Equivalence between ICNP® and SNOMED CT concepts: theoretical reflection / Equivalencia entre conceptos ICNP® y SNOMED CT: reflexión teórica / Equivalência entre conceitos da CIPE® e da SNOMED CT: reflexão teórica

ABSTRACT Objective: to reflect on the equivalence between the concepts of the International Classification for Nursing Practice and the Systematized Nomenclature of Medicine International - Clinical Terms. Method: theoretical reflection based on the analysis of equivalence between the concepts of diagnoses, results and nursing interventions of the International Classification for Nursing Practice and the hierarchy of the Systematized Nomenclature of Medicine International - Clinical Terms. The researchers' experience and articles on the subject provided support for analysis. Results: nursing diagnoses and results of the International Classification for Nursing Practice are present in the hierarchies "clinical finding", "disorder" and "problem situation", while the interventions are included in the hierarchies "procedure" and "regime/therapy". The main causes of non-equivalence are linked to the problems of the specificity of the concept. Cross-mapping will require analysis by nursing specialists to improve the representativeness of the concepts. The equivalence table must be translated into Brazilian Portuguese, but the entire Systematized Nomenclature of Medicine International - Clinical Terms lacks interdisciplinary work. Conclusion: the representation of the International Classification for Nursing Practice in systematized Nomenclature of Medicine International - Clinical Terms will bring benefits related to the clarity of concepts. The concepts of nursing classification that are not equivalent will require conceptual analysis. The lack of translation of the Systematized Nomenclature of Medicine International - Clinical Terms for the Portuguese language will reflect the development of terminological subsets of the International Classification for Nursing Practice.

RESUMEN Objetivo: reflexionar sobre la equivalencia entre los conceptos de la Clasificación Internacional para la Práctica de Enfermería y la Nomenclatura Sistematizada de Medicina Internacional - Términos Clínicos. Método: reflexión teórica basada en el análisis de la equivalencia entre los conceptos de diagnósticos, resultados e intervenciones de enfermería de la Clasificación Internacional para la Práctica de Enfermería y la jerarquía de la Nomenclatura Sistematizada de Medicina Internacional - Términos Clínicos. La experiencia de los investigadores y los artículos sobre el tema sirvieron de apoyo para el análisis. Resultados: los diagnósticos y resultados de enfermería de la Clasificación Internacional para la Práctica de Enfermería están presentes en las jerarquías "hallazgo clínico", "trastorno" y "situación-problema", mientras que las intervenciones están incluidas en las jerarquías "procedimiento" y "régimen/terapia". Las principales causas de la no equivalencia están vinculadas a los problemas de especificidad del concepto. El mapeo cruzado requerirá el análisis de expertos en enfermería para mejorar la representatividad de los conceptos. La tabla de equivalencia debe ser traducida al portugués brasileño, pero la totalidad de la Nomenclatura Sistematizada de Medicina Internacional - Términos Clínicos carece de trabajo interdisciplinario. Conclusión: la representación de la Clasificación Internacional para la Práctica de Enfermería en la Nomenclatura Sistematizada de Medicina Internacional - Términos Clínicos traerá beneficios relacionados con la claridad de conceptos. Los conceptos de clasificación de enfermería que no sean equivalentes requerirán un análisis conceptual. La falta de traducción de la Nomenclatura Sistematizada de Medicina Internacional - Términos Clínicos para el portugués se reflejará en el desarrollo de subconjuntos terminológicos de la Clasificación Internacional para la Práctica de Enfermería.

