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Werner Ceusters, M.D.: Diagnoses in Electronic Healthcare Records: What do they mean?

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Abstract

During or after clinical encounters, providers typically enter one or more diagnostic codes into the electronic healthcare records of the patients they have been interacting with. But what does such an entry really means? What is it exactly about? How does it relate to what is the case not only on the side of the patient, but also on the side of the clinicians that entered the diagnoses? And if a query for the diagnoses that have been assigned to a patient over time returns many entries, some of which seemingly inconsistent, how should such a list be interpreted? Clinicians can within the context of a single patient usually make sense out of such data. But when the data are used for secondary research on populations of several thousands of patients, then accurate interpretation of the raw data needs to come from software methods rather than human inspection.

This talk will demonstrate the extent to which the Ontology of General Medical Science and other OBO Foundry ontologies cover the domain that needs to be represented as well as the potential of Referent Tracking to accurately represent what is the case at the level of individual patients. At the same time, it will be shown that the full potential cannot be realized unless some egregious shortcomings in modern electronic healthcare record system design are corrected.

About Werner Ceusters

Werner Ceusters studied medicine, neuro-psychiatry, informatics and knowledge engineering in Belgium. Since 1993, he has been involved in numerous national and European research projects in the areas of Electronic Health Records, Natural Language Understanding and Ontology. Prior to coming to Buffalo, he was Executive Director of the European Centre for Ontological Research at Saarland University, Germany.  He is currently Professor in the Departments of Biomedical Informatics and Psychiatry of the School of Medicine and Biomedical Sciences, SUNY at Buffalo NY, Director of the Ontology Research Group of the New York State Center of Excellence in Bioinformatics and Life Sciences, Director of Research of the UB Institute for Healthcare Informatics, and PhD Program Director of the UB Department of Biomedical Informatics.

His research is focused on the application of Referent Tracking for data management and the requirements of ontologies and terminologies to be useful for annotation under this framework.

Link to full CV: http://www.referent-tracking.com/RTU/?page=ceusters_vita