Dutch Nurses' Association, PO Box 8212, 3503 RE Utrecht, Netherlands.
Nursing Healthcare Innovation Technology Platform of the Dutch Nurses' Association, PO Box 8212, 3503 RE Utrecht, Netherlands.
Int J Med Inform. 2018 Mar;111:77-82. doi: 10.1016/j.ijmedinf.2017.12.025. Epub 2017 Dec 28.
Nurses register data in electronic health records, which can use various terminology and coding systems. The net result is that information cannot be exchanged and reused properly, for example when a patient is transferred from one care setting to another. A nursing subset of patient problems was therefore developed in the Netherlands, based on comparable and exchangeable terms that are used throughout the healthcare sector and elsewhere (semantic interoperability). The purpose of the current research is to develop a mapping between the subset of patient problems and three classifications in order to improve the exchangeability of data. Those classifications are the Omaha System, NANDA International, and ICF (the International Classification of Functioning, Disability and Health).
Descriptive research using a unidirectional mapping strategy.
Some 30%-39% of the 119 SNOMED CT patient problems can be mapped one-to-one from the subset onto each separate classification. Between 6% and 8% have been mapped partially to a related term. This is considered to be a one-to-one mapping, although the meanings do not correspond fully. Additionally, 23%-51% of the patient problems could be mapped n-to-one, i.e. more specifically than the classification. Some loss of information will always occur in such exchanges. Between 1% and 4% of the patient problems from the subset are defined less specifically than the problems within the individual classifications. Finally, it turns out that 9%-32% of the terms from the subset of patient problems could not be mapped onto a classification, either because they did not occur in the classification or because they could not be mapped at a higher level.
To promote the exchange of data, the subset of patient problems has been mapped onto three classifications. Loss of information occurs in most cases when the patient problems are transformed from the subset into a classification. This arises because the classifications are different in structure and in the degree of detail. Structural cooperation between suppliers, healthcare organisations and the experts involved is required in order to determine how the mapping should be used within the electronic health records, and whether it is usable in day-to-day practice.
护士在电子健康记录中录入数据，而这些记录可能使用了不同的术语和编码系统。其结果是，信息无法正确地交换和重复使用，例如当患者从一个护理环境转移到另一个护理环境时。因此，荷兰开发了一个基于整个医疗保健领域和其他领域中使用的可比和可交换术语的护理患者问题子集（语义互操作性）。当前研究的目的是开发患者问题子集与三个分类之间的映射关系，以提高数据的可交换性。这三个分类是奥马哈系统、国际疾病与相关健康问题分类（NANDA International）和国际功能、残疾和健康分类（ICF）。
采用单向映射策略的描述性研究。
在 119 个 SNOMED CT 患者问题中，约有 30%-39%可以一对一地从子集中映射到每个单独的分类中。6%-8%的问题被部分映射到相关术语。这被认为是一对一映射，尽管其含义并不完全对应。此外，23%-51%的患者问题可以 n 对 1 映射，即比分类更具体。在这种交换中，总是会发生一些信息丢失。子集的 1%-4%的患者问题的定义不如各分类中的问题具体。最后，事实证明，子集的 9%-32%的患者问题术语无法映射到分类中，要么是因为它们不在分类中，要么是因为它们无法在更高的级别上进行映射。
为了促进数据的交换，已将患者问题子集映射到三个分类中。当将患者问题从子集转换为分类时，大多数情况下都会发生信息丢失。这是因为分类在结构和详细程度上有所不同。供应商、医疗保健组织和相关专家之间需要进行结构上的合作，以确定映射应如何在电子健康记录中使用，以及它在日常实践中是否可用。