RESUMO Objetivo: refletir sobre a equivalência entre os conceitos da Classificação Internacional para a Prática de Enfermagem e da Systematized Nomenclature of Medicine International - Clinical Terms. Método: reflexão teórica baseada na análise da equivalência entre os conceitos de diagnósticos, resultados e intervenções de enfermagem da Classificação Internacional para a Prática de Enfermagem e a hierarquia da Systematized Nomenclature of Medicine International - Clinical Terms. A experiência das pesquisadoras e artigos sobre o tema ofereceram suporte para análise. Resultados: diagnósticos e resultados de enfermagem da Classificação Internacional para a Prática de Enfermagem estão presentes nas hierarquias "achado clínico", "transtorno" e "situação-problema", enquanto as intervenções constam nas hierarquias "procedimento" e "regime/terapia". As principais causas de não equivalência são ligadas aos problemas da especificidade do conceito. O mapeamento cruzado exigirá análise por especialistas na enfermagem para melhorar a representatividade dos conceitos. A tabela de equivalência deverá ser traduzida para o português brasileiro, porém a totalidade da Systematized Nomenclature of Medicine International - Clinical Terms carece de trabalho interdisciplinar. Conclusão: a representação da Classificação Internacional para a Prática de Enfermagem na Systematized Nomenclature of Medicine International - Clinical Terms trará benefícios relacionados à clareza dos conceitos. Os conceitos da classificação de enfermagem que não foram equivalentes necessitarão de análise conceitual. A ausência de tradução da Systematized Nomenclature of Medicine International - Clinical Terms para o português refletirá no desenvolvimento de subconjuntos terminológicos da Classificação Internacional para a Prática de Enfermagem.

SNOMED-CT as a standardized language system model for nursing: an integrative review / SNOMED-CT como modelo de sistema de lenguaje estándar para enfermería: revisión integradora / SNOMED-CT como modelo de sistema de linguagem padronizada à enfermagem: revisão integrativa

ABSTRACT Objective: To describe the use of the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) as a model for interoperability of the nursing terminology in the national and international contexts. Methods: This is an integrative literature review according to Cooper, which searched for articles in Portuguese, English and Spanish, published between September 2011 and November 2018 in the BVS, PubMed, SCOPUS, CINAHL, EMBASE, and Web of Science databases, ending in a sample of 15 articles. Results: The SNOMED-CT is a multi-professional nomenclature used by nursing in different care contexts, being associated with other standardized languages of the discipline, such as ICNP®, NANDA-I, and the Omaha System. Conclusion: This review has shown that the use of SNOMED- CT is incipient in the national context, justifying the need to develop studies aimed at mapping the interoperability of existing systems of standardized language, especially NANDA-I, ICNP and Omaha System, in order to adapt the implementation of SNOMED-CT.

RESUMEN Objetivo: Describir el uso de Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) como modelo de interoperabilidad de las terminologías de enfermería en el contexto nacional e internacional. Metodología: Se trata de revisión integradora de la literatura según Cooper, que buscó estudios en portugués, inglés y español, publicados entre septiembre de 2011 y noviembre de 2018 en las bases de datos BVS, PubMed, SCOPUS, CINAHL, EMBASE y Web of Science, que culminó en una muestra de 15 artículos. Resultados: SNOMED-CT es una nomenclatura multiprofesional empleada por la enfermería en diferentes contextos de cuidado, asociado a otros lenguajes estandarizados de enfermería como CIPE®, NANDA-I y Omaha System. Conclusión: Esta revisión demostró que el uso de SNOMED-CT es incipiente en el contexto nacional, lo que justifica la necesidad de desarrollar estudios destinados a mapear los sistemas de lenguajes estandarizados existentes, especialmente NANDA-I, CIPE y Omaha System, con el propósito de adaptar la implementación de SNOMED-CT.

RESUMO Objetivo: Descrever a utilização do Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) como modelo de interoperabilidade das terminologias da enfermagem no contexto nacional e internacional. Metodologia: Trata-se de revisão integrativa da literatura segundo Cooper, que buscou artigos em português, inglês e espanhol, publicados entre setembro de 2011 a novembro de 2018 nas bases de dados BVS, PubMed, SCOPUS, CINAHL, EMBASE e Web of Science, finalizando em uma amostra de 15 artigos. Resultados: O SNOMED-CT é uma nomenclatura multiprofissional utilizada pela enfermagem em diferentes contextos de cuidado, sendo associada com outras linguagens padronizadas da disciplina, como CIPE®, NANDA-I e Omaha System. Conclusão: Esta revisão mostrou que o uso do SNOMED-CT é incipiente no contexto nacional, justificando a necessidade de desenvolvimento de estudos visando o mapeamento dos sistemas de linguagem padronizadas existentes, especialmente a NANDA-I, CIPE® e Omaha System, para fins de adequar a implementação do SNOMED-CT.

