Terminology Services: Standard Terminologies to Control Health Vocabulary

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

• References

• 1 Bates DW, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc [Internet] 2003; 10 (02) 115-28 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=150365&tool=pmcentrez&ren-dertype=abstract
• 2 Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proc Annu Symp Comput Appl Med Care [Internet] 1994; 00 (01) 996 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2247898&tool=pmcentrez&render-type=abstract
• 3 Rector AL. Clinical terminology: why is it so hard?. Methods Inf Med [Internet] 1999; Dec 38 (4-5): 239-52 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/10805008
• 4 Shapiro JS, Bakken S, Hyun S, Melton GB, Schlegel C, Johnson SB. Document ontology: supporting narrative documents in electronic health records. AMIA Annu Symp Proc [Internet] 2005; 684-8 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1560738&tool=pmcentrez&render-type=abstract
• 5 Health Informatics. Hannah KJ, Ball MJ. editors (Formerly Computers in Health Care).
• 6 Evans DA, Cimino JJ, Hersh WR, Huff SM, Bell DS, Group C. Toward a Medical-concept Representation Language; 1994
• 7 Giannangelo K. Healthcare Code Sets, Clinical Terminologies, and Classification Systems. 2nd edition. Chicago: American Health Information Management Association (AHIMA); 2015. . Available from: http://library.ahima.org/PB/DataQualityModel#.Wmo5FrziaM9
• 8 Chute CG. Clinical Classification and Terminology. J Am Med Informatics Assoc 2000; 7 (03) 298-303
• 9 Cimino J. Desiderata for Controlled Medical Vocabularies in the Twenty-First Century. Methods Inf Med 2012; 37 (1998): 394-403
• 10 Alakrawi ZM. Clinical Terminology and Clinical Classification Systems: A Critique Using AHIMA's Data Quality Management Model. Perspectives Heal Inf Manag [Internet] 2016; Available from: http://perspectives.ahima.org/clinical-terminology-and-clinical-classifica-tion-systems-a-critique/
• 11 Perspectives in Health Information Management. Fall 2014 introduction. Perspect Heal Inf Manag [Internet] 2014; 11: 1a . Available from: http://www.ncbi.nlm.nih.gov/pubmed/25593567
• 12 ISO/TS 17117:2002(E): Health Informatics-Controlled health terminology—Structure and high-level indicators: Technical Committee ISO/ TC 215, Health Informatics; 2002. 18. Available from: https://www.iso.org/obp/ui/#iso:st-d:iso:ts:17117:en
• 13 International Standards Organization (ISO). TC 215 - Health Informatics. 2007; (Tc 215). Available from: http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_tc_browse.htm?com-mid=54960
• 14 Cimino JJ. Terminology tools: State of the art and practical lessons. Methods Inf Med 2001; 40 (04) 298-306
• 15 Wong ET, Pryor TA, Huff SM, Haug PJ, Warner HR. Interfacing a Stand-Alone Diagnostic Expert System with a Hospital Information System. Comput Biomed Res [Internet] 1994; Apr 27 (02) 116-29 . Available from: http://linkinghub.elsevier.com/retrieve/pii/S0010480984710123
• 16 Rosenbloom ST, Miller RA, Johnson KJ, Elkin P, Brown SH. Interface Terminologies: Facilitating Direct Entry of Clinical Data into Electronic Health Record Systems. J Am Med Inf Assoc [Internet] 2006; 13 (03) 277-88 . Available from: http://jamia.oxfordjournals.org/content/13/3/277.abstract\nhttp://www.ncbi.nlm.nih.gov/pubmed/16501181
• 17 Cimino JJ. High-quality, standard, controlled healthcare terminologies come of age. Methods Inf Med 2011; 50 (02) 101-4
• 18 Chute CG, Cohn SP, Campbell JR. A framework for comprehensive health terminology systems in the United States: Development guidelines, criteria for selection, and public policy implications. J Am Med Informatics Assoc 1998; 5 (06) 503-10
• 19 Imel M, Campbell J. Mapping from a Clinical Terminology to a Classification. AHIMA's 75th Anniv Natl Conv [Internet]. 2003; Available from: http://scholar.google.com/scholar?hl=en&btnG=-Search&q=intitle:Mapping+from+a+Clinical+-Terminology+to+a+Classification#0
• 20 Cornet R, Chute C. Health Concept and Knowledge Management: Twenty-five Years of Evolution. IMIA Yearb [Internet] 2016; 25 (Suppl. 01) S32-41 . Available from: http://www.schat-tauer.de/index.php?id=1214&doi=10.15265/IYS-2016-s037
• 21 Davoudi S, Dooling JA, Glondys B, Jones TD, Kadlec L, Overgaard SM. et al. Data Quality Management Model (2015 Update). J AHIMA [Internet] 2015; 86 (10) 62-5
• 22 Chavis S. Two Systems, One Direction. Rec [Internet] 2013; 25: 10 . Available from: http://www.fortherecordmag.com/archives/1013p10.shtml
