Background: Ultrasound - one of the most common tests in diagnostic medicine and studies of abdominal organs are more than two thirds of all the ultrasound studies. Ultrasound findings include a description of pathologies found. Various information systems provide the ability to document the pathology found in the form of coded values. But due to the lack of uniform terminology different concepts are used to describe the same pathology. A lack of common principles of coding of health information leads to difficulties of interpretation and automatic processing of ultrasound findings, as well as the inability to ensure interoperability.
Objectives: Creation of interface terminology of the pathologies found during abdominal ultrasonography using a SNOMED CT, followed by automation of the process of the creation of ultrasound note.
Methods: Approach has been developed to design the interface terminology on the basis of international experience of SNOMED CT using. Approach includes five phases: domain analysis, determining level of detail for the concepts, determining selection criteria for concepts in given domain, creating subset of concepts, mapping from the subset to the set of terms already in use. Designed interface terminology of the pathologies was introduced in the hospital information system. On the basis of coded values, an automated process of forming the ultrasound note was built.
Results: Interface terminology of the pathologies of the abdominal cavity have been created as the result, which included 93 pathologies, 80 of which were unambiguously mapped with SNOMED CT concepts. For the remaining 13 pathologies, post coordinated concepts were designed. The final interface terminology contains 82% more terms (from 51 to 93 terms) in comparison with the original.
Conclusions: SNOMED CT has shown high efficiency in the encoding of specialized clinical terminology. The methodology used allowed us to extract the necessary terms for a given domain. W e plan to continue our work to create various interface terminologies of pathologies based on SNOMED CT for other study methods.