UNMC/NHS Creates Medical Vocabulary for Computers,
Clinicians
Several years ago, clinicians and computers didn’t speak the same language.
Today, they can because of a multi-year effort by the University of
Nebraska Medical Center and Nebraska Health System to identify, clarify
and code existing medical terminology into a language understood by man
and machine.
IDX Systems recently incorporated UNMC’s Clinical Lexicon, or controlled
medical vocabulary, into the IDX LastWord enterprise clinical system. IDX
recently publicized the efforts of UNMC/NHS when it announced that the
software was available to clients across the country.
“The lexicon is like a translator between the way a doctor talks and
the way a computer stores information,” said James Campbell, M.D., medical
director of clinical informations systems development for UNMC/NHS. “Prior
to the lexicon there had not been an interface to a standardized vocabulary.”
In the 1980s, the General Accounting Office did a nationwide study that
determined that computerized clinical information systems could improve
patient care, as well as save money. However, they recognized that a substantial
barrier to this development was creation of standard vocabulary.
In 1995, staff at UNMC/NHS had begun gathering medical terms used across
campus. Over the course of some 10,000 hours of hard work, they organized,
clarified and coded 14,000 different clinical terms. In doing so, they
were able to create an interface for a computerized “problem list” (a summary
of issues that might impact the health care of a patient).
Today, UNMC/NHS has a computerized record-keeping system that allows
clinicians to have instant access to a patient’s complete medical chart,
including health-related conditions, medications, test results and allergies.
“It’s like building a car,” Dr. Campbell said. “We built the steering
wheel and IDX provided the chassis.
An electronic browsing tool allows clinicians to easily search a patient’s
record, as well as access necessary codes for billing purposes. The software,
for example, allows a physician to identify patients who may need a particular
vaccine based on their medical summary, or ‘problem list.’ It also allows
the clinician to search the entire database for patients who would most
benefit from a treatment.
UNMC/NHS has been using the software for nearly three years. Making
a standardized record available on the computer has improved access to
clinical information for decisions whenever and wherever the patient seeks
care, Dr. Campbell said. The computerized clinical data also helps ongoing
efforts to reduce errors in patient care and make further improvements
in treating patients.
It was important to provide clinical staff with the tools they need
to effectively care for patients,” Dr. Campbell said. “Clinical systems
must employ language familiar to the clinical community.”