System for Supporting the Codification of Diagnoses in the Hospital Discharge Form
Friuli Venezia Giulia Region, Call for the granting of contributions for clinical, translational, basic, epidemiological and organizational research (February 2017-February 2020)

Objective: realization of a prototype of a coding support web service that guides the doctor during the compilation of hospitalized discharge cards, allowing correct coding in ICD-9-CM and, in anticipation of its future use, of ICD-10 .

Who: developed in collaboration with the Italian Collaborating Center of the World Health Organization of Udine, which deals with international classifications, the Bruno Kessler Foundation of Trento and the University of Udine.

How: the system is designed to use both encodings, ICD-9-CM and ICD-10, in a mutually exclusive way, and is based on standardized encoding rules; a rule management algorithm for verifying the accuracy of the coding and for identifying the main clinical condition; a dictionary of clinical terms for managing the transition from natural language used by doctors in their medical records to coding language. A knowledge base has been created which, in addition to the ICD-9-CM classification (alphabetical and systematic index), comprises a diagnosis glossary extracted from first aid files; a vocabulary of synonyms and terms related to ICD-9-CM diagnoses; the national classification of rare diseases; a glossary of common terms used by GPs to define problems and diagnoses, extracted from a corpus of 250,000 medical records; the Italian version of the ICD-10 classification in processable format.