A rule-based Support System for the Validation of Diagnoses coding in the Patient Summary

Semantic interoperability is crucial in the frame of federated Electronic Health Records (EHRs) to share understandable and reusable data among the different healthcare information systems. The use of specific and integrated coding systems is recommended by Governments all over Europe, in particular concerning the registration of clinical data in the Patient Summary (PS). To support General Practitioners (GPs), we propose a Coding Support System (CSS) provided as a Web Service that aims, on one hand, to validate and, on the other, to suggest the most appropriate coding of clinical diagnoses in the PS digitized by the GP in his EHR tool, to avoid errors and misspecifications. The system leverages on a Knowledge Base composed of an ICD-9-CM ontology, built for the project, integrated with different terminological resources, and based on standardized coding rules. Preliminary tests for the validation of the Problem List coding show promising results and new tests are being carried out on other elements of the PS.