Computer-based clinical coding activity analysis for neurosurgical terms / 영남의대학술지

BACKGROUND: It is not possible to measure how much activity is required to understand and code a medical data. We introduce an assessment method in clinical coding, and applied this method to neurosurgical terms.METHODS: Coding activity consists of two stages. At first, the coders need to understand a presented medical term (informational activity). The second coding stage is about a navigating terminology browser to find a code that matches the concept (code-matching activity). Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) was used for the coding system. A new computer application to record the trajectory of the computer mouse and record the usage time was programmed. Using this application, we measured the time that was spent. A senior neurosurgeon who has studied SNOMED CT has analyzed the accuracy of the input coding. This method was tested by five neurosurgical residents (NSRs) and five medical record administrators (MRAs), and 20 neurosurgical terms were used.RESULTS: The mean accuracy of the NSR group was 89.33%, and the mean accuracy of the MRA group was 80% (p=0.024). The mean duration for total coding of the NSR group was 158.47 seconds, and the mean duration for total coding of the MRA group was 271.75 seconds (p=0.003).CONCLUSION: We proposed a method to analyze the clinical coding process. Through this method, it was possible to accurately calculate the time required for the coding. In neurosurgical terms, NSRs had shorter time to complete the coding and higher accuracy than MRAs.

Development of an Integrated Biospecimen Database among the Regional Biobanks in Korea / 대한의료정보학회지

OBJECTIVES: This study developed an integrated database for 15 regional biobanks that provides large quantities of high-quality bio-data to researchers to be used for the prevention of disease, for the development of personalized medicines, and in genetics studies. METHODS: We collected raw data, managed independently by 15 regional biobanks, for database modeling and analyzed and defined the metadata of the items. We also built a three-step (high, middle, and low) classification system for classifying the item concepts based on the metadata. To generate clear meanings of the items, clinical items were defined using the Systematized Nomenclature of Medicine Clinical Terms, and specimen items were defined using the Logical Observation Identifiers Names and Codes. To optimize database performance, we set up a multi-column index based on the classification system and the international standard code. RESULTS: As a result of subdividing 7,197,252 raw data items collected, we refined the metadata into 1,796 clinical items and 1,792 specimen items. The classification system consists of 15 high, 163 middle, and 3,588 low class items. International standard codes were linked to 69.9% of the clinical items and 71.7% of the specimen items. The database consists of 18 tables based on a table from MySQL Server 5.6. As a result of the performance evaluation, the multi-column index shortened query time by as much as nine times. CONCLUSIONS: The database developed was based on an international standard terminology system, providing an infrastructure that can integrate the 7,197,252 raw data items managed by the 15 regional biobanks. In particular, it resolved the inevitable interoperability issues in the exchange of information among the biobanks, and provided a solution to the synonym problem, which arises when the same concept is expressed in a variety of ways.

Development of an Integrated Biospecimen Database among the Regional Biobanks in Korea / 대한의료정보학회지

