Improving interoperability of clinical documents: A case study of LOINC mapping in analysis laboratories

Health care organizations are increasing their efforts towards administrative and clinical-process informatization. In this field, the electronic health record (EHR) can be usefully employed to improve the patient care process, as it allows the health care operator to chronologically gather care events. In achieving such a goal, the possibility of storing care events issuing from different sources is the main challenge to be faced, as it involves the possibility of rendering interoperable different proprietary systems that use customized encoding systems. System interoperability requires the exchange of standardized information and documents, using specialized document templates and encoding systems. This is the case of the Health Level 7/Clinical Document Architecture (HL7/CDA2), which requires the Logical Observation Identifiers Names and Codes (LOINC®) system for encoding clinical documents. This paper presents a case study of an interoperability system aimed at producing HL7/CDA2 documents to be sent to a centralized EHR. The case study deals with the standardization of an analysis laboratory encoding system based on LOINC, focusing on a software tool for semi-automatic mapping of internal analysis laboratory codes into LOINC codes. It was carried out at the University of Pittsburgh Medical Center, Italy (UPMC Italy) within the Smart Health 2.0 (Pon04a2_C) project, and aimed at realizing an advanced EHR that enables the collection of structured documents produced by different health care organizations in the region of Sicily, and facilitates data retrieval and longitudinal or cross-sectional analysis.