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First published February 24, 2006 as JAMIA PrePrint; doi:10.1197/jamia.M1957
Journal of the American Medical Informatics Association 2006;13(3):277-288
© 2006 American Medical Informatics Association

A more recent version of this article appeared on May 1, 2006
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Submitted on August 31, 2005
Accepted on January 9, 2006

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

S. Trent Rosenbloom MD, MPH1*, Randolph A. Miller MD2, Kevin B. Johnson MD2, Peter L. Elkin MD3, and Steven H. Brown MD4

Affiliation of the authors: 1 Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University, Nashville, TN, USA; School of Nursing, Vanderbilt University, Nashville, TN, USA; 2 Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University, Nashville, TN, USA; 3 Mayo Foundation for Medical Education and Research, Rochester, MN, USA; 4 Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA; U.S. Department of Veterans Affairs, USA

* To whom correspondence should be addressed.

Previous investigators have defined clinical interface terminology as a systematic collection of healthcare 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 healthcare 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 healthcare-related terminologies used for storage (e.g., SNOMED-CTr), information retrieval (e.g., MeSH) and classification (e.g., ICD9-CMr). 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 manuscript reviews historical goals and challenges of clinical terminology development in general, then focuses on the unique features of interface terminologies.




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