三位医生使用两种术语浏览器进行SNOMED-CT编码的可靠性。
Reliability of SNOMED-CT coding by three physicians using two terminology browsers.
作者信息
Chiang Michael F, Hwang John C, Yu Alexander C, Casper Daniel S, Cimino James J, Starren Justin B
机构信息
Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, NY, USA.
出版信息
AMIA Annu Symp Proc. 2006;2006:131-5.
SNOMED-CT has been promoted as a reference terminology for electronic health record (EHR) systems. Many important EHR functions are based on the assumption that medical concepts will be coded consistently by different users. This study is designed to measure agreement among three physicians using two SNOMED-CT terminology browsers to encode 242 concepts from five ophthalmology case presentations in a publicly-available clinical journal. Inter-coder reliability, based on exact coding match by each physician, was 44% using one browser and 53% using the other. Intra-coder reliability testing revealed that a different SNOMED-CT code was obtained up to 55% of the time when the two browsers were used by one user to encode the same concept. These results suggest that the reliability of SNOMED-CT coding is imperfect, and may be a function of browsing methodology. A combination of physician training, terminology refinement, and browser improvement may help increase the reproducibility of SNOMED-CT coding.
SNOMED-CT已被推广为电子健康记录（EHR）系统的参考术语。许多重要的EHR功能基于这样一种假设，即医学概念将由不同用户进行一致编码。本研究旨在测量三位医生使用两种SNOMED-CT术语浏览器对一份公开临床杂志中五个眼科病例报告的242个概念进行编码时的一致性。基于每位医生精确编码匹配的编码员间信度，使用一种浏览器时为44%，使用另一种浏览器时为53%。编码员内信度测试显示，当一名用户使用两种浏览器对同一概念进行编码时，高达55%的情况下会获得不同的SNOMED-CT代码。这些结果表明，SNOMED-CT编码的可靠性并不理想，可能是浏览方法的一个函数。医生培训、术语完善和浏览器改进相结合可能有助于提高SNOMED-CT编码的可重复性。
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