A clinical interface terminology is a systematic collection of healthcare related phrases that supports clinicians’ entry of patient-related information into computer programs. Interface terminologies also facilitate display of computer-stored patient information to clinician users as simple human-readable text. Thus interface terminologies “interface” between clinicians’ own unfettered, colloquial conceptualizations of patient descriptors and the more structured, coded internal data elements used by specific clinical computer programs. Interface terminologies allow users to interact easily with concepts through common colloquial terms and synonyms. These terminologies generally embody a rich set of flexible, “user friendly” phrases.
According to Rector, human users require flexible, expressive terminologies that model common colloquial phrases, while computer programs are generally designed to process formally defined concepts having rigidly defined interrelationships. This fundamental conflict between the needs of humans and those of computer programs that use terminologies creates a tension between clinical usability and meticulous knowledge representation.
An obstacle to widespread adoption of electronic health record systems is the difficulty associated with capturing structured clinical information from care providers, who prefer to document healthcare findings, processes and outcomes using unfettered “free text” natural language.
Electronic health record systems depend on interface terminologies for successful implementation in clinical settings because such terminologies provide the translation from clinicians’ own natural language expressions into the more structured representations required by application programs.
Clinical interface terminologies have been used for:
- Problem list entry
- Clinical documentation in EHRs
- Text generation
- Care provider order entry (CPOE) with decision support
- Diagnostic expert programs
- Design and usability study of an iconic user interface to ease information retrieval of medical guidelines
- Exploiting the potential of large databases of electronic health records for research using rapid algorithms and an intuitive query interface
- Integrating clinical research with the Healthcare Enterprise: from the RE-USE project to the EHR4CR platform
Source: Rosenbloom ST, Miller RA, Johnson KB, Elkin PL, Brown SH. Interface Terminologies: facilitating direct entry of clinical data into electronic health record systems. J Am Med Inform Assoc. 2006 Feb 24
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