RACSEL: Technical Recommendations for Electronic Health Record Implementation

The development of the Electronic Health Record (EHR), includes the preparation of reports and technical documents about medical terminology. This document aims to describe a reference model to adopt information standards among countries.   In this way, it is not intended to evaluate the adequacy of the national drug catalog for each country, nor to modify or replace it. The intention is to indicate which is the controlled vocabulary that is considered most appropriate to represent the information related to the medicines when it is being shared with another country.

This book presents the basic concepts of interoperability and types of language and tools considered in the semantic field. Then, it defines the use case considered to prepare all the studies and technical documents of the terminology component and summarizes what initiatives have been considered to identify and select the reference vocabulary.

The use of standardized terminologies is necessary for all dimensions of clinical work. This book focuses only on the dimension of the pharmaceutical and biological products due to the restriction of the project's own time and not because other areas of clinical work are not considered important.