Difference between revisions of "Facilitating direct entry of clinical data into electronic health record systems"

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Revision as of 16:43, 11 October 2008

Interface Terminologies: Development, Use and Evaluation

The number, size, and intended uses of clinical terminologies have expanded over time. While many terminologies have been developed, no single terminology has been accepted as a universal standard for the representation of clinical concepts.

The growth and expanded use of clinical terminologies led to a recognition of the need for standards in their development and evaluation. Published desiderata for terminology development include complete domain coverage which is often achieved by providing for both pre-coordination and post-coordination of concepts.

In order to balance terminology domain coverage with clinical usability, terminology developers should limit their scope to building terminologies designed for specific use cases. 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 allow users to interact easily with concepts through common colloquial terms and synonyms.

Clinical terminologies should be developed and evaluated based on their intended use because this use determines its structure and content. Interface terminologies should be evaluated on at least the following attributes:

· Presence of relevant assertional medical knowledge.

· Adequacy of synonymy.

· A balance between pre-coordination and post-coordination

· Mapping to terminologies having formal concept representation

Historically, developers have created various types of clinical terminologies to meet specific needs. The authors believe that, to improve and guide the evolution of interface terminologies, feedback based on formally defined evaluation metrics are necessary.

Comment: This article draws on the major historical work in clinical terminologies to summarize the standards used to develop and evaluate clinical terminologies. This historical overview of terminologies lays the ground work for understanding why we need interface terminologies, what purpose they serve, how they differ from reference terminologies, and what standards they must meet. A must read for anyone interested in the use of clinical terminologies (whether as a reference or interface terminology).