Summary
Healthcare Information Systems should capture clinical data in a structured and preferably
coded format. This is crucial for data exchange between health information systems,
epidemiological analysis, quality and research, clinical decision support systems,
administrative functions, among others. Structured data entry is an obstacle for the
usability of electronic health record (EHR) applications and their acceptance by physicians
who prefer to document patient EHRs using “free text”. Natural language allows for
rich expressiveness but at the same time is ambiguous; it has great dependence on
context and uses jargon and acronyms. Although much progress has been made in knowledge
and natural language processing techniques, the result is not yet satisfactory enough
for the use of free text in all dimensions of clinical documentation. In order to
address the trade-off between capturing data with free text and at the same time coding
data for computer processing, numerous terminological systems for the systematic recording
of clinical data have been developed. The purpose of terminology services consists
of representing facts that happen in the real world through database management in
order to allow for semantic interoperability and computerized applications. These
systems interrelate concepts of a particular domain and provide references to related
terms with standards codes. In this way, standard terminologies allow the creation
of a controlled medical vocabulary, making terminology services a fundamental component
for health data management in the healthcare environment. The Hospital Italiano de
Buenos Aires has been working in the development of its own terminology server. This
work describes its experience in the field.
Keywords
Terminology server - interface vocabulary - controlled vocabularies - semantic interoperability
- standard terminology