OBJECTIVES: This study developed an integrated database for 15 regional biobanks that provides large quantities of high-quality bio-data to researchers to be used for the prevention of disease, for the development of personalized medicines, and in genetics studies. METHODS: We collected raw data, managed independently by 15 regional biobanks, for database modeling and analyzed and defined the metadata of the items. We also built a three-step (high, middle, and low) classification system for classifying the item concepts based on the metadata. To generate clear meanings of the items, clinical items were defined using the Systematized Nomenclature of Medicine Clinical Terms, and specimen items were defined using the Logical Observation Identifiers Names and Codes. To optimize database performance, we set up a multi-column index based on the classification system and the international standard code. RESULTS: As a result of subdividing 7,197,252 raw data items collected, we refined the metadata into 1,796 clinical items and 1,792 specimen items. The classification system consists of 15 high, 163 middle, and 3,588 low class items. International standard codes were linked to 69.9% of the clinical items and 71.7% of the specimen items. The database consists of 18 tables based on a table from MySQL Server 5.6. As a result of the performance evaluation, the multi-column index shortened query time by as much as nine times. CONCLUSIONS: The database developed was based on an international standard terminology system, providing an infrastructure that can integrate the 7,197,252 raw data items managed by the 15 regional biobanks. In particular, it resolved the inevitable interoperability issues in the exchange of information among the biobanks, and provided a solution to the synonym problem, which arises when the same concept is expressed in a variety of ways.

Usage Patterns of Nursing Diagnoses among Student Nurses in Psychiatric Unit: Relation with NANDA and SNOMED CT / 정신간호학회지

PURPOSE: The aim of this study was to explore how nursing diagnoses are made by undergraduate students of psychiatric unit in Korea. METHODS: Data were collected from case reports and analyzed based on NANDA (North American Nursing Diagnosis Association) nursing diagnoses and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) as reference terminology. RESULTS: The 30 different nursing diagnoses from 135 distinct nursing diagnosis statements were assessed after removing repetition of case studies from a of total of 1,140 statements of nursing diagnoses. The most frequently used NANDA diagnosis was "ineffective coping" The thirty nursing diagnoses were grouped under 10 out of the 13 NANDA domains. In addition, 98 related factors were classified into SNOMED CT hierarchies of Clinical Finding, Procedure, and Observable Entity. The content validity index for the mapping of nursing diagnoses was 0.97, indicating a relatively strong agreement. CONCLUSION: These results can help students to improve their knowledge and better formulate appropriate diagnoses. Using standardized terminology would improve competency of education and help to ratify the steps of the nursing process, especially nursing planning. Educational strategies that enhance diagnostic accuracy are recommended.

Current National Approach to Healthcare ICT Standardization: Focus on Progress in New Zealand / 대한의료정보학회지

OBJECTIVES: Many countries try to efficiently deliver high quality healthcare services at lower and manageable costs where healthcare information and communication technologies (ICT) standardisation may play an important role. New Zealand provides a good model of healthcare ICT standardisation. The purpose of this study was to review the current healthcare ICT standardisation and progress in New Zealand. METHODS: This study reviewed the reports regarding the healthcare ICT standardisation in New Zealand. We also investigated relevant websites related with the healthcare ICT standards, most of which were run by the government. Then, we summarised the governance structure, standardisation processes, and their output regarding the current healthcare ICT standards status of New Zealand. RESULTS: New Zealand government bodies have established a set of healthcare ICT standards and clear guidelines and procedures for healthcare ICT standardisation. Government has actively participated in various enactments of healthcare ICT standards from the inception of ideas to their eventual retirement. Great achievements in eHealth have already been realized, and various standards are currently utilised at all levels of healthcare regionally and nationally. Standard clinical terminologies, such as International Classification of Diseases (ICD) and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) have been adopted and Health Level Seven (HL7) standards are actively used in health information exchanges. CONCLUSIONS: The government to New Zealand has well organised ICT institutions, guidelines, and regulations, as well as various programs, such as e-Medications and integrated care services. Local district health boards directly running hospitals have effectively adopted various new ICT standards. They might already be benefiting from improved efficiency resulting from healthcare ICT standardisation.

