MEDCIN, a system of standardized medical terminology, is a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems.

Developed by Medicomp, it includes over 250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 26 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED, CPT, ICD, GSM and LOINC. The MEDCIN coding system is the ideal coding system for point-of-care documentation and architecture. Several Electronic Medical Record (EMR) systems are embedded with MEDCIN, which produces fully structured and numerically codified patient charts that enable the aggregation, analysis, and extensive mining of all clinical and practice management data related to a disease, a patient or a population.

In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged. ^[9]

In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda.[4] EMRs, while an important factor in interoperability, are not a critical first step to sharing data between practicing physicians, pharmacies and hospitals. Many physicians currently have computerized practice management systems that can be used in conjunction with health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centered and portable care. There are currently multiple competing vendors of EHR systems, each selling a software suite that in many cases is not compatible with those of their competitors. Only counting the outpatient vendors, there are more than 25 major brands currently on the market. In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer, in order to address interoperability issues and to establish a National Health Information Network (NHIN). Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. Congress is currently working on legislation to increase funding to these and similar programs.

The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with CCHIT interoperability standards.

The Center for Information Technology Leadership described four different categories (“levels”) of data structuring at which health care data exchange can take place. ^[10] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.