Review Paper: 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 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.

[1]  P Carpenter,et al.  Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions, and clarity. CPRI Work Group on Codes and Structures. , 1997, Journal of the American Medical Informatics Association : JAMIA.

[2]  Lawrence M. Fagan,et al.  Development of a Controlled Medical Terminology: Knowledge Acquisition and Knowledge Representation , 1995, Methods of Information in Medicine.

[3]  R A Miller,et al.  Empirical Derivation of an Electronic Clinically Useful Problem Statement System , 1999, Annals of Internal Medicine.

[4]  H. Warner,et al.  An interlingua for electronic interchange of medical information: using frames to map between clinical vocabularies. , 1991, Computers and biomedical research, an international journal.

[5]  James J. Cimino,et al.  Distributed cognition and knowledge-based controlled medical terminologies , 1998, Artif. Intell. Medicine.

[6]  J J Cimino.  The concepts of language and the language of concepts. , 1998, Methods of information in medicine.

[7]  Randolph A. Miller,et al.  Review: Medical Diagnostic Decision Support Systems - Past, Present, And Future: A Threaded Bibliography and Brief Commentary , 1994, J. Am. Medical Informatics Assoc..

[8]  Ian Horrocks,et al.  The GRAIL concept modelling language for medical terminology , 1997, Artif. Intell. Medicine.

[9]  Alexa T. McCray,et al.  Research Paper: Evaluating the Coverage of Controlled Health Data Terminologies: Report on the Results of the NLM/AHCPR Large Scale Vocabulary Test , 1997, J. Am. Medical Informatics Assoc..

[10]  C. Chute,et al.  The content coverage of clinical classifications. For The Computer-Based Patient Record Institute's Work Group on Codes & Structures. , 1996, Journal of the American Medical Informatics Association : JAMIA.

[11]  Christopher G. Chute,et al.  Standardized problem list generation, utilizing the Mayo canonical vocabulary embedded within the Unified Medical Language System , 1997, AMIA.

[12]  Peter L. Elkin,et al.  Guideline and quality indicators for development, purchase and use of controlled health vocabularies , 2002, Int. J. Medical Informatics.

[13]  F E Masarie,et al.  Quick medical reference (QMR) for diagnostic assistance. , 1986, M.D.Computing.

[14]  J. Myers,et al.  The INTERNIST-1/QUICK MEDICAL REFERENCE project--status report. , 1986, The Western journal of medicine.

[15]  W W Stead,et al.  Functional characteristics of a computerized medical record. , 1980, Methods of information in medicine.

[16]  H. E. Pople,et al.  Internist-I, an Experimental Computer-Based Diagnostic Consultant for General Internal Medicine , 1982 .

[17]  Hans-Ulrich Prokosch,et al.  Data dictionaries at Giessen University Hospital: past-present-future , 1998, AMIA.

[18]  Alan L. Rector,et al.  A formal representation for messages containing compositional expressions , 2003, Int. J. Medical Informatics.

[19]  Robert A. Greenes,et al.  A study of collaboration among medical informatics research laboratories , 1998, Artif. Intell. Medicine.

[20]  Christopher G. Chute,et al.  Viewpoint: Clinical Classification and Terminology: Some History and Current Observations , 2000, J. Am. Medical Informatics Assoc..

[21]  S. Trent Rosenbloom,et al.  Quill: A Novel Approach to Structured Reporting , 2003, AMIA.

[22]  Blackford Middleton,et al.  Evaluating Consensus Among Physicians in Medical Knowledge Base Construction , 1993, Methods of Information in Medicine.

[23]  Christopher G. Chute,et al.  The Content Coverage of Clinical Classifications , 1996 .

[24]  R. Weinshilboum.  The genomic revolution and medicine. , 2002, Mayo Clinic proceedings.

[25]  J M Teich,et al.  Impact of computerized physician order entry on physician time. , 1994, Proceedings. Symposium on Computer Applications in Medical Care.

[26]  Lawrence M. Fagan,et al.  Augmented transition networks as a representation for knowledge-based history-taking systems. , 1992, Proceedings. Symposium on Computer Applications in Medical Care.

[27]  Christopher G. Chute,et al.  A clinical terminology in the post modern era: pragmatic problem list development , 1998, AMIA.

[28]  Douglas A. Talbert,et al.  Surveying Housestaff Opinions Regarding Clinical Decision Support , 2002, AMIA.

[29]  D. Lindberg,et al.  Building the Unified Medical Language System , 1989 .

[30]  Robert H. Baud,et al.  Compositional and enumerative designs for medical language representation , 1997, AMIA.