Development of Health Information Search Engine Based on Metadata and Ontology / 대한의료정보학회지

OBJECTIVES: The aim of the study was to develop a metadata and ontology-based health information search engine ensuring semantic interoperability to collect and provide health information using different application programs. METHODS: Health information metadata ontology was developed using a distributed semantic Web content publishing model based on vocabularies used to index the contents generated by the information producers as well as those used to search the contents by the users. Vocabulary for health information ontology was mapped to the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), and a list of about 1,500 terms was proposed. The metadata schema used in this study was developed by adding an element describing the target audience to the Dublin Core Metadata Element Set. RESULTS: A metadata schema and an ontology ensuring interoperability of health information available on the internet were developed. The metadata and ontology-based health information search engine developed in this study produced a better search result compared to existing search engines. CONCLUSIONS: Health information search engine based on metadata and ontology will provide reliable health information to both information producer and information consumers.

Book Review: Principles of Health Interoperability HL7 and SNOMED / 대한의료정보학회지

No abstract available.

Contribution of Clinical Archetypes, and the Challenges, towards Achieving Semantic Interoperability for EHRs / 대한의료정보학회지

OBJECTIVES: The objective is to introduce 'clinical archetype' which is a formal and agreed way of representing clinical information to ensure interoperability across and within Electronic Health Records (EHRs). The paper also aims at presenting the challenges building quality labeled clinical archetypes and the challenges towards achieving semantic interoperability between EHRs. METHODS: Twenty years of international research, various European healthcare informatics projects and the pioneering work of the openEHR Foundation have led to the following results. RESULTS: The requirements for EHR information architectures have been consolidated within ISO 18308 and adopted within the ISO 13606 EHR interoperability standard. However, a generic EHR architecture cannot ensure that the clinical meaning of information from heterogeneous sources can be reliably interpreted by receiving systems and services. Therefore, clinical models called 'clinical archetypes' are required to formalize the representation of clinical information within the EHR. Part 2 of ISO 13606 defines how archetypes should be formally represented. The current challenge is to grow clinical communities to build a library of clinical archetypes and to identify how evidence of best practice and multi-professional clinical consensus should best be combined to define archetypes at the optimal level of granularity and specificity and quality label them for wide adoption. Standardizing clinical terms within EHRs using clinical terminology like Systematized Nomenclature of Medicine Clinical Terms is also a challenge. CONCLUSIONS: Clinical archetypes would play an important role in achieving semantic interoperability within EHRs. Attempts are being made in exploring the design and adoption challenges for clinical archetypes.

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.

Comparison of Knowledge Levels Required for SNOMED CT Coding of Diagnosis and Operation Names in Clinical Records / 대한의료정보학회지

OBJECTIVES: Coding Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) with complex and polysemy clinical terms may ask coder to have a high level of knowledge of clinical domains, but with simpler clinical terms, coding may require only simpler knowledge. However, there are few studies quantitatively showing the relation between domain knowledge and coding ability. So, we tried to show the relationship between those two areas. METHODS: We extracted diagnosis and operation names from electronic medical records of a university hospital for 500 ophthalmology and 500 neurosurgery patients. The coding process involved one ophthalmologist, one neurosurgeon, and one medical record technician who had no experience of SNOMED coding, without limitation to accessing of data for coding. The coding results and domain knowledge were compared. RESULTS: 705 and 576 diagnoses, and 500 and 629 operation names from ophthalmology and neurosurgery, were enrolled, respectively. The physicians showed higher performance in coding than in MRT for all domains; all specialist physicians showed the highest performance in domains of their own departments. All three coders showed statistically better coding rates in diagnosis than in operation names (p < 0.001). CONCLUSIONS: Performance of SNOMED coding with clinical terms is strongly related to the knowledge level of the domain and the complexity of the clinical terms. Physicians who generate clinical data can be the best potential candidates as excellent coders from the aspect of coding performance.

