Richesson Rachel L, Andrews James E, Krischer Jeffrey P
Pediatrics Epidemiology Center, University of South Florida College of Medicine, Department of Pediatrics, Tampa, FL 33612, USA.
J Am Med Inform Assoc. 2006 Sep-Oct;13(5):536-46. doi: 10.1197/jamia.M2093. Epub 2006 Jun 23.
To estimate the coverage provided by SNOMED CT for clinical research concepts represented by the items on case report forms (CRFs), as well as the semantic nature of those concepts relevant to post-coordination methods.
Convenience samples from CRFs developed by rheumatologists conducting several longitudinal, observational studies of vasculitis were selected. A total of 17 CRFs were used as the basis of analysis for this study, from which a total set of 616 (unique) items were identified. Each unique data item was classified as either a clinical finding or procedure. The items were coded by the presence and nature of SNOMED CT coverage and classified into semantic types by 2 coders.
Basic frequency analysis was conducted to determine levels of coverage provided by SNOMED CT. Estimates of coverage by various semantic characterizations were estimated.
Most of the core clinical concepts (88%) from these clinical research data items were covered by SNOMED CT; however, far fewer of the concepts were fully covered (that is, where all aspects of the CRF item could be represented completely without post-coordination; 23%). In addition, a large majority of the concepts (83%) required post-coordination, either to clarify context (e.g., time) or to better capture complex clinical concepts (e.g., disease-related findings). For just over one third of the sampled CRF data items, both types of post-coordination were necessary to fully represent the meaning of the item.
SNOMED CT appears well-suited for representing a variety of clinical concepts, yet is less suited for representing the full amount of information collected on CRFs.
评估SNOMED CT对病例报告表（CRF）上项目所代表的临床研究概念的覆盖程度，以及这些概念与后组配方法相关的语义性质。
选取了由进行多项血管炎纵向观察研究的风湿病学家所制定的CRF中的便利样本。本研究共使用了17份CRF作为分析基础，从中识别出总共616个（唯一）项目。每个唯一的数据项目被分类为临床发现或程序。这些项目根据SNOMED CT覆盖的存在和性质进行编码，并由两名编码员分类为语义类型。
进行基本频率分析以确定SNOMED CT提供的覆盖水平。估计了各种语义特征的覆盖范围。
这些临床研究数据项目中的大多数核心临床概念（88%）被SNOMED CT覆盖；然而，完全覆盖的概念要少得多（即CRF项目的所有方面都可以在无需后组配的情况下完全表示；23%）。此外，绝大多数概念（83%）需要后组配，要么是为了澄清上下文（如时间），要么是为了更好地捕捉复杂的临床概念（如疾病相关发现）。对于略超过三分之一的抽样CRF数据项目，两种类型的后组配对于充分表示项目的含义都是必要的。
SNOMED CT似乎非常适合表示各种临床概念，但不太适合表示CRF上收集的全部信息。
