Brammen Dominik, Dewenter Heike, Heitmann Kai U, Thiemann Volker, Majeed Raphael W, Walcher Felix, Röhrig Rainer, Thun Sylvia
Department of Trauma Surgery, Otto-von-Guericke-University Magdeburg, Germany.
Hochschule Niederrhein, University of Applied Sciences, Krefeld, Germany.
Stud Health Technol Inform. 2017;243:175-179.
The German Emergency Department Medical Record (GEDMR) was created by medical domain experts and healthcare providers providing a dataset as well as a form. The trauma module of GEDMR was syntactically standardized using HL7 CDA and semantically standardized using different terminologies including SNOMED CT, LOINC and proprietary coding systems. This study depicts the mapping accuracy with aforementioned syntactical and semantical standards in general and especially the content coverage of SNOMED CT.
The specification of GEDMR (V2015.1) concepts with eHealth-standards HL7-CDA, LOINC, SNOMED CT was analyzed. A content coverage assessment was made using the ISO TR 12300 rating scheme, following descriptive analysis.
The trauma module of GEDMR contains 489 concepts, with 202 concepts expressed via HL7 CDA structure. It is possible to code 89 % of the remaining concepts via SNOMED CT. 79 % provide an advanced level of semantic interoperability, as they represent the source information either lexically or as an approved synonym.
The terminology binding problem is relevant when combining different standards for syntactic and semantic interoperability with best practice documents and reference specifications providing guidance. A national license and extension for SNOMED CT in Germany as well as an ongoing effort in contributing to the International Version of SNOMED CT would be necessary to gain full coverage for concepts in German Emergency Medicine and to leverage the associated standardization process.
德国急诊科医疗记录（GEDMR）由医学领域专家和医疗服务提供者创建，提供了一个数据集和一种表单。GEDMR的创伤模块在语法上使用HL7 CDA进行了标准化，在语义上使用了包括SNOMED CT、LOINC和专有编码系统在内的不同术语进行了标准化。本研究描述了与上述语法和语义标准的映射准确性，特别是SNOMED CT的内容覆盖范围。
分析了GEDMR（V2015.1）概念与电子健康标准HL7-CDA、LOINC、SNOMED CT的规范。在描述性分析之后，使用ISO TR 12300评级方案进行了内容覆盖评估。
GEDMR的创伤模块包含489个概念，其中202个概念通过HL7 CDA结构表示。通过SNOMED CT可以对其余89%的概念进行编码。79%的概念提供了高级别的语义互操作性，因为它们要么在词汇上表示源信息，要么作为认可的同义词表示。
在将不同的语法和语义互操作性标准与提供指导的最佳实践文档和参考规范相结合时，术语绑定问题是相关的。为了在德国急诊医学中实现概念的全面覆盖并利用相关的标准化过程，有必要在德国获得SNOMED CT的国家许可和扩展，以及持续努力为SNOMED CT国际版做出贡献。
