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使用SNOMED CT®和LOINC®对基层医疗哮喘电子健康记录的术语进行标准化。

Use of SNOMED CT® and LOINC® to standardize terminology for primary care asthma electronic health records.

作者信息

Lougheed M Diane, Thomas Nicola J, Wasilewski Nastasia V, Morra Alison H, Minard Janice P

机构信息

a Department of Medicine , Queen's University , Kingston , Ontario , Canada.

b Asthma Research Unit, Clinical Research Centre, Kingston General Hospital , Ontario , Canada.

出版信息

J Asthma. 2018 Jun;55(6):629-639. doi: 10.1080/02770903.2017.1362424. Epub 2017 Oct 9.

Abstract

OBJECTIVES

The burden of asthma ranks among the highest for chronic diseases. Interoperable electronic health records (EHRs) can improve the management of chronic diseases such as asthma by facilitating sharing of data between health care settings along the continuum of care. Terminology such as SNOMED CT® (Systematized Nomenclature of Medicine-Clinical Terms) and LOINC® (Logistical Observation Identifier Names and Codes) are prerequisites for interoperability of EHRs. We sought to determine the extent to which data elements in a validated asthma care map (ACM) are congruent with these terminologies.

METHODS

A certified asthma educator entered all 169 elements in the ACM into the SNOMED CT® browser. Matched elements were assigned a concept name, an identification number, and classified into a hierarchy. LOINC® terminology was reviewed for asthma-related pulmonary function tests (PFTs).

RESULTS

Forty-two percent of the ACM elements were complete matches to existing SNOMED CT® concepts, 24% partial matches, and 34% unmatched. Specific asthma control parameters were either complete (n = 3) or partial (n = 4) matches, but overall "asthma control" was unmatched. There were 92% complete or partial matches for PFT elements to SNOMED CT® and 83% to LOINC Conclusions: The majority of ACM elements are congruent with standardized terminology, enabling EHR interoperability. Future requests for new concepts in SNOMED CT® and LOINC® should be pursued for asthma control parameters paramount to evidence-based practice.

摘要

目的

哮喘负担在慢性病中位列最高。可互操作的电子健康记录(EHR)能够通过促进医疗服务机构之间在连续医疗过程中的数据共享,改善诸如哮喘等慢性病的管理。诸如医学系统命名法临床术语(SNOMED CT®)和逻辑观察标识符名称与代码(LOINC®)等术语是EHR互操作性的先决条件。我们试图确定经过验证的哮喘护理地图(ACM)中的数据元素与这些术语的一致程度。

方法

一名经过认证的哮喘教育工作者将ACM中的所有169个元素输入到SNOMED CT®浏览器中。匹配的元素被赋予一个概念名称、一个识别号,并分类到一个层次结构中。对与哮喘相关的肺功能测试(PFT)的LOINC®术语进行了审查。

结果

42%的ACM元素与现有的SNOMED CT®概念完全匹配,24%部分匹配,34%不匹配。特定的哮喘控制参数要么完全匹配(n = 3),要么部分匹配(n = 4),但总体“哮喘控制”不匹配。PFT元素与SNOMED CT®的完全或部分匹配率为92%,与LOINC®的匹配率为83%。结论:大多数ACM元素与标准化术语一致,实现了EHR的互操作性。对于基于循证实践至关重要的哮喘控制参数,未来应寻求在SNOMED CT®和LOINC®中提出新的概念。

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