Improving Semantic Interoperability in Healthcare: Experiences Implementing the ISO 13940 Standard in Estonia (Preprint)

BACKGROUND Socio-technical problems cannot be solved by technology alone. Implementing event-based data exchange in a large-scale digital health platform (DHP) to support continuity of care requires conceptual clarity across diverse health system stakeholders and domains. The ISO 13940:2015 (ContSys) standard provides a system of concepts for the structured description of healthcare processes and events. There is a gap in the literature on implementing conceptual standards such as the ContSys. OBJECTIVE This implementation report documents the translation and contextualization of the ContSys standard in Estonia as a foundational step toward higher levels of semantic interoperability for effective digitalization of care. METHODS A multi-stakeholder implementation effort was undertaken using a structured six-step methodology. Country-specific notes and a concept mapping method were introduced to preserve local context fidelity while preventing conceptual deviation from the international standard. RESULTS The work revealed substantial conceptual misalignment among stakeholders and domains. Country-specific notes and mapping provided a mechanism to support conceptual harmonization without local adaptation. In total, 71 country-specific notes and 93 term synonyms were added. The translated ContSys has already influenced national terminology development and system architectures. CONCLUSIONS Translating and adopting foundational conceptual standards is a necessary precursor to implementing higher levels of conceptual interoperability for interconnective healthcare processes to support continuity of care. This study highlights the importance of conceptual infrastructure and contributes a replicable model for other health systems.