Clinical Terminologies: A Solution for Semantic Interoperability / 대한의료정보학회지

To realize the benefits of electronic health records, electronic health record information needs to be shared seamlessly and meaningfully. Clinical terminology systems, one of the current semantic interoperability solutions, were reviewed in this article. Definition, types, brief history, and examples of clinical terminologieswere introduced along with phases of clinical terminology use and issues on clinical terminology use in electronic health records. Other attempts to standardize the capture, representation and communication of clinical data were also discussed briefly with future needs.

Developing a Reference Terminology Model for Health Care Using an Object-Oriented Approach / 대한의료정보학회지

OBJECTIVE: A reference terminology is essential to achieve semantic interoperability and enhance the quality of health care. Reference terminologies that have achieved common acceptance contain many concepts that clinicians would not want in healthcare, which preclude their practical use in documentation of patient information. To solve the problems, this document proposes a reference terminology model which contains concepts that physicians can use satisfactorily. METHODS: We analyzed the structures of the UMLS and SNOMED CT. We also analyzed health care terms which had been collected by the Korea National Health Information Standard Committee. Based on the results of the analysis, we developed an object-oriented reference terminology model. And, we designed database schema with the model. RESULTS: Eight components of the UMLS and six components of the SNOMED CT were analyzed. The collected terms had various properties and mapping vocabularies according to the characteristics of their respective domains. A reference terminology model was developed from a three-level view using UML. A database schema was developed using ERD. CONCLUSION: This study mainly focuses on reference terminology modeling. It is hoped that this reference terminology modeling helps the semantic interoperable exchange of clinical documents as the basis of common EMR.

Standardization of Main Concept in Chief Complaint Based on SNOMED CT for Utilization in Electronic Medical Record / 대한의료정보학회지

The electronic medical record is gradually penetrating the world-wide healthcare environment, including Korea. Users of electronic medical record want to get full advantages of it, but benefits would not be realized by simple implementation. Wellorganized architecture and controlled medical vocabulary are needed for achieving effective electronic medical record system. Many terminologies are introduced in healthcare system but single noble terminology to cope with users' need is not present. To extract clinically useful and standardized set of chief complaints for electronic medical record in our institutional environment, we analyzed chief complaints in 235,426 discharge summaries in Seoul National University Hospital. We normalized the chief complaint by 27 medical experts. First of all, researchers parsed chief complaints as main concept, qualifier, and modifier. We normalized main concepts, keeping applicability and usability of extracted set to electronic medical record in mind. And then, mapping set of chief complaint to SNOMED CT was done by 4 physicians. Among 94,913 unique strings, we selected 6,317 terms as standard set of chief complaint. The potential users of electronic medical record were asked to evaluate usability of the set and accepted it as representative of chief complaint. The majority of terms in set were completely mapped to SNOMED CT. We discussed several principles in normalizing chief complaints. We also pointed pros and cons of SNOMED CT as reference terminology to chief complaint domain. Through this study, we developed conceptually standardized chief complaint domain with user-friendly terms in Seoul National University Hospital Environment. Furthermore, this result would be the starting point to evolve medical terms in Korea into ontology based terminology system.