Kolbotn Norway Phone: 47-55-12-1990 Fax: 47-55-12-3329Cheong, Ian R., B.Med.Sc., MBBS, AACS Information Management Fellow The Royal Australia College of General Practitioners 49 Christie Street Canungra QLD 4275 Australia Phone: 61-7-5543-5688 Fax: 61-7-5543-5660 cheongi@acslink.net.auChute, Christopher, M.D., Dr.P.H. Assistant Professor of Epidemiology Department of Health Sciences Research Mayo Clinic Harwick 670 Rochester, MN 55905 Phone: 507-284-5506 Fax: 507-284-1516 chute@mayo.eduNancy B. Clark, M.Ed. University of South Alabama College of Medicine 1504 Springhill Avenue Mobile, AL 36604 Phone: 334-434-3480 Fax: 334-928-0106 nclark@jaguar1.usouthal.eduDeshazer, Charles R., M.D. Vice President, Health Care Informatics Prudential Insurance Company 250 Gibraltar Road, 1 South Horsham, PA 19044 Phone: 215-443-2221 deshazer@aol.comElson, Robert, M.D. Informatics Fellow National Library of Medicine Division of Health Computer Sciences University of Minnesota Box 511 UMHC 420 Delaware Street, SE Minneapolis, MN 55455 Phone: 612-625-3246 Fax: 612-625-7166 relson@medinfo.labmed.umn.eduGnassi, John Angelo, M.D. Consultant, Laboratory of Computer Science Massachusetts General Hospital 50 Staniford Street, 5th Floor Boston, MA 02114-2517 Phone: 617-724-3543 Fax: 617-726-8481 jgnassi@lcs.mgh.harvard.eduGrayson, Rebecca R. Kaiser Permanente Medical Care Program Clinical Information System Group 1800 Harrison Street, 10th Floor Oakland, CA 94612-2998 Phone: 510-267-5629Gremp, Jennifer Associate Editor Medi-Span 8425 Woodfield Crossing P.O. Box 40930 Indianapolis, IN 46240Hagen, Michael D., M.D., FAACP Professor, Department of Family Practice University of Kentucky Kentucky Clinic K-322 Lexington, KY 40536-0284 Phone: 606-323-6711 Fax: 606-323-6661 hagen@ukcc.uky.eduHagen, Philip T., M.D. Assistant Professor of Preventive Medicine Mayo Clinic Ba5a Rochester, MN 55905 Phone: 507-284-9203 Fax: 507-284-4251 phagen@mayo.eduHannah, Kathryn J., Ph.D., R.N. Partner and Leader Health Informatics Group Sierra Systems Consultants, Inc. Suite 660 202-6th Avenue, SW Calgary, Alberta T2P 2R9 Canada Phone: 403-264-0955 Fax: 403-233-2108 khannah@sierrasys.comHarmon, Bart J., M.D. Fellow Laboratory of Computer Science Massachusetts General Hospital 8 Hudson Street Quincy, MA 02169Hausam, Robert, M.D. Postdoctoral Fellow Department of Family and Preventative Medicine Hospital and Clinical Medical Informatics University of Utah School of Medicine 1138 East Wilmington Avenue Salt Lake City, UT 84106 Phone: 801-581-2000 Fax: 801-463-0313 robert.hausam@hsc.utah.eduHayes, Glyn M., M.D. Primary Health Care Specialist Group British Computer Society 3 Beech Avenue North Worcester WR3 8PX U.K. Phone: 44-1527-579414 Fax: 44-1905-456817 glyn@conline.demon.co.ukHollingworth, Gary R., M.D. Assistant Professor Department of Family Medicine University of Ottawa 75 Bruyere Street Ottawa, Ontario K1N 5C8 Canada Phone: 613-241-3344 Fax: 613-241-1971 grholl@aix1.uottawa.caJenkins, Rolland, M.D. Senior Staff Internist and Clinical Instructor Long Beach VA Medical Center Hospital (111-GM) 5901 East Seventh Street Long Beach, CA 90822 Phone: 310-494-5748 Fax: 310-494-5155 jenkins.rolland@forum.va.govJernigan, Clarence A., M.D., M.Ph. Associate Professor, Family Medicine University of Texas Medical Branch 301 University Boulevard Galveston, TX 77555-0853 Phone: 409-772-9859 Fax: 409-772-5820 cjerniga%utmbgalv@mhost.utmb.eduJones, Neill, M.D. Clinical Consultant 2 Saxon Close Cleadon Village, Sunderland S46 7SD U.K. Phone: 44-191-519-0136 Fax: 44-191-519-3798Kay, Stephen, Ph.D. Senior Lecturer Department of Computer Science The University of Manchester Oxford Road Manchester M13 9PL U.K. Phone: 44-161-275-5719 Fax: 44-161-275-6932 sky@cs.man.ac.ukKern, Valerie C., R.N., M.S. Senior Editor Oceania 3145 Porter Drive, Suite 103 Palo Alto, CA 94304 Phone: 415-812-3038 Fax: 415-493-2202 vkern@oceania.comKetchell, Debra, M.L.S. Deputy Director, Health Sciences Libraries University of Washington Box 357155 Seattle, WA 98195-7155 Phone: 206-543-3409 Fax: 206-543-8066 ketchell@u.washington.eduKidd, Michael, M.D., FRACGP Professor of General Practice Central Clinical School The University of Sydney 37A Booth Street Balmain 2041 Australia Phone: 02-9818-1400 Fax: 02-9818-1343 michael@sugp.bal.cs.nsw.gov.auKlinkman, Michael S., M.D., M.S. University of Michigan Assistant Professor, Department of Family Practice 1818 Fuller Street Ann Arbor, MI 48109-0708 Phone: 313-998-7120, ext. 309 Fax: 313-998-7335 mklinkma@umich.eduKokiko, Elaine South Tower, Suite 1105 4340 East-West Highway Bethesda, MD 20814 Phone: 301-229-3000 Fax: 301-654-6940Legler, James D., M.D. Associate Professor, Family Practice University of Texas Health Science Center at San Antonio 7703 Floyd Curl Drive San Antonio, TX 78284 Phone: 210-270-3911 Fax: 210-220-3763 legler@uthscsa.eduLincoln, Michael J., M.D. Assistant Professor of Medicine Department of Medical Informatics University of Utah School of Medicine Room AB-193, Medical Center Salt Lake City, UT 84132 Phone: 801-581-4080 Fax: 801-581-4297 mlincoln@cmed.utah.eduLorenzi, Nancy M., Ph.D. Associate Senior Vice President and Provost Health Education University of Cincinnati Medical Center 250 Health Professions Building P.O. Box 70663 Cincinnati, OH 45267-0663 Phone: 513-558-3024 Fax: 513-558-2962 lorenzi@uc.eduLussier, Yves A., M.D., P.Eng. Accurate Informatics and Medicine, Consultants 250 King Sherbrooke, Quebec J1G 1A9 Canada Phone: 819-563-0510 Fax: 819-564-6889 ylussier@multi-medias.caMcCallie, David P., Jr., M.D. Cerner Corporation Director, Core Technologies Community Products and Services 2800 Rockcreek Parkway Kansas City, MO 64117-2551 Phone: 816-221-1024 Fax: 816-474-1742 dmccallie@cerner.comMcCormick, Kathleen A., Ph.D., R.N. Senior Science Advisor Agency for Health Care Policy and Research 2101 East Jefferson, Suite 602 Rockville, MD 20852 Phone: 301-594-1483 Fax: 301-594-2333 kmccormi@ahrq.govMcDaniel, Mary AMI Salt Lake City, UTMcGuire, Sam A., M.D. Family and Community Medicine University of Arkansas Medical Sciences Slot 530 4301 West Markham Little Rock, AR 72205 Phone: 501-686-6632 Fax: 