In the frame of federated and interoperable Electronic Health Rec-ords (EHRs), specific coding systems are mandatory for filling out healthcare documents such as the Patient Summary (PS). PS cannot be automatically gen-erated from the patient's EHR data, because of the sensitivity of its content. For this reason it needs to be validated by a General Practitioner (GP), who is the sole responsible of this document. The literature shows that the practice of cod-ing is recognized as a difficult task for GPs and it often generates coding errors and misspecifications of clinical data. To overcome this issue, a support system based on standardized and formalized coding rules for the domain of applica-tion is proposed, to facilitate a more accurate coding process without breaking the law.
Towards a rule-based support system for the coding of health conditions in the Patient Summary
E Cardillo;E Pasceri;M T Chiaravalloti;
2015
Abstract
In the frame of federated and interoperable Electronic Health Rec-ords (EHRs), specific coding systems are mandatory for filling out healthcare documents such as the Patient Summary (PS). PS cannot be automatically gen-erated from the patient's EHR data, because of the sensitivity of its content. For this reason it needs to be validated by a General Practitioner (GP), who is the sole responsible of this document. The literature shows that the practice of cod-ing is recognized as a difficult task for GPs and it often generates coding errors and misspecifications of clinical data. To overcome this issue, a support system based on standardized and formalized coding rules for the domain of applica-tion is proposed, to facilitate a more accurate coding process without breaking the law.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
