This section identifies terminology services required to support the design of data entry forms and templates that incorporate terminology bindings. The objective of these templates is to facilitate the entry of appropriate concepts (or expressions) into electronic health records.
As noted in the previous section, there are a variety of different EHR data entry contexts and each context logically constrains the range of concepts that can be used. This logical constraint can be formally specified using a value set binding represented as an expression constraint. Similarly, the data entry context may affect the meaning of data entered and this can be formally specified using a meaning binding represented by an expression or expression constraint.
A well designed template can simplify data entry and improve data quality by limiting the range of concepts available to those appropriate to a particular data entry context. Table 3.2.2-1 provides examples of some practical uses of templates with terminology bindings.
Data entry templates can also be used to combine and structure related data items, or to enable addition of refinements a selected concept. Different requirements can be met by a common template structure with different terminology bindings. In other cases, a more complex template may be required containing a collection of data items with different value set bindings. Similarly, a meaning binding may be applied to an individual template or to a collection of templates that share a similar interpretation (e.g. past medical history entries). Terminology bound templates that are designed to meet the needs of different data entry contexts can be combined into a more complex template that supports a complete data entry scenario.
Table 3.2.2-1: Practical Uses of Terminology Binding in a Data Entry Template
| Practical Use | Examples |
| To specify a concept or expression to that is added to the record entry when a particular data entry option is selected |
|
| To constrain the range of concepts that can be entered into a specific data entry field |
|
To support the structured entry of specific refinements relevant to a selected concept |
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| To support the entry of any refinement permitted by the concept model (or a constrained version of the concept model) |
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Table 3.2.2-2 shows a summary of the terminology services required to enable terminology bindings to be created and edited when developing user interface templates for health record data entry.
Table 3.2.2-2: Services Required for EHR User Interface Template Editing
| Practical Requirement | Status 1 | Required Terminology Services2 | Additional Terminology Service Dependencies3 |
| Select the SNOMED CT edition and version to be used. | REQUIRED | 4.1 Select Edition and Version | N/A |
| Create or edit a user interface template or control that records specific concepts in EHR depending on user selections | REQUIRED | N/A | |
| Create or edit a user interface template including expression constraints that limit permitted values that can be entered through a specific data entry control | REQUIRED | 4.7 Validate and Apply Expression Constraints | N/A |
| Create or edit a user interface template or control that records a specific expression in an EHR depending on user selections (in cases where no specific concept matches the required meaning) | OPTIONAL | 4.14 Validate Concept Definitions and Expressions | N/A |
| Get attributes that can be applied to an identified concept | OPTIONAL | 4.13 Get Concept Model Rules | N/A |
| Get the range of values that can be applied to an identified attribute | OPTIONAL | 4.13 Get Concept Model Rules | N/A |
Footnotes
Applications designed to address this use case must support the practical requirements marked as Required. Support for the practical requirements marked as Optional is recommended as these provide enhanced functionality that may be required by some users.
In most cases, a reference to a subsection of 4 Terminology Service Types, implies a requirement for all services marked as Required in that subsection. However, where a reference is followed by a bulleted list, that list specifies the specific terminology services required. Some of the specific services listed as required for an Optional practical requirement may be marked as Recommended in the referenced subsection.
The Additional Terminology Service Dependencies column contains references to services on which a Required Terminology Service depends. This column does not restate dependencies on services listed as required service or additional dependencies for essential requirements listed in earlier rows. A full list of the dependencies of each terminology service is provided in the relevant subsection of 4 Terminology Service Types.
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