The Development of Clinical Terminology Dictionary for Integration and Management of Clinical Terminologies in EMR Systems

Abstract

Objective: The development of a dictionary of clinical terminology based on medical concepts is essential for understanding the precise meanings of the clinical terminologies used in EMR systems. For an unambiguous presentation and retrieval of the terminologies in practical data entry, this study propose a clinical terminology dictionary, which integrates and manages the wide range of data in EMR Systems. Methods: The structure of the system and attributes were defined. The structures should satisfy the following: all terminologies should be consistent with the medical concepts, all concepts have multiple relationships, all concepts have many synonyms, all concepts can be mapped to concepts in an external medical terminology system, and all concepts can be grouped as value sets by setting the "domain". Results: With the derived entity objects and attributes, the physical clinical terminology database was constructed and an editor was developed using MySQL 5.0.45 and JAVA Swing. To verify the structure and contents of the developed clinical terminology dictionary, the terminology experts used the editor to search and register the medical concepts. Conclusion: Although the contents refinement and complements are an unsolved problem, it is anticipated that the proposed research will provide unambiguous meanings of the clinical terminology and be applicable to many services in EMR systems. (Journal of Korean Society of Medical Infor- matics 15-4, 411-421, 2009)