Princípios ontológicos aplicados à classificação internacional de doenças: alternativas para a busca por interoperabilidade semântica entre sistemas de prontuários eletrônicos de pacientes

Abstract

The need of providing proper healthcare services to the population poses challenges for information management in healthcare units. A current world-wide challenge is the demand for integration among clinical information systems, which make possible to provide suitable medical treatments during the stay of a patient. In order to reach the desired quality in such treatments, healthcare units need to access the several medical records of a certain patient, which may be disperse among different information systems with distinct representations, in different geographical and temporal regions. The investigation carried out in this paper is developed within this context, contributing to the research in clinical information systems integration for purposes of continuous treatment through improvements in clinical information representation. Our goal is to develop a prototype of an ontology, we called "Ontological Artifact ICD", with the aim of improving the representation of the information present in the International Classification of Diseases (ICD) declarations. In order to reach our goals, we first describe the main current healthcare clinical terminologies and the clinical information models in Brazil, which have been the instruments used in the country in the search for interoperability. Next, a method based on ontological principles is developed to deal with the characteristics of clinical terminologies that hinder semantic interoperability in information systems. As result, we present an ontology (an artifact) for the ICD from the application of the method and its resulting improvements. This method can be applied to any fragment of the ICD, in order to obtain a vocabulary aligned with interoperability needs of medical information systems. As contributions, we list the aforementioned method, a systematization of problems present in clinical terminologies and an intermediate ontological model created to seek improvements. We hope that this research will foster semantic interoperability and automation through information systems, as well as make available, to the professional information, tools to deal with real issues of everyday activities in medical units.