Petersson H, Nilsson G, Strender L E, Ahlfeldt H
Medical Informatics, Linköpings universitet, Linköping, Sweden.
Med Inform Internet Med. 2001 Apr-Jun;26(2):87-99.
Implementation of problem lists and their relation to standardized coding systems have been approached and analysed in different ways. Most evaluations concern quantitative aspects such as content coverage in a specific domain. In order to reveal the qualitative aspects of diagnostic coding, medical record texts from primary health care encounters were compared with terms from a coding system that was used for describing them statistically. The records were coded by six general practitioners, and in some cases, an applied diagnostic term was found within the text, while other record text-coding system relationships were categorized as synonyms, alternative terms, and interpretations. Thus, the categories roughly corresponded to a measure of semantic distance between the terms in the record text and the rubrics of the coding system, and there was a correlation between semantic distance and inter-rater agreement. The subcategories of this scheme corresponded fairly well to recently published desiderata for clinical terminology servers, including functionality such as word normalization and spelling correction. However, not all problems could have been automatically coded by means of lexical methods, which can be partly explained by the fact that diagnostic coding also relies on clinical knowledge. In addition, proper automation relies on context representation within the records.
问题列表的实施及其与标准化编码系统的关系已经以不同方式进行了探讨和分析。大多数评估关注定量方面，例如特定领域的内容覆盖范围。为了揭示诊断编码的定性方面，将初级卫生保健诊疗记录文本与用于对其进行统计描述的编码系统中的术语进行了比较。这些记录由六位全科医生进行编码，在某些情况下，在文本中找到了一个应用的诊断术语，而其他记录文本与编码系统的关系则被归类为同义词、替代术语和解释。因此，这些类别大致对应于记录文本中的术语与编码系统条目的语义距离度量，并且语义距离与评分者间一致性之间存在相关性。该方案的子类别与最近发布的临床术语服务器的要求相当吻合，包括诸如单词规范化和拼写校正等功能。然而，并非所有问题都可以通过词汇方法自动编码，这可以部分解释为诊断编码还依赖于临床知识。此外，适当的自动化依赖于记录中的上下文表示。
