journal of biomedical informatics
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Language of Czech Medical Reports and Classification Systems in Medicine

Author(s): Přečková P

The objective of the paper is to compare Czech medical reports written in a free text and by means of a software application; to analyze the usability of international classification systems in the Czech healthcare environment. The analysis of medical reports was based on the attributes of the Minimal Data Model for Cardiology (MDMC). We have used medical reports written in a free text and medical reports from the ADAMEK software application where data are stored in a structured way. For our work SNOMED CT and ICD-10 have been used. We have focused on the language of Czech medical reports and t he application o f aforementioned international classification systems in MDMC. We have compared how well attributes of MDMC are recorded in textual medical reports and in medical reports recorded structurally by means of the ADAMEK software application. We have made the language analysis of the Czech textual medical reports. We compared how MDMC attributes are recorded in the ADAMEK application and in medical reports written in a free text. To conclude, using a free text in medical reports is very inhomogeneous and not s tandardized. The s tandardized terminology would bring benefits to physicians, patients, administrators, software developers and payers. It would help healthcare providers that it could provide complete and easily accessible information that belongs to the process of healthcare and it would result in better care of patients. The use of international classification systems is a necessary first step to enable interoperability of heterogeneous electronic health records.