title: Automatic mapping of clinical documentation to SNOMED CT.
abstract: Clinical documentation needs to be fine-grained to truthfully represent the history, development, and treatment of a patient. But natural language, as the main information carrier, is characterized by many issues, like idiosyncratic terminology, spelling and grammar errors, and a lack of grammatical structure. Therefore coding systems, like ICD-10, have been introduced, but their use varies highly among physicians, and they are often used incompletely or incorrectly. The almost exponential growth of clinical data is yet another problem. We present a new methodology to process this data: Through combining several natural language processing methods we extract morphemes from clinical texts and map them onto concepts from SNOMED CT. We first performed a manual analysis of clinical texts received from a university hospital and evaluated the issues found in them. Based on this we implemented a prototypical system which incorporates both the OpenNLP and the MorphoSaurus natural language processing systems.
authors.affiliation: Institute for Medical Biometry and Medical Informatics, University Medical Center, 79104 Freiburg, Germany. holger.stenzhorn@uniklinik-freiburg.de
authors.forename: Holger
authors.initials: H
authors.lastname: Stenzhorn
authors.forename: Edson José
authors.initials: EJ
authors.lastname: Pacheco
authors.forename: Percy
authors.initials: P
authors.lastname: Nohama
authors.forename: Stefan
authors.initials: S
authors.lastname: Schulz
mesh_terms: D004282:Documentation; D001330:Electronic Data Processing / Q000379:methods*; D016347:Medical Records Systems, Computerized; D039061:Systematized Nomenclature of Medicine; D009626:Terminology as Topic