Modelling and Standardisation of EHR Data for Mild Traumatic Brain Injury Patient Management

In Spain, traumatic brain injury (TBI) affects 200 new cases per 100,000 inhabitants, making it a significant cause of morbidity and mortality globally and a frequent reason for emergency department attention. This study addresses the lack of consensus on the use of diagnostic tests to exclude intracranial lesions, leading to overuse of Computed Tomography (CT) scans. To this end, we propose to improve the structuring and standardisation of information on Traumatic Brain Injury (TBI) in the Electronic Health Record (EHR) using terminologies and standards. To this end, a unification of the TBI diagnostic code, the creation of a formulary for the structured collection of clinical observations and the development of a dashboard in Power Business Inteligence (PowerBI) are carried out. Results revealed a cohort of 442 TBI cases and reduced data search time, improving management efficiency and real-time indicator monitoring. This approach enhances clinical care, promotes data interoperability, and supports TBI research.