STEP: An ontology-based smart clinical document template editing and production system

Clinical documents are complex in nature and reflective of the knowledge, structured or otherwise, of physicians. A clinical document template (CDT) is that in which this knowledge manifests itself in various relations that exist among clinical concepts or entities. In this work, we present (1) CDT ontology, (2) A web-based knowledge management system called STEP (Smart Template Editing and Production), (3) Web Services Interfaces to STEP, and (4) A GUI-based CDT editor that uses the Web Services. The CDT ontology explicitly specifies clinical document constituents called template description entities (TDE), and their inter-relations in the CDT. STEP stores CDTs and their components in accordance with the CDT ontology. Web Service interfaces were developed for search, retrieval and storage for CDTs and TDEs. STEP holds entities and relations in use, spanning across different functions such as admission and discharge. A GUI-based CDT editor was developed that uses the Web Services to access data stored in STEP.