[31]  Mark Lee,et al.  Adequacy of representation of the National Drug File Reference Terminology Physiologic Effects reference hierarchy for commonly prescribed medications , 2003, AMIA.

[32]  Kent A. Spackman,et al.  Compositional concept representation using SNOMED: towards further convergence of clinical terminologies , 1998, AMIA.

[33]  Antoine Geissbühler,et al.  Distributing knowledge maintenance for clinical decision-support systems: the "knowledge library" model , 1999, AMIA.

[34]  Peter L. Elkin,et al.  Human Interfaces: Face-to-Face with the Problem List , 1999, AMIA.

[35]  Kevin B. Johnson,et al.  Clictate: A Computer-Based Documentation Tool for Guideline-Based Care , 2004, Journal of Medical Systems.

[36]  W. Hammond,et al.  Computerized decision support based on a clinical practice guideline improves compliance with care standards. , 1997, The American journal of medicine.

[37]  Marc Berg,et al.  Viewpoint Paper: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors , 2003, J. Am. Medical Informatics Assoc..

[38]  A. Rector,et al.  A Terminology Server for Medical Language and Medical Information Systems , 1995, Methods of Information in Medicine.

[39]  A. L. Rector.  Clinical terminology : Why is it so hard? : Challenges to Progresses , 1999 .

[40]  Kent A. Spackman,et al.  SNOMED RT: a reference terminology for health care , 1997, AMIA.

[41]  Robert H. Baud,et al.  Modeling Just the Important and Relevant Concepts in Medicine for Medical Language Understanding: A Survey of the Issues , 1997 .

[42]  A. C. Scott,et al.  Evaluating the performance of a computer-based consultant. , 1979, Computer programs in biomedicine.

[43]  A L Rector,et al.  Goals for concept representation in the GALEN project. , 1993, Proceedings. Symposium on Computer Applications in Medical Care.

[44]  W. Slack,et al.  A computer-based medical-history system. , 1966, The New England journal of medicine.

[45]  Christopher G. Chute,et al.  Desiderata for a clinical terminology server , 1999, AMIA.

[46]  Christopher G. Chute,et al.  Position Paper: A Framework for Comprehensive Health Terminology Systems in the United States: Development Guidelines, Criteria for Selection, and Public Policy Implications , 1998, J. Am. Medical Informatics Assoc..

[47]  Ian R. Horrocks,et al.  A C OMPARISON OF TWO TERMINOLOGICAL KNOWLEDGE REPRESENTATION SYSTEMS , 1995 .

[48]  George Hripcsak,et al.  Review Paper: Detecting Adverse Events Using Information Technology , 2003, J. Am. Medical Informatics Assoc..

[49]  W R Hogan,et al.  Common medical terminology comes of age, Part One: Standard language improves healthcare quality. , 2001, Journal of healthcare information management : JHIM.

[50]  Stanley M. Huff,et al.  Position Paper: Toward a Medical-concept Representation Language , 1994, J. Am. Medical Informatics Assoc..

[51]  H. E. Pople,et al.  Internist-1, an experimental computer-based diagnostic consultant for general internal medicine. , 1982, The New England journal of medicine.

[52]  J M Teich,et al.  Enhancement of clinician workflow with computer order entry. , 1995, Proceedings. Symposium on Computer Applications in Medical Care.

[53]  S. G. Axline,et al.  Computer-based consultations in clinical therapeutics: explanation and rule acquisition capabilities of the MYCIN system. , 1975, Computers and biomedical research, an international journal.

[54]  Kent A. Spackman,et al.  Mapping between SNOMED RT and Clinical terms version 3: a key component of the SNOMED CT development process , 2001, AMIA.

[55]  G. Gorry,et al.  Towards the simulation of clinical cognition. Taking a present illness by computer. , 1976, The American journal of medicine.

[56]  Christopher G. Chute,et al.  A clinically derived terminology: qualification to reduction , 1997, AMIA.

[57]  William T. Hole,et al.  Research Paper: Integrating SNOMED CT into the UMLS: An Exploration of Different Views of Synonymy and Quality of Editing , 2005, J. Am. Medical Informatics Assoc..

[58]  Yves A. Lussier,et al.  Putting Data Integration into Practice: Using Biomedical Terminologies to Add Structure to Existing Data Sources , 2003, AMIA.

[59]  James R. Campbell,et al.  n Phase II Evaluation of Clinical Coding Schemes : Completeness , Taxonomy , Mapping , Definitions , and Clarity , 2022 .

[60]  D. Stallknecht.  FACT SHEET , 2006 .

[61]  Olivier Bodenreider,et al.  The lexical properties of the gene ontology , 2002, AMIA.

