Cornet Ronald, de Keizer Nicolette F
Department of Medical Informatics, Academic Medical Center, University of Amsterdam, The Netherlands.
Stud Health Technol Inform. 2011;169:824-8.
Multidisciplinary communication about patients with multiple and often interrelated diseases is of utmost importance to guarantee high quality of care. In this paper we focus on storing into the electronic medical record patients' disorders which are associated with each other, taking into account the role of SNOMED CT. The objectives of this paper are to design and discuss possibilities to appropriately record the associations between two disorders as defined in SNOMED CT and to get insight into the use of the relationship "associated with" in SNOMED CT and its consequences for data reuse. Our study showed that textual and concept-based reproducible recording of reusable data is hampered due to incorrect or incomplete modeling of associations between disorders in SNOMED CT. A possible solution for this is to record constituting characteristics of concepts directly into the record, instead of only being represented in the terminology. Further research on binding of information models and terminologies is needed.
对于患有多种且通常相互关联疾病的患者，多学科沟通对于确保高质量护理至关重要。在本文中，我们着重探讨如何将相互关联的患者疾病信息存储到电子病历中，并考虑了SNOMED CT的作用。本文的目的是设计并讨论如何恰当地记录SNOMED CT中定义的两种疾病之间的关联，并深入了解SNOMED CT中“与……相关”关系的使用及其对数据重用的影响。我们的研究表明，由于SNOMED CT中疾病之间关联的建模不正确或不完整，阻碍了基于文本和概念的可重复使用数据的记录。对此的一个可能解决方案是将概念的构成特征直接记录到记录中，而不是仅在术语中表示。需要对信息模型和术语的绑定进行进一步研究。
