Terms used in clinical practice and their connection with standardized terminologies

Abstract

The Electronic Patient Record (PEP) represents an important source of real health information. However, most of its information is made available as unstructured data, which makes it difficult to use for research purposes. Due to advances in health information technologies, the need for standardized terminology in clinical texts has increased with a view to information retrieval and interoperability. To enable an improvement in these processes, to support patient care and the discovery of new knowledge for the benefit of health, some type of harmonization between the terms colloquially recorded by professionals and the terminologies is necessary. An alternative is to connect the first type of terminology, the colloquial, with the second type, standard clinical terminologies. Identifying and testing ways of connecting textual clinical data from PEP with standardized clinical terminologies is a relevant investigation involving Information Science and health areas. The methodology consists of text mining techniques for the extraction and analysis of clinical texts, to verify the level of connection between terminological resources based on the standard for mapping clinical terminologies.