Definitions management: A semantics-based approach for clinical documentation in healthcare delivery

Abstract

Structured Clinical Documentation is a fundamental component of the healthcare enterprise, linking both clinical (e.g., electronic health record, clinical decision support) and administrative functions (e.g., evaluation and management coding, billing). Documentation templates have proven to be an effective mechanism for implementing structured clinical documentation. The ability to create and manage definitions, i.e., definitions management, for various concepts such as diseases, drugs, contraindications, complications, etc. is crucial for creating and maintaining documentation templates in a consistent and cohesive manner across the organization. Definitions management involves the creation and management of concepts that may be a part of controlled vocabularies, domain models and ontologies. In this paper, we present a real-world implementation of a semantics-based approach to automate structured clinical documentation based on a description logics (DL) system for ontology management. In this context we will introduce the ontological underpinnings on which clinical documents are based, namely the domain, document and presentation ontologies. We will present techniques that leverage these ontologies to render static and dynamic templates that contain branching logic. We will also evaluate the role of these ontologies in the context of managing the impact of definition changes on the creation and rendering of these documentation templates, and the ability to retrieve documentation templates and their instances precisely in a given clinical context. © Springer-Verlag Berlin Heidelberg 2005.