实施 SNOMED CT 进行质量报告：避免陷阱。
Implementing SNOMED CT for Quality Reporting: Avoiding Pitfalls.
机构信息
Clinical Informatics Consulting , Atlanta, GA, USA.
出版信息
Appl Clin Inform. 2011 Dec 21;2(4):534-45. doi: 10.4338/ACI-2011-10-RA-0056. Print 2011.
OBJECTIVE
To implement the SNOMED CT electronic specifications for reporting quality measures and to identify critical issues that affect implementation.
BACKGROUND
The Centers for Medicare and Medicaid (CMS) have issued the electronic specifications for reporting quality measures requiring vendors and hospital systems to use standardized data elements to provide financial incentives for eligible providers.
METHODS
The electronic specifications from CMS were downloaded and extracted. All SNOMED CT codes were examined individually as part of the creation of a mapping table for distribution by a vendor for incorporation into electronic health record systems. A qualitative and quantitative evaluation of the SNOMED CT codes was done as a follow up to the mapping project.
RESULTS
A total of 10643 SNOMED codes were examined for the 44 measures. The approved SNOMED CT code sets contain aberrancies in content such as incomplete IDs, the use of description IDs instead of concept IDs, inactive codes, morphology and observable codes for clinical findings and the inclusion of non-human content.
CONCLUSION
Implementers of these approved specifications must do additional rigorous review and make edits in order to avoid incorporating errors into their EHR products and systems.
目的
实现 SNOMED CT 电子规范报告质量措施，并确定影响实施的关键问题。
背景
医疗保险和医疗补助服务中心 (CMS) 发布了报告质量措施的电子规范，要求供应商和医院系统使用标准化数据元素，为符合条件的提供者提供经济激励。
方法
下载并提取 CMS 的电子规范。作为创建映射表的一部分，对所有 SNOMED CT 代码进行了单独检查，以便由供应商分发，以便纳入电子健康记录系统。对映射项目进行了后续的 SNOMED CT 代码的定性和定量评估。
结果
对 44 项措施进行了总计 10643 个 SNOMED 代码的检查。批准的 SNOMED CT 代码集在内容上存在异常，例如 ID 不完整、使用描述 ID 而不是概念 ID、无效代码、临床发现的形态和可观察代码以及包含非人类内容。
结论
实施这些批准规范的人员必须进行额外的严格审查，并进行编辑，以避免在其 EHR 产品和系统中纳入错误。
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