501-686-8421 samcguire@dfcm.uams.eduMilholland, Kathy, Ph.D., R.N. Senior Policy Fellow Practice, Economics and Policy American Nurses Association 600 Maryland Avenue, SW Suite 100 West Washington, DC 20024-2520 Phone: 202-651-7060 Fax: 202-651-7001 milholl@ana.orgMorrison, Patricia Manager, Group Systems Prudential 250 Gibraltar Road, 1 South Horsham, PA 19044Moshman, John Moshman Associates, Inc. Suite 1105 South Tower 4340 East-West Highway Bethesda, MD 20814 Phone: 301-229-3000 Fax: 301-654-6940Mullins, Henry C., M.D. Professor, Family Practice University of South Alabama College of Medicine 1504 Springhill Avenue Mobile, AL 36604 Phone: 334-434-3480 Fax: 334-928-0106 hmullins@jaguar1.usouthal.eduNelsen, David A., M.D. Assistant Director Family and Community Medicine University of Arkansas 4301 West Markham, Slot 530 Little Rock, AR 72205 Phone: 501-686-6608 Fax: 501-686-8421 dnelsen@dfcm.uams.eduNelson, Brent D., Ph.D. Senior Computer Scientist Ameritech Health Connections 801 East Campbell Road, Suite 450 Richardson, TX 75081 Phone: 214-301-5503 Fax: 214-301-6161 brent.nelson@ameritech.comNelson, Stuart J., M.D. Head, Medical Subject Headings National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Phone: 301-496-1495 Fax: 301-402-2002Oates, Randall, M.D. Family Physician President and Chief Executive Officer SOAPware 803 Quandt Street Springdale, AR 72764 Phone: 501-751-9236 Fax: 501-751-7013Ojala, Matti, M.D. National Agency, Welfare and Health Box 220 Siitasaarenkatu 118 00530 Helsinki Finland Phone: 358-0-39672103 Fax: 358-0-714469 URL: http://www.stakes.fiOlenick, Jeffrey S., M.D. Pacific Medical Group 4510 Southwest Hall Boulevard Beaverton, OR 97005Olson, Kenneth P., M.D. Family Physician Park Nicollet Medical Center 1885 Plaza Drive Eagan, MN 55122-2612 Phone: 612-993-4000/4046 Fax: 612-993-4075 olson174@maroon.tc.umn.edu olsonkp@ergan.hsmnet.comPace, Wilson D., M.D. Associate Professor, Director of Information Services University of Colorado Department of Family Medicine Center for Studies in Family Medicine University of Colorado Health Sciences Center 1180 Clermont Street Denver, CO 80220 Phone: 303-270-5191 Fax: 303-270-3210 wilson.pace@uchsc.eduPedigo, Thurman L., M.D., Vanderbilt University Oxford House, Suite 405 Nashville, TN 37232-4335 Phone: 615-936-1341 Fax: 615-936-0320 pedigotl@ctrvax.vanderbilt.eduPrice, Robert D., Ph.D. Professor, Family Medicine Director, Division of Medical Informatics University of Arkansas Department of Family and Community Medicine 4301 West Markham, Slot 530 Little Rock, AR 72205 Phone: 501-686-6608 Fax: 501-686-8421 rdprice@dfcm.uams.eduPurves, Ian, MBBS, MRCGP Director, Department of Primary Health Care Informatics Sowerby Unit for Primary Care Informatics University of Newcastle Newcastle Upon Tyne NE2 4HH U.K. Phone: 44-91-222-7884 Fax: 44-91-222-6043 ian.purves@ncl.ac.ukReynoso, Guillermo A., M.D. Chief, Medical Informatics Section CEMIC-Buenos Aires Argentinean Biomedical Informatics Society Sanchez de Bustamante 2560 Buenos Aires 1425 Argentina Phone: 54-1-788-2201 Fax: 54-1-780-2000 