RESUMO
The DIOGENE hospital information system has been expanded with a centralized and integrated patient clinical database recording structured patient data. The objective is to provide a standardized framework for the building of future clinical databases and for the integration of existing heterogeneous ones. The combined 'across time view' and 'across departments view' generated from the integrated clinical data will enable an evolutionary view of the patient state, both across time and across medical specialties. For this purpose and to permit the communication and exchange of data, a new controlled vocabulary for representing clinical data has been created. The construction of this vocabulary is based on the international ICD classification, already being used in DIOGENE for encoding patient diagnosis and procedures. A new extension of the ICD is proposed for medical information that goes beyond diagnosis and procedures encoding. The building of a common clinical findings dictionary, recording the definition of clinical entities, is based on this newly developed clinical vocabulary. This process is incremental, manual and substantial.
