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; 13: 277-88

Bridging the Gap Between Clinician Data Capture and Clinical Data Entry in an EHR with Interface Terminologies

Interface terminologies exist to create a supported pathway between storage structures and clinician data capture in an electronic health record (EHR). These tools provide translation between natural language expresses that humans are used to into the structured representation required by machines using software applications for documentation. This review article provides the history of terminology development in health care and provides a listing of important research works that form a foundation use today that uses concepts as building blocks rather than words, terms and phrases that may have more than one meaning. A table that outlines the overlap and differences among the three sets of desiderata currently recognized based on work by Cimino, Chute, et al and ISO (International Standards Organization) is featured.

This review also a confirms that terminologies allowing post-coordination provide better domain coverage than those that do not; and then outlines the consequence of post-coordination of terms. The rigor required for terminologies to serve as a controlled medical vocabulary may create a system that requires interface terminologies to simplify use and keep the terminology down “inside the box”.

The needs of human users that deposit data and the machines that process and store it for retrieval have fundamentally different needs. Humans prefer expressive terminologies while a computer works best with rigidly defined interrelationships so interface terminologies are developed and specifically designed to support a user-friendly data entry portal to the EHR. These interface terminologies can be mapped to the reference terminology and this research provides a table to illustrate the relative importance of terminology attributes comparing an interface terminology with clinical terminology systems in general. These attributes are expected to have an impact on terminology usability to serve as the supported pathway for data transfer between humans and machines. Interface terminologies designed with the desiderata in mind and the insight provided in this review article that summarizes their use will improve the human/computer relationship.