van Mens Hugo J Th, de Keizer Nicolette F, Nienhuis Remko, Cornet Ronald
Department of Medical Informatics, Amsterdam Public Health research institute, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Research and Development, ChipSoft B.V., Amsterdam, The Netherlands.
Stud Health Technol Inform. 2018;247:900-904.
Patient access to electronic health records (EHRs) is associated with improved efficiency, self-management, and patient engagement. However, the EHR contains medical language that can be difficult to comprehend by patients. In Dutch hospitals, the Diagnosethesaurus (DT) is used as an interface terminology to register diagnoses, but it does not contain patient-friendly terms. Fortunately, the DT is partly mapped to SNOMED CT and there is a proportionately small set of patient-friendly terms available in the Dutch SNOMED CT release. The purpose of this study was, therefore, to investigate if SNOMED CT can be used to generate clarifications of diagnoses for patients. Only 1.2% of the DT diagnoses that were already mapped to SNOMED CT had patient-friendly synonyms that were different from the diagnoses descriptions. However, by generalizing diagnoses to SNOMED CT concepts with patient-friendly terms, this number could be increased to 71%. In conclusion, we showed that a high percentage of diagnoses could be clarified to at least some extent with the relatively small set of patient-friendly terms. Future research will involve the further optimization of the clarifications, and evaluation with clinicians and patients.
患者获取电子健康记录（EHR）与提高效率、自我管理和患者参与度相关。然而，电子健康记录中包含的医学术语患者可能难以理解。在荷兰医院，诊断叙词表（DT）被用作登记诊断的接口术语，但其中不包含便于患者理解的术语。幸运的是，诊断叙词表部分映射到了SNOMED CT，并且在荷兰版的SNOMED CT发布版本中有一小部分便于患者理解的术语。因此，本研究的目的是调查SNOMED CT是否可用于为患者生成诊断说明。在已映射到SNOMED CT的诊断叙词表诊断中，只有1.2%的诊断具有与诊断描述不同的便于患者理解的同义词。然而，通过将诊断归纳为带有便于患者理解术语的SNOMED CT概念，这一比例可提高到71%。总之，我们表明，使用相对较少的便于患者理解的术语，很大一部分诊断至少可以在一定程度上得到说明。未来的研究将涉及对这些说明的进一步优化，以及与临床医生和患者进行评估。
