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创建与SNOMED CT的本地接口术语。

Creation of a local interface terminology to SNOMED CT.

作者信息

Osornio Alejandro Lopez, Luna Daniel, Gambarte Maria Laura, Gomez Adrian, Reynoso Guillermo, de Quirós Fernán González Bernaldo

机构信息

Medical Informatics Department, Hospital Italiano de Buenos Aires, Argentina.

出版信息

Stud Health Technol Inform. 2007;129(Pt 1):765-9.

Abstract

This paper describes the steps followed in the creation of a local Interface Terminology to SNOMED CT (as reference terminology) with a strong focus on user acceptability. The resulting list of terms is used for clinical data input by physicians and nurses at the Hospital Italiano in Buenos Aires, Argentina. Description includes data model, mappings to SNOMED CT and classifications, subsets definitions and extensibility mechanisms. The Interface Terminology is currently used in the recording of diagnosis and procedures in inpatient discharge summaries and its coverage is improving from user feedback. Its current size is 24,800 concepts, 67% of them needed post-coordination for appropriate semantic representation, due to a very flexible policy that allows the use of any number of modifiers on concepts.

摘要

本文描述了创建一个本地接口术语表(以SNOMED CT作为参考术语表)所遵循的步骤,重点关注用户可接受性。所得的术语列表供阿根廷布宜诺斯艾利斯意大利医院的医生和护士用于临床数据输入。描述包括数据模型、到SNOMED CT的映射和分类、子集定义以及可扩展性机制。该接口术语表目前用于住院患者出院小结中诊断和手术的记录,并且根据用户反馈其覆盖范围正在改善。其当前规模为24,800个概念,其中67%需要进行后置协调以实现适当的语义表示,这是因为采用了非常灵活的策略,允许在概念上使用任意数量的修饰词。

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