title: Terminology-Based Recording of Clinical Data for Multiple Purposes Within Oncology.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: Department of Oncology, Aalborg University Hospital, Denmark.
authors: Dorthe
authors: D
authors: Brønnum
authors: Department of Health Science and Technology, Aalborg University, Denmark.
authors: Anne Randorff
authors: AR
authors: Højen
authors: Department of Health Science and Technology, Aalborg University, Denmark.
authors: Kirstine Rosenbeck
authors: KR
authors: Gøeg
authors: Department of Health Science and Technology, Aalborg University, Denmark.
authors: Pia Britt
authors: PB
authors: Elberg
mesh_terms: D003625:Data Collection / Q000379:methods*; D057286:Electronic Health Records; D066275:Health Information Exchange; D006751:Hospital Information Systems; D006801:Humans; D008495:Medical Oncology / Q000706:statistics & numerical data*; D012042:Registries; D039061:Systematized Nomenclature of Medicine; D009626:Terminology as Topic