Clinical terminology: why is it so hard?

Area of Science:

• Health Informatics
• Clinical Software Engineering
• Medical Terminology

Background:

• Widespread adoption of reusable clinical terminologies remains elusive despite significant efforts.
• Traditional uses of clinical terminology for statistical and financial reporting differ substantially from patient-centered software requirements.

Purpose of the Study:

• To identify and explain the key challenges in developing reusable clinical terminologies for modern healthcare software.
• To highlight the underestimation of complexity and scale required for patient-centered systems.

Main Methods:

• Analysis of the fundamental difficulties in creating and implementing clinical terminologies within software systems.
• Examination of the gap between manual management capabilities and the rigor required for software applications.
• Consideration of 'clinical pragmatics'—practical aspects of data entry, presentation, and retrieval in clinical workflows.

Main Results:

• Ten primary reasons are presented, emphasizing the underestimation of the transition from traditional reporting to patient-centered software.
• The scale and complexity of clinical data for software far exceed manual management capabilities.
• Addressing the differences between user needs and software requirements, including clinical pragmatics, is essential.

Conclusions:

• Developing reusable clinical terminologies requires acknowledging and addressing significant increases in scale and complexity.
• Integrating clinical pragmatics and ensuring software usability are critical for successful implementation.
• Validation must extend to the practical application of terminologies within implemented software systems.