Part 2 · Future Vision

Beyond ICD Coding: Structuring All Patient Data

The next frontier is not just coding discharge summaries — it is transforming every piece of clinical documentation into structured, interoperable data that flows automatically to whoever needs it.

Unstructured Patient Data: A Hidden Crisis

Clinical information is created in many systems and many forms — discharge summaries, letters, operation reports, lab results. But it mostly remains as unstructured free text inside hospital information systems, invisible to the rest of the healthcare ecosystem.

  • No interoperability: data does not reach downstream providers, registries, or payers in the right format
  • No end-to-end digital process from documentation to forwarding
  • Information loss at transitions between institutions and systems
  • Manual re-entry of the same data into different forms and registries
  • Delays in quality assurance and billing due to missing structure
  • No automated reporting to cancer registries, implant registries, or payers

One Platform for All Patient Data

Our platform captures the entire patient record — not just individual report types. The moment a document is created or updated in the hospital system, a fully automated, AI-powered process takes over.

1

Detection

The system detects the event from the hospital system and automatically picks up the document.

2

AI Extraction

Diagnoses, procedures, medications, lab values, and all relevant attributes are extracted from free text using AI.

3

AI Coding

A specialized AI assigns the extracted information to the correct ICD codes.

4

Validation

An integrated AI validation model checks every coding suggestion and provides a traceable explanation.

5

Transformation

Structured data is automatically transformed into the required formats: openEHR, FHIR, or CDA documents.

6

Delivery

Data flows to where it is needed: back into the hospital system, to registries, quality assurance, or downstream providers.

From Hospital System to Structured Data

Hospital Systems · Letters · Reports · Lab Data · Operation Notes
↓ event-driven ↓
AI Structuring Engine — Extraction → Coding → Validation
↓ structured data + ICD codes ↓
Transformation & Validation — openEHR · FHIR · CDA
↓ ↓ ↓
Hospital System — coded & structured
Registries & QA — cancer, implant registries
Downstream Providers — follow-up / payers

Every Major Standard, One Platform

StandardUse case
openEHRClinical documentation — compositions based on archetypes and templates
HL7 FHIR R4/R5Data exchange — resources, bundles, subscriptions
HL7 v2 / ADTHospital system integration — event-based messages
CDA (HL7)Document exchange — structured and unstructured documents
ICD-10 / ICD-11Diagnosis coding — automatic assignment with explanation
SNOMED CTClinical terminology — semantic coding of clinical concepts
LOINCLab data — standardised laboratory parameters

Real-World Applications

🏥

Discharge Management

After discharge, the report is automatically structured, ICD-coded, and sent as a FHIR bundle to the GP — including medication plan, diagnoses, and follow-up recommendations.

🎗️

Cancer Registry Reporting

Oncological findings are automatically identified; TNM classification, histology, and treatment decisions are extracted and submitted to the relevant registry in the required format.

📊

Quality Assurance & Billing

All coded data is immediately available for billing and quality indicators. Missing codes or inconsistencies are flagged and reported automatically.

🔬

Research & Secondary Use

Structured, standardised data enables secondary use for clinical trials, health services research, and AI training — without manual data preparation.

What You Gain

Fully automatic — physicians document as usual; everything else happens in the background
All document types — not just discharge summaries, but the entire patient record
Precise ICD coding — AI extraction + coding + validation with over 95% accuracy
Traceable — every coding comes with an explanation your team can verify
Interoperable — openEHR, FHIR, CDA, HL7 from a single platform
Quality-assured — continuous learning from expert feedback for ongoing improvement
Future-proof — automatic updates for ICD catalogues and coding guidelines
Scalable — from 50 to 5,000 cases per day without additional staffing

One seamless, automated process for all patient data

From creation in the hospital system, through intelligent coding and structuring, to delivery in the right format to the right recipient — automatically, transparently, and fully traceable.

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