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Interface terminologies: facilitating direct entry of clinical data into electronic health record systems.

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 terminolog...

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Published in:Journal of the American Medical Informatics Association Vol. 13; no. 3; pp. 277 - 289
Main Authors: Rosenbloom ST, Miller RA, Johnson KB, Elkin PL, Brown SH, Rosenbloom, S Trent, Miller, Randolph A, Johnson, Kevin B, Elkin, Peter L, Brown, Steven H
Format: review tables/charts Journal Article
Published: Oxford University Press / USA May/Jun2006
Online Access:View this record in EBSCOhost
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      pub: Oxford University Press / USA
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        atl: Interface terminologies: facilitating direct entry of clinical data into electronic health record systems.
      aug:
        au:
          Rosenbloom ST
          Miller RA
          Johnson KB
          Elkin PL
          Brown SH
          Rosenbloom, S Trent
          Miller, Randolph A
          Johnson, Kevin B
          Elkin, Peter L
          Brown, Steven H
        affil: Department of Biomedical Informatics, School of Nursing, Vanderbilt University, and Department of Veterans Affairs, Nashville, TN, USA
      sug:
        subj:
          Classification
          Electronic Health Records
          Nomenclature
          Medicine Classification
      ab: 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.
      pubtype: Academic Journal
      doctype:
        review
        tables/charts
        Journal Article
      ougenre: Article
    language: English
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