An interface terminology for medical imaging ordering purposes

Area of Science:

• Medical Informatics
• Health Data Management
• Clinical Terminology

Background:

• Reference terminologies (RT) in electronic health records (EHRs) present usability challenges for end-users.
• Interface terminologies (IT) offer a potential solution by tailoring terms for specific users and tasks while linking to RT.
• Structured data is crucial for efficient EHRs, but current systems often lack user-friendly terminologies.

Purpose of the Study:

• To propose and qualitatively evaluate an interface terminology (IT) for medical imaging prescription.
• To assess the usability and effectiveness of an IT based on the French Common Classification of Medical Acts (CCAM) nomenclature.
• To explore improvements in data structuring and adoption of computerized ordering processes in healthcare.

Main Methods:

• Developed an IT for medical imaging prescription, linking to the French CCAM nomenclature.
• Adapted creation and evaluation processes from established guidelines for IT development.
• Qualitatively evaluated the developed IT, assessing its features and user-friendliness.

Main Results:

• The developed IT contains 290 orderable terms linked to 249 CCAM codes, available via a web platform.
• The prescription IT demonstrates significantly richer synonymy and shorter labels compared to the CCAM nomenclature.
• Challenges were identified with the CCAM, primarily due to its billing-oriented nature.

Conclusions:

• The developed IT enhances medical imaging prescription by providing more user-friendly and semantically rich terminology.
• Mapping the IT to international terminologies like RadLex or SNOMED is planned for broader compatibility.
• This IT has the potential to accelerate the adoption of computerized ordering systems in France.