Structured terminologies in clinical information systems: implementation through collaboration

The structure and content of the dialog with a clinical end-user is a critical aspect of clinical information system use, data capture and retrieval, and efficient and effective health care. This dialog is driven ultimately by embedded structures and processes that: a) provide functional models of clinical expression in support of professional practice, and b) determine how structured terminologies ought to populate these models. Based on diverse practical experience, this study identifies challenges to implementing structured clinical terminologies, categorizing them by both stakeholder group and application area. Collaboration across all stakeholders and across a wide range of application areas is identified as a key ingredient to successful terminology implementation and use.