greynoso@pinos.comRichmond, Robin, Ph.D. Healthcare Information United HealthCare Corporation MNO6-6130 P.O. Box 1459 Minneapolis, MN 55440-1459 Phone: 612-945-6152 Fax: 612-945-6502 rrichmo@uhc.comRiley, Robert T., Ph.D. President Riley Associates 221 Hilltop Lane Cincinnati, OH 45215 Phone: 513-521-3125 Fax: 513-521-9319 rileyrt@uc.eduRothwell, David J., M.D. Editor SNOMED College of American Pathologists 14515 Woodbridge Circle Brookfield, WI 53005Russler, Daniel C., M.D. MEDICALdesk P.O. Box 47 Lodi, WI 53555-0047Shoulders, Harrison H. Tracy Clinic P.O. Box 623 Monteagle, TN 37356Slager, J.N. HIS User Group c/o Achtergracht 25 The NetherlandsSneiderman, Charles A., M.D., Ph.D. Research Medical Officer National Library of Medicine B 1 N 28 L 8600 Rockville Pike Bethesda, MD 20894 Phone: 301-496-6280 Fax: 301-480-3035 charlie@nlm.nih.govSpiers, Suzanne Court Reporter/Transcriber 5060 Longview Road Elmore, AL 36025 Phone: 205-251-4200 Voice: 205-350-7895 Fax: 205-252-5644Stuart-Buttle, Charles National Health Service Center for Coding and Classification Info. Mat. Group Executive Headquarters Woodgate Loughborough Leicestershire LE11 2TG U.K. Phone: 44-1509-211411 Fax: 44-1509-211611Takeda, Hiroshi, M.D., D.Sc. Associate Professor Department of Medical Information Science Osaka University Hospital 2-15, Yamada-oka Suita 565 Japan Phone: 81-6-879-5900 Fax: 81-6-879-5903 takeda@hp-info.med.osaka-.u.ac.jpTeasdale, Sheila MAAG Manager Lincolnshire MAAG P.O. Box 206 Lincoln LN4 2JE U.K. Phone: 44-1522-569814 Fax: 44-1522-569874 sheila@informat.demon.co.ukThornton, Thomas C., M.D. Family Health Care P.O. Box 314 Upper Sandusky, OH 43351 Phone and Fax: 419-294-5711Timka, Toomas, M.D., Ph.D. Head Physician and Associate Professor of Medical Informatics and Social Medicine Departments of Community Medicine and Computer Science Linkopina University S-581 85 Linkopina Sweden Phone: 46-13-221037 tooti@da.liu.seViner, Gary, M.D. Assistant Professor University of Ottawa Department of Family Medicine 770 Broadview Avenue, Suite 105 Ottawa, Ontario K2A 3Z3 Canada Phone: 613-728-7700 Fax: 613-722-6214 gviner@uottawa.caWilliams, David, R.N. U.S. Army 902 130th Street East Tacoma, WA 98445-2967 Phone: 206-968-1605 Fax: 206-968-0974 david.williams@xmail1.ha.osd.milWilson, Rob, B.Sc. Research Assistant Sowerby Unit for Primary Care Informatics University of Newcastle 21 Claremont Place Newcastle Upon Tyne NE 24AA U.K. Phone: 44-191-222-5415 Fax: 44-191-222-6043 rob.wilson@newcastle.ac.ukWood, Maurice, M.D. Emeritus Professor, Family Practice Medical College of Virginia Route 1, Box 672 Roseland, VA 22967 Phone and Fax: 804-325-1383 wood150@aol.comZee, G.N., M.D. HIS-User-Group Hoofdwal 23-25 4207 EA Gorinchem The NetherlandsReturn to Contents Proceed to Next Section Current as of November 1995 Internet Citation: Highlights of Moving Toward International Standards in Primary Care Informatics: Clinical Vocabulary. November 1995. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/pcinform/dept1.html
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