A CTS2 Based Terminology Service for Managing Semantic Interoperability in the Italian Federated Electronic Health Record

Semantic interoperability is crucial for data and document exchanges between and among Healthcare Information Systems, and to assure efficient communication among the different domain experts involved in the patient process of care. In this context, integrated terminology services offer the chance to manage clinical code systems, both standard and local, as well as value sets, through a series of functionalities such as searching, querying, import/export, cross-mapping, etc. This paper describes the approach used for the implementation of an integrated terminology service, namely Servizio Terminologico Integrato, in the Italian Federated Electronic Health Record setting. The service is based on Common Terminology Service Release 2 by Health Level 7, which is the main referenced standard in the domain and has the aim to support domain experts and healthcare organizations in managing medical terminologies for ensuring semantic interoperability. Preliminary tests show promising results and the usefulness of such a service, above all for the retrieval of coding systems mapping and updates. The main output of this paper is the implementation in the Italian healthcare setting of an open source, standard-based and bilingual integrated terminology service to support professionals and stakeholders in sharing, querying and maintaining official and up-to-date terminological artifacts.