Edeler B, Majeed R W, Ahlbrandt J, Stöhr M R, Stommel F, Brenck F, Thun S, Röhrig R
Dr. Rainer Röhrig, Medical Informatics in Anesthesiology and Intensive Care Medicine, Justus-Liebig-University Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany.
Methods Inf Med. 2014;53(2):87-91. doi: 10.3414/ME12-02-0015. Epub 2013 Nov 5.
Treatment of patients picked up by emergency services can be improved by data transfer ahead of arrival. Care given to emergency patients can be assessed and improved through data analysis. Both goals require electronic data transfer from the emergency medical services (EMS) to the hospital information system. Therefore a generic semantic standard is needed.
Objective of this paper is to test the suitability of the international nomenclature Logical Observation Identifiers Names and Codes (LOINC) to encode the core data-sets for rescue service protocols (MIND 2 and MIND 3). Encoding diagnosis and medication categories using ICD-10 and ATC were also assessed.
Protocols were broken down into concepts, assigned to categories, translated and manually mapped to LOINC codes. Each protocol was independently encoded by two healthcare professionals and in case of discrepancies a third expert was consulted to reach a consensus.
Currently 39% of parameters could be mapped to LOINC. Additional use of other coding systems such as International Statistical Classification of Diseases and Related Health Problems (ICD-10) for diagnoses and Anatomical Therapeutic Chemical Classification System (ATC) for medications increases the rate of 'mappable' parameters to 56%.
Although the coverage is low, mapping has shown that LOINC is suitable to encode concepts of the rescue services. In order to create a generic semantic model to be applied in the field our next step is to request new LOINC codes for the missing concepts.
通过在患者到达之前进行数据传输，可以改善急诊服务所接诊患者的治疗情况。通过数据分析可以评估和改进对急诊患者的护理。这两个目标都需要将电子数据从紧急医疗服务（EMS）传输到医院信息系统。因此，需要一个通用的语义标准。
本文的目的是测试国际术语逻辑观察标识符名称和代码（LOINC）对救援服务协议（MIND 2和MIND 3）核心数据集进行编码的适用性。还评估了使用国际疾病分类第10版（ICD-10）和解剖治疗化学分类系统（ATC）对诊断和药物类别进行编码的情况。
将协议分解为概念，分配到类别中，进行翻译并手动映射到LOINC代码。每个协议由两名医疗专业人员独立编码，如有差异，则咨询第三位专家以达成共识。
目前39%的参数可以映射到LOINC。额外使用其他编码系统，如用于诊断的国际疾病及相关健康问题统计分类（ICD-10）和用于药物的解剖治疗化学分类系统（ATC），可将“可映射”参数的比例提高到56%。
尽管覆盖率较低，但映射表明LOINC适用于对救援服务的概念进行编码。为了创建一个适用于该领域的通用语义模型，我们的下一步是为缺失的概念申请新的LOINC代码。