[62]  Vimla L. Patel,et al.  Research Paper: Studying the Human- Computer-Terminology Interface , 2001, J. Am. Medical Informatics Assoc..

[63]  G. Kuperman,et al.  Computer Physician Order Entry: Benefits, Costs, and Issues , 2003, Annals of Internal Medicine.

[64]  J J Cimino,et al.  Toward a medical-concept representation language. The Canon Group. , 1994, Journal of the American Medical Informatics Association : JAMIA.

[65]  M. Roux,et al.  A Model for Medical Knowledge Representation Application to the Analysis of Descriptive Pathology Reports , 1995, Methods of Information in Medicine.

[66]  D. Durack.  The weight of medical knowledge. , 1978, The New England journal of medicine.

[67]  Steffen Schulze-Kremer,et al.  The Ontology of the Gene Ontology , 2003, AMIA.

[68]  Mark A. Musen,et al.  Research Paper: A Logical Foundation for Representation of Clinical Data , 1994, J. Am. Medical Informatics Assoc..

[69]  Lawrence M. Fagan,et al.  Research Paper: The PEN-Ivory Project: Exploring User-interface Design for the Selection of Items from Large Controlled Vocabularies of Medicine , 1996, J. Am. Medical Informatics Assoc..

[70]  E. B. Steen,et al.  The Computer-Based Patient Record: An Essential Technology for Health Care , 1992, Annals of Internal Medicine.

[71]  Betsy L. Humphreys,et al.  Technical Milestone: The Unified Medical Language System: An Informatics Research Collaboration , 1998, J. Am. Medical Informatics Assoc..

[72]  Douglas S. Bell,et al.  Structured entry of radiology reports using World Wide Web technology. , 1996, Radiographics : a review publication of the Radiological Society of North America, Inc.

[73]  Lawrence M. Fagan,et al.  Medical Informatics: Computer Applications in Health Care , 1991 .

[74]  Kent A. Spackman,et al.  Review: Representing Thoughts, Words, and Things in the UMLS , 1998, J. Am. Medical Informatics Assoc..

[75]  Christopher G. Chute,et al.  The Copernican era of healthcare terminology: a re-centering of health information systems , 1998, AMIA.

[76]  James R. Campbell.  Semantic Features of an Enterprise Interface Terminology for SNOMED RT , 2001, MedInfo.

[77]  Alan L. Rector,et al.  Research Paper: Medical-Concept Models and Medical Records: An Approach Based on GALENand PEN&PAD , 1995, J. Am. Medical Informatics Assoc..

[78]  Peter L Elkin,et al.  Primer on medical genomics part V: bioinformatics. , 2003, Mayo Clinic proceedings.

[79]  Christopher G. Chute,et al.  Barriers to the clinical implementation of compositionality , 1999, AMIA.

[80]  George Hripcsak,et al.  Research Paper: Knowledge-based Approaches to the Maintenance of a Large Controlled Medical Terminology , 1994, J. Am. Medical Informatics Assoc..

[81]  A. Rector.  Thesauri and Formal Classifications: Terminologies for People and Machines , 1998, Methods of Information in Medicine.

[82]  J. Cimino.  Desiderata for Controlled Medical Vocabularies in the Twenty-First Century , 1998, Methods of Information in Medicine.

[83]  Christopher G. Chute,et al.  A large-scale evaluation of terminology integration characteristics , 1999, AMIA.

[84]  W W Stead,et al.  Computer-assisted interview of patients with functional headache. , 1972, Archives of internal medicine.

[85]  A. Rector.  Clinical Terminology: Why Is it so Hard? , 1999, Methods of Information in Medicine.

[86]  Standards for medical identifiers, codes, and messages needed to create an efficient computer-stored medical record. American Medical Informatics Association. , 1994, Journal of the American Medical Informatics Association : JAMIA.

[87]  D J Madlon-Kay.  The weight of medical knowledge: still gaining. , 1989, The New England journal of medicine.

[88]  P. Miller,et al.  Critiquing Anesthetic Management: The “ATTENDING” Computer System , 1983, Anesthesiology.

[89]  Reed M. Gardner,et al.  The HELP hospital information system: update 1998 , 1999, Int. J. Medical Informatics.

[90]  et al.,et al.  The Regenstrief Medical Record System: a quarter century experience , 1999, Int. J. Medical Informatics.

[91]  J R Campbell,et al.  A framework for comprehensive health terminology systems in the United States: development guidelines, criteria for selection, and public policy implications. ANSI Healthcare Informatics Standards Board Vocabulary Working Group and the Computer-Based Patient Records Institute Working Group on Codes , 1998, Journal of the American Medical Informatics Association : JAMIA.