Next generation assisting clinical applications by using semantic-aware electronic health records

The health care sector is no longer imaginable without electronic health records. However; since the original idea of electronic health records was focused on data storage and not on data processing, a lot of current implementations do not take full advantage of the opportunities provided by computerization. This paper introduces the Patient Summary Ontology for the representation of electronic health records and demonstrates the possibility to create next generation assisting clinical applications based on these semantic-aware electronic health records. Also, an architecture to interoperate with electronic health records formatted using other standards is presented

Semantic annotation of medical documents in CDA context

The goal of this work is to recover semantic and structural information from medical documents in electronic format. Despite the progressive diffusion of Electronic Health Record systems, a lot of medical information, also for legacy reasons, is available to patients and physicians in image-only or textual format. The difficulties of obtaining such information when needed result in high costs for health providers. In this work we develop the concept of a system designed to convert legacy medical documents into a standard and interoperable format compliant with the Clinical Document Architecture model by the means of semantic annotation

A Prototype Model Using Clinical Document Architecture (CDA) with a Japanese Local Standard : Designing and Implementing a Referral Letter System

Since clinical document architecture (CDA) became an American National Standards Institute (ANSI)-approved health level seven (HL7) Standard, many countries have begun making an eff ort to make local standards conform to CDA. In order to make CDA compatible with the many diff erent local standards existing in diff erent countries, we designed a prototype model using HL7 CDA R2 with medical markup language (MML), a Japanese medical data exchange standard. Furthermore, a referral letter system based on this model was developed. Archetypes were used to express medical concepts in a formal manner and to make 2 diff erent standards work collaboratively. We share herein the experience gathered in designing and implementing a referral letter system based on HL7 CDA, Release 2 (CDA R2). We also outline the challenges encountered in our project and the opportunities to widen the scope of this approach to other clinical documents.</p

Knowledge discovery methodology for medical reports

Medical reports contain valuable information, not only for the patient that waits for the results but also the latent knowledge that is possible to extract from them. The recent introduction of standard structured formats like the Digital Imaging and Communications in Medicine Structured Report and the Clinical Document Architecture Health Level Seven provide an efficient generation, distribution, and management mechanism. Also, they provide an intuitive and effective manner of information representation, unlike the traditional plain text format. In this paper we present a knowledge discovery methodology for structured report interchange based on plain text medical reports using YALE, a leading open-source data mining tool and Open-ESB platform that provides conversion, parsing, different protocols and message formats interchange capabilities.Centro de Imagiologia da Trindade (CIT

Privacy provision in eHealth using external services

Privacy provision is a key issue for successful secure access to patients’ health information. Current approaches do not always provide patients with the ability to define suitable rules to access to their information in a secure way. This paper presents an approach to give patients control over their information by means of external services. In this way, health information management and access control are kept independent and more secure.Postprint (published version

ELECTRONIC MEDICAL RECORD - SUCCESS OR FAILURE IN THE MEDICAL DECISION FROM THE ROMANIAN HEALTH SYSTEM ?

The investments in informational and communicational technologies in the health field represent a for of investing in human capital because health and medical services will exceed the physician – patient relationship and the improvement of the physical and emotional condition of the individuals of a society will become a prioritary problem of the community. In Romania is noticed a high degree of data fragmenting, with a negligible communication, often inexistent, within and outside the system, and the decision makers of the health system hold exclusivity on their own data, fact that makes them unavailable to the other participants to the system. The software-s, the formats and supports used differ both inside the system and outside it. And because a patient is given a diagnosis without complete and safe medical data, the medical error is one of the causes for the incorrect diagnosis of the patient. The decision makers from the health system must take on responsibilities for the efficient and safe management of these data, to represent a desired issue for all medical institutions. Only the interconnected and standardized electronic medical files will be able to improve the medical decision and the care given to patients. The care will be safer, more efficient, the medical information will be also useful to other clinic physicians in time and space by using the informational and communicational technologies. The complete electronic medical record must include all types of information connected to the patient`s health (medical, family history, health file, hereditary-collateral antecedents, treatments, prescriptions, allergies) and they must be protected, shared by physicians, patients and those interested in a safe and extended environment. It is necessary to computerize the medical information specific to patient and the clinical processes, and performance in the health system will depend on the transformation of the medical services system by bringing the benefits of the medical science and technology to all individuals.critical; inefficient medical service; electronic medical record; medical information computerization, interconnected electronic medical files, medical error, health electronic file, clinical decision, protected and shared medical information, interoperability, standard.