Terminology Services: Standard Terminologies to Control Medical Vocabulary. “Words are Not What they Say but What they Mean”

Abstract

Data entry is an obstacle for the usability of electronic health records (EHR) applications and the acceptance of physicians, who prefer to document using “free text”. Natural language is huge and very rich in details but at the same time is ambiguous; it has great dependence on context and uses jargon and acronyms. 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, etc. In order to address this point, numerous terminological systems for the systematic recording of clinical data have been developed. These systems interrelate concepts of a particular domain and provide reference to related terms and possible definitions and codes. The purpose of terminology services consists of representing facts that happen in the real world through database management. This process is named Semantic Interoperability. It implies that different systems understand the information they are processing through the use of codes of clinical terminologies. Standard terminologies allow controlling medical vocabulary. But how do we do this? What do we need? Terminology services are a fundamental piece for health data management in health environment.