International Patient Summary Terminology.

SNOMED CT is a comprehensive medical ontology used in health care sectors across the world covering a wide range of concepts that support diversity at the point of healthcare. However, not all these concepts are needed for every use case; it is better to concentrate on those parts that apply to the particular application while preserving the meaning of relevant concepts. This paper considers the application of a novel subontology extraction method to create a new resource, called the IPS terminology, which functions as a standalone ontology with the same features as SNOMED CT, but is designed for cross-border patient care. The IPS terminology has been released for free use under an open license, with the intention of promoting interoperability of health information worldwide.

A practical approach to advanced terminology services in health information systems.

As the medical informatics field evolves, new functions appear as the focus of interest; a more advanced management of terminology is one of them. Using comprehensive and detailed terminology to represent clinical rules in computer systems, associated with patient information, would allow clinical software to provide patient specific recommendations or alerts. In order to uniform data collection through our HIS, and lay the foundations for future clinical decision support systems, we decided to move from our previous classification-based medical record into new terminology services built around Snomed CT, Spanish Language Version. This paper describes the characteristics of our Terminology Server. The most important achievements of our new terminology system are the centralization of knowledge representation, using a much more detailed terminology system. Clinical data entered at any place of the institution and level of care, is represented uniformly through the whole health information system.

Creation and evaluation of a terminology server for the interactive coding of discharge summaries.

Free text entry versus structured data has been proposed as models in data entry in health information systems. A new user interface was developed with the objective of improving data capture. It also implemented a modification of the discharge summary data entry user interface that allowed the selection of already coded terms from a local terminology in the context of an inpatient electronic medical record. This software interacts online with a terminology server to provide feedback on data entry to clinical users in order to automatically code data. To evaluate the impact of this new software, we measured user satisfaction and the impact on autocodification rate. The new system had good acceptance from the users who ranked it high using QUIS (Questionnaire for User Interaction Satisfaction) and the auto codification rate improved from 61.5% to 88.39%.

Creation of a local interface terminology to SNOMED CT.

This paper describes the steps followed in the creation of a local Interface Terminology to SNOMED CT (as reference terminology) with a strong focus on user acceptability. The resulting list of terms is used for clinical data input by physicians and nurses at the Hospital Italiano in Buenos Aires, Argentina. Description includes data model, mappings to SNOMED CT and classifications, subsets definitions and extensibility mechanisms. The Interface Terminology is currently used in the recording of diagnosis and procedures in inpatient discharge summaries and its coverage is improving from user feedback. Its current size is 24,800 concepts, 67% of them needed post-coordination for appropriate semantic representation, due to a very flexible policy that allows the use of any number of modifiers on concepts.