Avaliação crítica das nomenclaturas diagnósticas dos exames citopatológicos cervicais utilizadas no Sistema Único de Saúde (SUS) / Critical evaluation of the diagnostic nomenclatures of cervical cytopathological exams used in the Brazilian Unified Health System (SUS)

OBJETIVO: identificar as nomenclaturas diagnósticas dos exames citopatológicos cervicais utilizadas pelos laboratórios que atendem o Sistema Único de Saúde (SUS) e participantes do Monitoramento Externo de Qualidade (MEQ). Avaliar as informações adquiridas de profissionais ginecologistas que atuam no SUS sobre os tipos de classificação diagnóstica que recebem nos laudos citopatológicos cervicais. MÉTODOS: foram avaliados 94 laudos citopatológicos liberados pelos laboratórios participantes do MEQ no Estado de São Paulo e 126 questionários aplicados aos ginecologistas que atenderam o SUS. RESULTADOS: dos 94 laboratórios, 81 (86,2 por cento) utilizam uma única nomenclatura diagnóstica: 79 (97,6 por cento) utilizam a Nomenclatura Brasileira para Laudos Citopatológicos (NBLC), 1 (1,2 por cento) utiliza a classificação de Papanicolaou e 1 (1,2 por cento) utiliza a de Richart. Dos 13 (13,8 por cento) laboratórios que utilizam mais de uma nomenclatura, 5 apresentam 2 tipos, e 8, de 3 a 4, 9 dos quais incluem a classificação de Papanicolaou. O estudo demonstrou que 52 (55,3 por cento) laboratórios apresentaram mais de um diagnóstico descritivo num mesmo laudo. Dos 126 ginecologistas que responderam ao questionário de avaliação dos laudos citopatológicos, 78 (61,9 por cento) disseram receber laudos dos laboratórios com apenas uma classificação diagnóstica, 48 (38,1 por cento), laudos com mais de uma classificação, e 2 receberam as 4 classificações. Entre os 93 (73,8 por cento) ginecologistas que preferem uma classificação, 56 (60,2 por cento) alegaram que a NBLC contribui para a conduta clínica, 13 (14,0 por cento) optaram pela nomenclatura de Richart, 8 (8,6 por cento), de Reagan e 16 (17,2 por cento), a de Papanicolaou. De 33 (26,2 por cento) ginecologistas que preferem mais de uma nomenclatura, 5 optaram pelas 4 classificações...

PURPOSE: to identify the nomenclature for reporting cervical cytological diagnoses used by laboratories which render services to the Brazilian Unified Health System (SUS) and which participate in External Quality Monitoring (MEQ). To evaluate the information acquired from gynecologists of the SUS regarding the various diagnostic classifications that they receive in the cervical cytology diagnostic reports. METHODS: we evaluated 94 cytology reports issued by laboratories which participate in the MEQ in the State of São Paulo, Brazil, and 126 questionnaires applied to gynecologists who work for the SUS. RESULTS: out of the 94 laboratories, 81 (86.2 percent) use one diagnostic classification: 79 (97.6 percent) use the Brazilian Nomenclature for Cytological Reports (NBLC), 1 (1.2 percent) uses the Papanicolaou classification and 1 (1.2 percent) uses the Richart diagnostic classification. Of the 13 (13.8 percent) laboratories that use more than one classification, 5 use 2 types and 8 use 3 to 4 types, with 9 including the Papanicolau diagnostic classification. The study showed that 52 (55.3 percent) laboratories presented more than one descriptive diagnosis in the same report. Out of the 126 gynecologists who filled out a questionnaire evaluating the cytopathology reports, 78 (61.9 percent) stated that they received laboratory reports with only one diagnostic classification, 48 (38.1 percent) received reports with more than one classification and 2 received reports with all 4 classifications. Among the 93 (73.8 percent) gynecologists who prefer only one classification, 56 (60.2 percent) claimed that the NBLC contributes to clinical practice, 13 (14.0 percent) opted for the Richart classification, 8 (8.6 percent) for the Reagan classification and 16 (17.2 percent) for the Papanicolaou classification. Out of 33 (26.2 percent) gynecologists who prefer more than one classification, 5 opted for the 4 classifications...

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP / 대한의료정보학회지

OBJECTIVES: The purpose of this study is to explore possibility of information sharing between the medical and nursing domains. METHODS: Narrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts. RESULTS: A total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts. CONCLUSIONS: These mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.

