Development of a Case Index for a Clinical Document Repository for Chronic Kidney Disease Management

Abstract

The internship placement was supervised to build a case index for clinical documents repository in order to use as a portal website tool to teach medical resident students. This internship was performed from September 7, 2006 to December 9, 2006 and it had two objectives. The first objective is to learn how the standards of HL7 CDA improve data quality for research outcomes through the task of enhancing the existent discharge summary template by mapping the different diagnosis codes among standardized diagnostic systems: ICD-9, ICD-10-CA and SNOMEDCT. The second objective is primary and to focus on the use of HL7 CDA Version 2 for structure standardization, SNOMED CT for terminology standardization and topic maps for ontological standardization to develop a case index for a clinical document repository from hospital records and discharge summaries for the purpose of teaching medical students. The first objective focused on the implementation of standardization and interoperability and allowed the intern to learn how medical terminologies and medical concepts are recorded differently among medical professionals, and how they are related to each other in a common ontology to enable sharing among health care providers. As the primary objective of this internship, the second objective is for the intern to learn the standards available to build a case index for clinical documents. The conclusion has been draw and the recommendation has been made. One of the missions of health informatics is to inform and promote health information standards and technologies among healthcare communities and their stakeholders in term of management and sharing health information and knowledge to improve the outcomes of healthcare, research and teaching.