Interface Terminologies
Facilitating Direct Entry of Clinical Data into Electronic Health Record Systems
- Affiliations of the authors: Departments of Biomedical Informatics (STR, RAM, KBJ, SHB) and Pediatrics (STR, KBJ), School of Nursing (STR, RAM), Vanderbilt University, Nashville, TN; Mayo Foundation for Medical Education and Research, Rochester, MN (PLE); U.S. Department of Veterans Affairs, Nashville, TN (SHB)
- Correspondence and reprints: S. Trent Rosenbloom; e-mail: <trent.rosenbloom{at}vanderbilt.edu>
- Received 31 August 2005
- Accepted 9 January 2006
Abstract
Previous investigators have defined clinical interface terminology as a systematic collection of health care–related phrases (terms) that supports clinicians' entry of patient-related information into computer programs, such as clinical “note capture” and decision support tools. Interface terminologies also can facilitate display of computer-stored patient information to clinician-users. Interface terminologies “interface” between clinicians' own unfettered, colloquial conceptualizations of patient descriptors and the more structured, coded internal data elements used by specific health care application programs. The intended uses of a terminology determine its conceptual underpinnings, structure, and content. As a result, the desiderata for interface terminologies differ from desiderata for health care–related terminologies used for storage (e.g., SNOMED-CT®), information retrieval (e.g., MeSH), and classification (e.g., ICD9-CM®). Necessary but not sufficient attributes for an interface terminology include adequate synonym coverage, presence of relevant assertional knowledge, and a balance between pre- and post-coordination. To place interface terminologies in context, this article reviews historical goals and challenges of clinical terminology development in general and then focuses on the unique features of interface terminologies.
Footnotes
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The project was supported by the Vanderbilt Physician Scientist Development Program and by Grants from the United States National Library of Medicine (grant 1K22 LM008576-01 [STR] and grant 5R01 LM007995 [RAM]).
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The authors appreciate the assistance of Elizabeth Madsen in the preparation of this manuscript.
