Please use this identifier to cite or link to this item: https://hdl.handle.net/10316/113773
Title: Design and Implementation of a Collaborative Clinical Practice and Research Documentation System Using SNOMED-CT and HL7-CDA in the Context of a Pediatric Neurodevelopmental Unit
Authors: Direito, Bruno 
Santos, André 
Mouga, Susana 
Lima, João
Brás, Paulo
Oliveira, Guiomar 
Castelo-Branco, Miguel 
Keywords: healthcare documentation; electronic medical records; medical research; autism spectrum disorder; longitudinal medical records; data harmonization; disease classification
Issue Date: 29-Mar-2023
Publisher: MDPI
Serial title, monograph or event: Healthcare (Switzerland)
Volume: 11
Issue: 7
Abstract: This paper introduces a prototype for clinical research documentation using the structured information model HL7 CDA and clinical terminology (SNOMED CT). The proposed solution was integrated with the current electronic health record system (EHR-S) and aimed to implement interoperability and structure information, and to create a collaborative platform between clinical and research teams. The framework also aims to overcome the limitations imposed by classical documentation strategies in real-time healthcare encounters that may require fast access to complex information. The solution was developed in the pediatric hospital (HP) of the University Hospital Center of Coimbra (CHUC), a national reference for neurodevelopmental disorders, particularly for autism spectrum disorder (ASD), which is very demanding in terms of longitudinal and cross-sectional data throughput. The platform uses a three-layer approach to reduce components' dependencies and facilitate maintenance, scalability, and security. The system was validated in a real-life context of the neurodevelopmental and autism unit (UNDA) in the HP and assessed based on the functionalities model of EHR-S (EHR-S FM) regarding their successful implementation and comparison with state-of-the-art alternative platforms. A global approach to the clinical history of neurodevelopmental disorders was worked out, providing transparent healthcare data coding and structuring while preserving information quality. Thus, the platform enabled the development of user-defined structured templates and the creation of structured documents with standardized clinical terminology that can be used in many healthcare contexts. Moreover, storing structured data associated with healthcare encounters supports a longitudinal view of the patient's healthcare data and health status over time, which is critical in routine and pediatric research contexts. Additionally, it enables queries on population statistics that are key to supporting the definition of local and global policies, whose importance was recently emphasized by the COVID pandemic.
URI: https://hdl.handle.net/10316/113773
ISSN: 2227-9032
DOI: 10.3390/healthcare11070973
Rights: openAccess
Appears in Collections:FMUC Medicina - Artigos em Revistas Internacionais
I&D ICNAS - Artigos em Revistas Internacionais
I&D CIBIT - Artigos em Revistas Internacionais

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