Uma ferramenta para aplicação de mapeamentos entre termos SNOMED CT, CID-10 e CIAP-2 e enriquecimento terminológico em Segundas-Opiniões Formativas sobre hipertensão e diabetes

Abstract

Introduction: An Electronic Health Record System (EHR-S) requires that usage of controlled terminology and vocabulary (such as SNOMED-CT, ICD-10, and ICPC-2) to ensure semantic interoperability. However, not all EHR-S incorporate such an approach, minimizing the use of terminological sources for clinical document coding. Objective: The objective of this work was to present a tool that allows exploring existing terminological mappings among ICD-10, ICPC-2 and SNOMED CT for the indication of correlated terms for terminological enrichment on Second opinions (SOFs). Method: Our approach enables the retrieval of SOFs directly from the BVS APS using Web scraping as well as the construction of a solution based on a database of mappings taken from consolidated sources, enabling queries and retrieval of new ICD-10 and SNOMED CT codes. Results: The result was the delivery of a simple approach for exploring mappings between terms of these terminological sources programmatically.Conclusion:As a conclusion, this work can be directly incorporated with SOFs orin a EHR-Sto suggest new terms and to enable broader encoding for clinical documents. Furthermore, future works on these mappings are necessary for the expansion of other important modules on primary healthcare.