• 23 Centers for Disease Control and Prevention. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). [Internet]. Available from: http://www.cdc.gov/nchs/icd/icd10cm.htm
• 24 Rassinoux M, Miller R, Baud RH, Scherrer JR. Compositional and enumerative designs for medical language representation. Proc AMIA Annu Fall Symp [Internet] 1997; 620-4 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2233357&tool=pmcentrez&render-type=abstract
• 25 Chute CG, Cohn SP, Campbell KE, Oliver DE, Campbell JR. The Content Coverage of Clinical Classifications. For The Computer-Based Patient Record Institute's Work Group on Codes & Structures. J Am Med Inform Assoc 1996; May-Jun; 3 (03) 224-33
• 26 Duarte J, Castro S, Santos M, Abelha A, Machado J. Improving Quality of Electronic Health Records with SNOMED. Procedia Technol [Internet] 2014; 16: 1342-50 . Available from: http://linkinghub.elsevier.com/retrieve/pii/S2212017314003788
• 27 Goeg KR, Chen R, Hojen AR, Elberg P. Content analysis of physical examination templates in electronic health records using SNOMED CT. Int J Med Inform [Internet] 2014; Oct 83 (10) 736-19 . Available from: http://linkinghub.elsevier.com/retrieve/pii/S1386505614001075
• 28 Lee D, de Keizer N, Lau F, Cornet R. Literature review of SNOMED CT use. J Am Med Informatics Assoc [Internet] 2014; Feb 1; 21 (e1): e11-9 . Available from: https://academic.oup.com/jamia/article-lookup/doi/10.1136/amiajnl-2013-001636
• 29 Chute CG, Elkin PL, Sherertz DD, Tuttle MS. Desiderata for a clinical terminology server. Proc AMIA Symp [Internet] 1999; 2 (01) 42-6 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2232621&tool=p-mcentrez&rendertype=abstract
• 30 Gambarte ML, Osornio AL, Martinez M, Reynoso G, Luna D, de Quirös FGB. A practical approach to advanced terminology services in health information systems. Stud Health Technol Inform [Internet] 2007; 129 (Pt 1): 621-5 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/17911791
• 31 Kahn CE, Wang K, Bell DS. Structured entry of radiology reports using World Wide Web technology. Radiographics 1996; 16 (03) 683-91
• 32 The Computer-Based Patient Record [Internet]. Washington, D.C.: National Academies Press; 1997. . Available from: http://www.nap.edu/cata-log/5306
• 33 Masarie FE, Miller RA, Bouhaddou O, Giuse NB, Warner HR. An Interlingua for electronic interchange ofmedical information: Using frames to map between clinical vocabularies. Comput Biomed Res [Internet] 1991; Aug ; 24 (04) 379-400 . Available from: http://linkinghub.elsevier.com/retrieve/pii/001048099190035U
• 34 Osornio AL, Gambarte ML, Otero C, Gomez A, Martinez M, Soriano E. , et al. Desarrollo de un servidor de terminología clínico. 8mo Simp Informática en Salud [Development of a clinical terminology server. 8mo Simp of health informatics]- 34 JAIIO. 2005 34(April): 29-43
• 35 Navas H, Osornio AL, Baum A, Gomez A, Luna D, de Quirós FGB. Creation and evaluation of a terminology server for the interactive coding of discharge summaries. Stud Health Technol Inform [Internet] 2007; 129 (Pt 1): 650-4 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/17911797
• 36 Luna D, de Quirós FGB, Garfi L, Soriano E, Flaherty MO. Reliability of secondary central coding of medical problems in primary care by non medical coders, using the International Classification of Primary Care (ICPC). Medinfo 2001; 10 (Pt 2): 94-7
• 37 de Quirós FGB, Dawidowsky A, Figar S. Representation of People's Decisions in Health Information Systems. Methods Inf Med 2017; 56 (Open): e13-e19 https://doi.org/10.3414/ME16-05-0001
• 38 Luna D, Lopez G, Otero C, Mauro A, Casanelli CT, de Quiros FGB. Implementation of interinstitution-al and transnational remote terminology services. AMIA Annu Symp Proc [Internet] 2010; 2010: 482-6 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3041368&tool=p-mcentrez&rendertype=abstract
• 39 Rodriguez JF, Lede DR, Perez D, Benitez S, Luna D. Abbreviations System: Preliminary Results of a Satisfaction Study. Sbis 2016; 1-6
• 40 Williams M, del PA, Perez D. Building an Snomed CT Content Extension with abbreviation support. SNOMED-CT Expo 2015
• 41 International Health Terminology Standards Development Organization (IHTSDO). SNOMED Clinical Terms User Guide. Development 2010; (January): 99
• 42 Osornio AL, Luna D, de Quiros FGB. Creación de un sistema para la codificación automática de una lista de problemas. [Creation of a system for automatic problem list codification] 5to Simp Informática en Salud - 31 JAIIO [Internet] 2002;31. Available from: http://www.sis.org.ar/sis2002/paperssis/SIS30.pdf