Integrating Medical Terminology into CDSS UIs for Primary Care Decision Support

Overview

This study presents a user-centered design approach to integrate standardized medical terminologies into clinical decision support system (CDSS) user interfaces (UIs) for primary care. It identifies key requirements for data entry support and highlights challenges related to interoperability and language use in German primary care settings.

Background

Clinical decision support systems have demonstrated potential to improve diagnostic accuracy in primary care, especially for chronic diseases. The SATURN project developed a CDSS prototype using artificial intelligence to reduce diagnostic uncertainty in unclear and rare diseases by leveraging clinical data from university hospitals standardized via the OMOP Common Data Model. However, integrating primary care data remains challenging due to heterogeneous data structures and country-specific vocabularies like ICD-10-GM in Germany. Effective UI design that supports standardized medical concept entry is essential to facilitate adoption by general practitioners.

Data Highlights

The study applied a five-step iterative user-centered design process including conceptualization, UI implementation, user and expert feedback analysis, expert workshops, and extended UI concept development. Usability testing revealed the need for refined input support and language adaptation to improve ease of use. The research identified the necessity of interfacing the CDSS with primary care electronic patient records to enhance interoperability.

Key Findings

• User-centered design effectively aligns CDSS UIs with clinicians’ workflows and usability needs.
• Standardized medical terminologies such as SNOMED CT and RxNorm can be integrated into CDSS UIs for primary care.
• Language and input support require optimization to accommodate general practitioners’ preferences and terminology usage.
• Interoperability challenges exist due to heterogeneous primary care data and country-specific vocabularies like ICD-10-GM.
• Connecting CDSS to primary care electronic health record systems is essential but technically challenging.
• Collaboration with domain experts is critical to identify feasible interface solutions and improve system design.

Clinical Implications

Clinicians and developers should prioritize user-centered design approaches when implementing CDSS UIs to ensure alignment with primary care workflows and terminology use. Enhancing interoperability through standardized vocabularies and seamless integration with electronic health records can improve data quality and diagnostic support. Optimizing language input support tailored to general practitioners will facilitate adoption and effective use of CDSS tools.

Conclusion

Integrating standardized medical terminologies into CDSS user interfaces for primary care is feasible and beneficial but requires careful attention to usability, language, and interoperability challenges. User-centered design and expert collaboration are key to developing effective decision support tools that meet the needs of general practitioners.

References

1. Neff MC et al. 2026 -- Integrating Medical Terminology into User Interfaces for Primary Care Decision Support Systems: A Conceptual and Developmental Analysis