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Towards the harmonization of Clinical Information and Terminologies by Formal Representation

Author(s): Catalina Martinez-Costa, Andre Queiroz de Andrade, Daniel Karlsson, Dipak Kalra, Stefan Schulz

Background: Semantic interoperability of clinical information is the capability to recognize and process semantically equivalent information in a homogeneous way, even if data instances are heterogeneously represented, i.e. differently structured and/or using different terminology systems. Ontologies and terminologies are recognized as playing an important role for achieving this task.

Objectives: The aim of this paper is to present an approach for enhancing clinical information by semantic annotations that makes it semantically interoperable.

Methods: We propose an ontological framework rooted in an expressive upper level ontology. It is used to add standardized semantics to clinical information by combining EHR information entities with SNOMED CT. BioTop, the upper level ontology used will help to constrain the ways in which information and clinical entities can be combined.

Results: We exemplify how the same clinical statement is heterogeneously represented depending on the EHR standard or terminology used. The same statement is represented according to the ontological framework proposed. Strengths and limitations of the approach are discussed.

Conclusions: Our approach constitutes a irst step towards interoperable representations of patient data in health records by using a shared framework using formal ontologies based on description logics. Such framework is required for the correct exchange of clinical information from heterogeneous sources, providing clear and unambiguous meaning of medical terms and the context in which they are used.