Towards the Development of a CTS2-based Terminology Service in the Italian Federated Electronic Health Record Elena Cardillo and Maria Teresa Chiaravalloti Institute of Informatics and Telematics National Research Council, IIT - CNR Rende, Italy Email: elena.cardillo@iit.cnr.it, maria.chiaravalloti@iit.cnr.it Abstract— Semantic interoperability is essential for advanced Electronic Health Records (EHRs) functionality, and in particular for data exchanges, and efficient communication among clinicians. Integrated terminology services offer the chance to manage clinical code systems, both standard and local, and value sets, through a series of functionalities such as searching, querying, cross mapping, etc. The main standard in the domain is Clinical Terminology Service Release 2 (CTS2) by Health Level 7 (HL7). This paper describes the approach used for designing and developing an integrated terminology service based on the CTS2 standard, namely Servizio Terminologico Integrato (STI), which aims to support domain experts and healthcare organizations in ensuring semantic interoperability in the Italian Federated EHR. Keywords—Coding Systems; Semantic Interoperability; Terminology Services; CTS2; Healthcare. I. INTRODUCTION Interoperability of clinical data essentially means that different systems are able to communicate among each other, exchange data, and, above all, reuse them. The general aim is ensuring a worldwide availability of information at the right time and place, in order to deliver better clinical services and improve healthcare. Interoperability is a required function for the proper use of Electronic Health Record (EHR) systems, which remain simple data containers if they do not have the chance to communicate using the same language. Standardized coding systems are the lingua franca of medical data, as they allow to uniquely identify the same concept despite languages, synonyms and local names that could be used to refer them. The advantages of standards are commonly recognized and their usefulness increases over time as they are employed in numerous health-related Information Technology applications. Nonetheless, their use is not always as easy as it may appear and health professionals often complain about the lack of adequate support systems. Managing clinical terminologies is not only a matter of making them available to the users, but their management needs to include further functions to offer a complete plethora of services allowing a meaningful use of standards. To pursue this aim, there is the need of a standard protocol to manage terminology standards in the same way across multiple healthcare facilities. This role is covered by integrated terminology services, which offer the possibility to interact with terminologies according to a series of standardized functionalities, such as research, hierarchical tree navigation, structured query, cross mapping. The Italian National Research Council (CNR) is working in accordance with the Digital Italy Agency (AgID) for realizing the national federate EHR (corresponding to the Italian acronym FSE, meaning “Fascicolo Sanitario Elettronico”) infrastructure in order to allow the exchange of clinical documents among the regional EHR systems [1]. In this frame, semantic interoperability is a non-trivial issue [2], especially because, over time, regional and local coding systems and habits have proliferated. The Prime Minister Decree No. 178/2015 [3] disciplines the use of the FSE and makes some medical terminologies mandatory, detailing their use in the two kinds of documents (Patient Summary and Laboratory Report) included in the minimum unit expected in the FSE first implementation phase. The objective of this paper is to describe the approach used for designing and developing an integrated terminology service, called STI (acronym of the Italian Servizio Terminologico Integrato), to support Regions, domain experts and health facilities in the management of the clinical coding systems and terminologies prescribed by the cited Decree, and to ease their use in the documents required in the FSE. To develop this terminology service, the standard protocol HL7 Common Terminology Services Rel. 2 (CTS2) [4] was tested. The paper is organized as follows. Section II gives an overview of the state of the art on semantic interoperability and the main features of CTS2. Section III describes the material used within the Italian implementation of the STI system and Section IV addresses the content approach. Section V shows some preliminary results. Discussion and conclusions in Section VI close the paper. II. BACKGROUND A. Semantic Interoperability: projects and initiatives The adjective semantic conveys the deep meaning of interoperability as it overcomes lexical and syntactical issues to deal with the meaning of the exchanged information. The best EHR system would be useless without semantic interoperability, as it could not unambiguously interpret data received from other systems. In fact, Semantic Interoperability in healthcare is defined as “the ability of a 12 Copyright (c) IARIA, 2017. ISBN: 978-1-61208-600-2 SEMAPRO 2017 : The Eleventh International Conference on Advances in Semantic Processing