Electronic Health Record diagnosis tool and a cross reference between coding standards

Abstract

Many computer applications have been released targeting the implementation of a general Electronic Health Record (EHR) system. The main goal of an EHR system is to digitally store useful medical information about a patient's history and to share it across different health care units. Furthermore, the EHR systems should provide important information to the medical doctors during or after an encounter of care that will facilitate their decisions on making the correct diagnosis. A major problem however, for adopting an EHR system, especially from older doctors corresponds to the time that is needed to become familiar with the tool and thus either prevents them from enjoying the full benefits of an advanced EHR system, or leads to a complete rejection of the system. Therefore one of the fundamental concepts for implementing an EHR system is to incorporate proper and easy to use tools that will enhance and guide the doctors' decisions in an optimal way without taking significant time of their usually busy schedule. In this paper we aim to tackle part of this problem by proposing an application tool that will help the doctor with the patient's diagnosis by suggesting a matching disease code based on the user's (doctor's) notes. In addition, the tool will offer cross reference functionality between two international standards, the International Classification of Diseases (ICD-10) and the Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT). This tool will be tested as a freemed-software module add-on and it will be implemented in a private group practice (the Center). With their cooperation and the feedback from the users the tool will be evaluated for the possibility to be used in other EHR applications.