Introduction and Comparison Study of RxNorm ，WHODrug and SNOMED CT Medicine Terminology / 中国药房

OBJECTIVE： To provide reference for the construction of medicine terminologysets in China.METHODS： By introducing and comparing naming rules， terminology type and classfication system of RxNorm， WHODrug and SNOMED CT， the relevant suggestions on the construction of medicine terminology sets in China were put forward. RESULTS & CONCLUSIONS： Due to the different demanding objects and specific application scenarios of different terminology sets， the three medicines terminology sets had their own characteristics.RxNorm mainly served electronic health records and medical insurance， and its medicine terminology contained the trade name information of the medicine. WHODrug mainly served ADR reports， and its structured medicine information data carried by the Drug Code， and the set adopted the system classification system-ATC. In order to promote the international interoperability of medicines concepts， SNOMED CT did not contained the trade name，and the purpose of classification was to define drugs. It is suggested that the construction of China’s medicine terminology sets should be based on the design and practical experience of foreign advanced drug terminology， encourage hospitals or pharmaceutical companies to disclose and share data， and try to build a drug model compatible with chemical drugs and proprietary Chinese medicines to adapt to the special nature of Chinese medicines and the needs of international communication.

Concept Relation Expression and Semantic Retrieval of SNOMED CT / 医学信息学杂志

The paper describes the organization framework,representation pattern,relation model and expression rule of SNOMED CT based on concept,and then explores the application of SNOMED CT in the expression of medical data and semantic retrieval.Thus,it can provide reference for the research and development of the terminology standard of clinical diagnosis and treatment,and promote the study of processing,mining and analysis of clinical medical data in China.

Exploration on Framework Construction of Clinical Terminology Classiifcation Standardization from Ancient TCM Literatures - Based on Qian Jin Fang / 世界科学技术-中医药现代化

With the global development of medical information standard, construction work of traditional Chinese medicine (TCM) information standard system has been promoted rapidly. The framework of ancient Chinese medical literature clinical terminology classification standardization is one of the foundations of TCM language system. Its research will further promote and perfect TCM information standard system. We have adhered to the connection among ancient TCM classification framework, modern TCM and western medicine classification framework. Exploration on framework construction of ancient Chinese medical literature clinical terminology classification standardization was based on previous work of Chinese medicine clinical terminology classification and code standard, reference frame structure of SNOMED CT, research findings of classification standard framework of Chinese medicine clinical terms, andQian Jin Fang.

Construction of the Nursing Diagnosis Ontology in Obstetric and Gynecologic Nursing Unit using Nursing Process and SNOMED CT

PURPOSE: This study was performed to propose an ontology methodology based on standardized nursing process as framework in obstetric and gynecologic nursing practice. METHODS: The instrument used in this study was based on the nursing diagnosis classification established by North American Nursing Diagnosis Association (NANDA) (2009-2011), fifth edition of the Nursing Interventions Classification (NIC) (2008), forth edition of the Nursing Outcomes Classification (NOC) (2008) developed by Iowa State University and systematized nomenclature of medicine clinical terms (SNOMED CT). The nursing records data were collected from electronic medical records of one hospital from August to October 2010. RESULTS: One hundred and forty-one nursing diagnosis statements used in obstetric and gynecologic nursing unit were linked standardized nursing classifications and constructed nursing diagnosis ontology including interoperability. CONCLUSION: Not only will this result be helpful to complete nurse's lack of knowledge and experience, it will also help to determine nursing diagnosis logically by using standardized nursing process. It will be utilized as the method to construct ontology including interoperability in other nursing units. It will be presented nursing interventions according to nursing diagnosis and thus will be easier to establish nursing planning. This can provide immediate feedback of the nursing process application.

Medical Image Retrieval: Past and Present / 대한의료정보학회지

With the widespread dissemination of picture archiving and communication systems (PACSs) in hospitals, the amount of imaging data is rapidly increasing. Effective image retrieval systems are required to manage these complex and large image databases. The authors reviewed the past development and the present state of medical image retrieval systems including text-based and content-based systems. In order to provide a more effective image retrieval service, the intelligent content-based retrieval systems combined with semantic systems are required.

Review of Semantically Interoperable Electronic Health Records for Ubiquitous Healthcare / 대한의료정보학회지

In order to provide more effective and personalized healthcare services to patients and healthcare professionals, intelligent active knowledge management and reasoning systems with semantic interoperability are needed. Technological developments have changed ubiquitous healthcare making it more semantically interoperable and individual patient-based; however, there are also limitations to these methodologies. Based upon an extensive review of international literature, this paper describes two technological approaches to semantically interoperable electronic health records for ubiquitous healthcare data management: the ontology-based model and the information, or openEHR archetype model, and the link to standard terminologies such as SNOMED-CT.

