Ontological and epistemic aspects in clinical terminologies: looking for semantic interoperability in the medical environment

Objective: The improvement in the continuing care provided to the huge population in healthcare units is a real challenge to Brazilian society. One of the main issues in this context, which healthcare professionals are not able to solve by themselves, is the difficulty of integration among the medical records of a patient that are scattered around different geographical and temporal regions. Method: The present research investigates the ambiguity inherent to medical terminologies - particularly the International Classification of Diseases (ICD) and the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) - which impacts in the possibilities of semantic interoperability among electronic healthcare records. Results: As solution, we study how to anchor medical terms exhibiting weak semantics to ontological and well-founded resources. The double process of anchoring, which consists of connecting terminologies to well-founded ontologies and adopting atomic terms, was created with the aim of reducing the ambiguity in the scope of healthcare information systems. Conclusions: Interoperability is an issue without a trivial solution. The proposed anchoring is a possibility to foster systems integration because of the connection to well-grounded resources built with the best practices. We hope the results can provide advances to the information systems used in healthcare systems and, ultimately, to the continuing care to the citizen, through the Information Science techniques.