System Design Challenges: The Integration of Controlled Vocabulary Use into Daily Practice

TL;DRAbstract

System developers face the challenge of providing tools to improve health care productivity and quality. While progress is being made, clearly defined requirements, standards and development guidelines are not yet complete enough to provide the details needed to build such software. We have moved forward and created a clinical documentation system using a controlled vocabulary. Doctors and nurses use data entry tools such as browsers and templates to access the vocabulary for creating clinical notes. Our library of terms is mapped to SNOMED which is not complete enough to support clinical documentation. Therefore our libraries have been expanded beyond SNOMED. Overall we have found that clinicians will use a controlled vocabulary when it is intuitive, predictable, flexible, complete and fast to use. Other benefits have surfaced such as more complete and consistent documentation. Our experiences to date confirm that there is still much to explore, discover, invent and create.

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