Toward the Automatic Generation of the Entry Level CDA Documents / 대한의료정보학회지

OBJECTIVE: CDA (Clinical Document Architecture) is a markup standard for clinical document exchange. In order to increase the semantic interoperability of documents exchange, the clinical statements in the narrative blocks should be encoded with code values. Natural language processing (NLP) is required in order to transform the narrative blocks into the coded elements in the level 3 CDA documents. In this paper, we evaluate the accuracy of text mapping methods which are based on NLP. METHODS: We analyzed about one thousand discharge summaries to know their characteristics and focused the syntactic patterns of the diagnostic sections in the discharge summaries. According to the patterns, different rules were applied for matching code values of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT). RESULTS: The accuracy of matching was evaluated using five-hundred discharge summaries. The precision was as follows: 86.5% for diagnosis, 61.8% for chief complaint, 62.7%, for problem list, and 64.8% for discharge medication. CONCLUSION: The text processing method based on the pattern analysis of a clinical statement can be effectively used for generating CDA entries.

Concept representation of decision logic for hypertension management using SNOMED CT / 대한의료정보학회지

OBJECTIVE: To obtain sharable and reusable knowledge among various hospital information systems, it is essential to represent each term with standard terminology. To support knowledge representation for interoperable clinical decision support system for hypertension management, the feasibility of SNOMED CT was evaluated. METHODS: Concept matching was conducted using the method of direct matching, post-coordinated matching and general matching. For semantic matching, the SNOMED CT hierarchy was considered, and for raising the mapping rate, preferred terms and synonyms were used. RESULTS: Excluding the recommendation concepts that were not used in clinical data, finally 182 concepts were evaluated in terms of concept matching. Seventy two percent of the concepts was directly matched to pre-coordinated concepts in SNOMED CT. For the post-coordinated matching and the general matching to broader meaning, 9.3% and 18.7% were covered respectively. CONCLUSION: The direct coverage of SNOMED CT was moderate to high level for representing guideline knowledge concepts without loss of semantics. To supplement the coverage, it is inevitable to consider defining local concepts for implementing hypertension management systems.

The Expressive Power of SNOMED-CT Compared with the Discharge Summaries / 대한의료정보학회지

OBJECTIVE: The standard vocabularies need to cover a diverse and enriched field of medical content, thereby facilitating semantic information retrieval, clinical decision support and efficient care delivery. SNOMED-CT(Systematized Nomenclature of Human and Veterinary Medicine-Clinical Term) is a comprehensive and precise clinical reference terminology that provides unsurpassed clinical content and expressivity for clinical documentation and reporting. To investigate whether the SNOMED-CT can serve this function in Seoul National University Hospital(SNUH) environment, we evaluated the coverage of SNOMED-CT as compared with clinical terms in the discharge summary at SNUH. METHODS: We tested for discordance of clinical terms between SNUH discharge summary and those from SNOMED-CT. We extracted 9,554 concepts from 1,000 discharge summaries. From these concepts, we obtained 3,545 unique concepts which are normalized to map with SNOMED-CT. These normalized terms are mapped to concepts of SNOMED-CT with semi-automatic method. RESULTS: We found a degree of concordance between SNOMED-CT and the clinical terms used in the discharge summary. Approximately, 89% of medical terms in the discharge summary are matched and 11% of the concepts are not mapped to those of SNOMED-CT. CONCLUSION: Through this study, we confirmed that SNOMED-CT is appropriate reference terminology in SNUH environment.

Standardization of Main Concept in Chief Complaint Based on SNOMED CT for Utilization in Electronic Medical Record / 대한의료정보학회지

The electronic medical record is gradually penetrating the world-wide healthcare environment, including Korea. Users of electronic medical record want to get full advantages of it, but benefits would not be realized by simple implementation. Wellorganized architecture and controlled medical vocabulary are needed for achieving effective electronic medical record system. Many terminologies are introduced in healthcare system but single noble terminology to cope with users' need is not present. To extract clinically useful and standardized set of chief complaints for electronic medical record in our institutional environment, we analyzed chief complaints in 235,426 discharge summaries in Seoul National University Hospital. We normalized the chief complaint by 27 medical experts. First of all, researchers parsed chief complaints as main concept, qualifier, and modifier. We normalized main concepts, keeping applicability and usability of extracted set to electronic medical record in mind. And then, mapping set of chief complaint to SNOMED CT was done by 4 physicians. Among 94,913 unique strings, we selected 6,317 terms as standard set of chief complaint. The potential users of electronic medical record were asked to evaluate usability of the set and accepted it as representative of chief complaint. The majority of terms in set were completely mapped to SNOMED CT. We discussed several principles in normalizing chief complaints. We also pointed pros and cons of SNOMED CT as reference terminology to chief complaint domain. Through this study, we developed conceptually standardized chief complaint domain with user-friendly terms in Seoul National University Hospital Environment. Furthermore, this result would be the starting point to evolve medical terms in Korea into ontology based terminology system.