Proposed Algorithm with Standard Terminologies (SNOMED and CPT) for Automated Generation of Medical Bills for Laboratory Tests / 대한의료정보학회지

OBJECTIVES: In this study, we proposed an algorithm for mapping standard terminologies for the automated generation of medical bills. As the Korean and American structures of health insurance claim codes for laboratory tests are similar, we used Current Procedural Terminology (CPT) instead of the Korean health insurance code set due to the advantages of mapping in the English language. METHODS: 1,149 CPT codes for laboratory tests were chosen for study. Each CPT code was divided into two parts, a Logical Observation Identifi ers Names and Codes (LOINC) matched part (matching part) and an unmatched part (unmatched part). The matching parts were assigned to LOINC axes. An ontology set was designed to express the unmatched parts, and a mapping strategy with Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) was also proposed. Through the proceeding analysis, an algorithm for mapping CPT with SNOMED CT arranged by LOINC was developed. RESULTS: 75% of the 1,149 CPT codes could be assigned to LOINC codes. Two hundred and twenty-five CPT codes had only one component part of LOINC, whereas others had more than two parts of LOINC. The system of LOINC axes was found in 309 CPT codes, scale 555, property 9, method 42, and time aspect 4. From the unmatched parts, three classes, 'types', 'objects', and 'subjects', were determined. By determining the relationship between the classes with several properties, all unmatched parts could be described. Since the 'subject to' class was strongly connected to the six axes of LOINC, links between the matching parts and unmatched parts were made. CONCLUSIONS: The proposed method may be useful for translating CPT into concept-oriented terminology, facilitating the automated generation of medical bills, and could be adapted for the Korean health insurance claim code set.

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.

Terminologia de incidentes com medicamentos no contexto hospitalar: [revisão] / Terminology for drug incidents in the hospital context: [review]

Incidentes com medicamentos geram problemas aos pacientes e custos adicionais ao sistema de saúde. A variedade de termos utilizada para comunicá-los propicia divergências nos resultados de pesquisas e confundem notificadores. Objetivou-se revisar os termos utilizados para descrever estes incidentes confrontando-os com as conceituações/definições oficiais disponíveis. Pesquisaram-se as bases PubMed, MEDLINE, IPA e LILACS para selecionar estudos publicados entre janeiro de 1990 e dezembro de 2005. Selecionaram-se 33 publicações. Verificou-se que a terminologia supranacional recomendada para descrever incidentes com medicamentos é insuficiente, mas que há consenso de uso das expressões em função do gênero do incidente. O termo Reação Adversa a Medicamento é mais utilizado quando não se verifica intencionalidade. A expressão Evento Adverso a Medicamento foi mais usada quando se descreviam incidentes durante a hospitalização; e Problema Relacionado a Medicamento foi mais utilizada em estudos que avaliaram atenção/cuidados farmacêuticos (uso/falta do medicamento). Ainda assim, a linha divisória entre essas três categorias não é clara e simples. Futuros estudos das relações entre as categorias e investigações multidisciplinares sobre erro humano podem subsidiar a proposição de novas conceituações.

In-hospital drug incidents cause problems for patients and additional costs for the health system. The variety of terms used to report them leads to disparities in research results and confuses the professionals that report them. This study aimed to review the terms used to describe drug incidents by collating them with the official concepts and definitions. PubMed, MEDLINE, IPA, and LILACS were searched to select studies published from January 1990 to December 2005. Thirty-three publications were selected. The supranational terminology recommended for describing drug incidents proved insufficient, but there was consensus that the expressions are used as a function of the type of incident. Adverse drug reaction is used when no intent is identified. Adverse drug event mainly describes incidents during hospitalization, and drug-related problem is used in studies on pharmaceutical care (use or lack of the drug). Still, the division between these categories is neither clear nor simple. Future studies on the relations between categories and multidisciplinary research on human error could support proposals for new concepts.

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.