Abstract

1. IMPROVING QUALITY OF INFORMATION IN HEALTH RECORDS WITH MEDICAL ONTHOLOGIES Author* JÚLIO DUARTE Supervisors: Supervisor AntónioAbelha, Co-Supervisor Manuel Filipe Santos * jduarte@di.uminho.pt Abstract The electronic record of medical information is critical to the quality of diagnosis and resolution of problems of patients in hospitals. On the other hand, medical education and training of health professionals can be improved by the fact that electronic records available to allow a vast repository of cases classified and evaluated. To normalize and parameterize this is fundamental the records of medical information, using medical ontologies and standards to enhance interoperability and assess the quality of information to reduce medical error. This project aims to set concrete guidelines accordingly and provide effective tools. It will use the platform AIDA-PCE, a system developed by researchers at the University of Minho and used in production at the Center Hospital of Porto, offering thousands of case studies. • State of Art and Motivation • AIDA (Agency for Integration, Diffusion and Archive of Medical Information) was created by researchers of Minho University and Centro Hospitalar do Porto. This platform features a pro-active behaviour in its main functions: • communication between heterogeneous systems, storage management and hospital information; • response to requests in time; • sending and receiving information from hospital sources like laboratories (labs) (medical reports, images, prescriptions, etc.). • As shown in Figure 1, AIDA provides interoperability between hospital subsystems. • There are several languages ​​for medical record. Each has been developed for a particular purpose and have different codes. The most used are the following: • The problem with these languages ​​is the incompatibility between them. A term used for a diagnosis can mean different in others. Research Methodologies The realization of this project will use three methodologies. These methodologies and tasks are explained in the following scheme. • Aims • The realization of this project aims to standardize and parameterize the registration of clinical information in the context of Electronic Clinical Process (ECP) by creating a communication language based on a common ontology: • Allow the interoperation of systems both within the same institution and between institutions; • Make registration accessible and understandable to any clinician; • Promote clinical decision support, helping to reduce medical errors and providing better quality service to the patient. • To achieve this main goal are associated with other secondary objectives, essential for achieving the same. Among them is the operation of the systems of classification and coding a regional, national and international use. • Conclusion and Contributions • This work will provide the following benefits: • Perceptible clinical information to all clinicians; • Increase quality and efficiency in the medical record; • Promoting the exchange of information between departments and institutions and systems interoperability • Reduction the quantity of information stored (reduced redundancy). • SNOMED • ICD • CIPE • LOINC • MeSH • MedRA Acknowledgment This research was performed with the support of the Portuguese Foundation for Science and Technology, with the grant SFRH/BD/70549/2010.