Terminology-Based Recording of Clinical Data for Multiple Purposes Within Oncology

Collecting clinical data once for the use in both electronic health record (EHR) and registries requires semantic interoperability. This paper presents the results of a systematic semantic analysis of similarities and differences in clinical documentation across regional EHR and a national oncology registry to assess options for an integration of recording templates.

A comparison of current clinical information in EHR and the national registry was carried out, using SNOMED CT as frame of reference to find exact-, similar- and non-match.

Exact match was found for 9 out of 19 items from the registry and EHR, relating to clinical history, observations and findings at the examination and tumor control. Similar match concerned clinical findings of more common side effects to therapy whether present or absent. Both EHR and the registry had information with no compared match.

Clinical documentation during a follow-up in head and neck cancer contains a core set of items recorded in both EHR and registry, representing clinical history, observations and more common side effects and tumor evaluation. These core items could be the point of departure for integration or re-design of EHR-systems.