title: Semantic enrichment of medical forms - semi-automated coding of ODM-elements via web services.
abstract: Semantic interoperability is an unsolved problem which occurs while working with medical forms from different information systems or institutions. Standards like ODM or CDA assure structural homogenization but in order to compare elements from different data models it is necessary to use semantic concepts and codes on an item level of those structures. We developed and implemented a web-based tool which enables a domain expert to perform semi-automated coding of ODM-files. For each item it is possible to inquire web services which result in unique concept codes without leaving the context of the document. Although it was not feasible to perform a totally automated coding we have implemented a dialog based method to perform an efficient coding of all data elements in the context of the whole document. The proportion of codable items was comparable to results from previous studies.
authors.affiliation: Institute of Medical Informatics, University of Münster, Germany. bernhard.breil@ukmuenster.de
authors.forename: Bernhard
authors.initials: B
authors.lastname: Breil
authors.forename: Andreas
authors.initials: A
authors.lastname: Watermann
authors.forename: Peter
authors.initials: P
authors.lastname: Haas
authors.forename: Philipp
authors.initials: P
authors.lastname: Dziuballe
authors.forename: Martin
authors.initials: M
authors.lastname: Dugas
mesh_terms: D059019:Clinical Coding / Q000379:methods*; D003628:Database Management Systems; D057286:Electronic Health Records; D055991:Health Records, Personal; D016247:Information Storage and Retrieval / Q000379:methods*; D020407:Internet; D008498:Medical Record Linkage / Q000379:methods*; D009323:Natural Language Processing; D010363:Pattern Recognition, Automated / Q000379:methods; D012660:Semantics; D018875:Vocabulary, Controlled