Facilitating direct entry of clinical data into electronic health record systems

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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. [1]

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.


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).

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.


  1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513664/