J Korean Med Assoc.  2012 Aug;55(8):720-728. 10.5124/jkma.2012.55.8.720.

Use of clinical terminology for semantic interoperability of electronic health records

• Park HA
• Kim HY
• Min YH

• KMID: 1435178
• DOI: http://doi.org/10.5124/jkma.2012.55.8.720

Abstract

Around the world electronic health records data are being shared and exchanged between two different systems for direct patient care, as well as for research, reimbursement, quality assurance, epidemiology, public health, and policy development. It is important to communicate the semantic meaning of the clinical data when exchanging electronic health records data. In order to achieve semantic interoperability of clinical data, it is important not only to specify clinical entries and documents and the structure of data in electronic health records, but also to use clinical terminology to describe clinical data. There are three types of clinical terminology: interface terminology to support a user-friendly structured data entry; reference terminology to store, retrieve, and analyze clinical data; and classification to aggregate clinical data for secondary use. In order to use electronic health records data in an efficient way, healthcare providers first need to record clinical content using a systematic and controlled interface terminology, then clinical content needs to be stored with reference terminology in a clinical data repository or data warehouse, and finally, the clinical content can be converted into a classification for reimbursement and statistical reporting. For electronic health records data collected at the point of care to be used for secondary purposes, it is necessary to map reference terminology with interface terminology and classification. It is necessary to adopt clinical terminology in electronic health records systems to ensure a high level of semantic interoperability.

Keyword

Semantic interoperability; Electronic health records; Clinical terminology

MeSH Terms

Dietary Sucrose
Electronic Health Records
Electronics
Electrons
Health Personnel
Humans
Patient Care
Policy Making
Public Health
Semantics
Dietary Sucrose

Figure

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  Figure 1 Relationship between interface, reference and aggregate terminologies (From Scott P, et al. An introduction to health terminologies. Lidcombe: National Centre for Classification in Health; 2002) [12]. DRG, diagnosis-related group; ICD-10-AM, International Classification of Diseases, Tenth Revision, Australian Modification; ICPC, International Classification of Primary Care; SNOMED, Systematized Nomen-Clature of Medicine.

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  Figure 2 Use of terminology in electronic health records. SNOMED CT, Systematized Nomenclature of Medicine Clinical Terms; ICD, International Classification of Diseases; MED, Medical Entities Dictionary; DSM, Diagnostic and Statistical Manual of Mental Disorders; LOINC, Logical Observation Identifiers Names and Codes; CPT, Current Procedural Terminologies; ATC, Anatomical Therapeutic Chemical Classification System.

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