电子健康记录和结核病索赔数据的诊断代码一致性。
Diagnostic code agreement for electronic health records and claims data for tuberculosis.
机构信息
Office of the Associate Director for Science, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
Division of Health Informatics and Surveillance, Center for Surveillance, Epidemiology and Laboratory Services, CDC, Atlanta, GA.
出版信息
Int J Tuberc Lung Dis. 2020 Jul 1;24(7):706-711. doi: 10.5588/ijtld.19.0792.
To measure the frequency of diseases related to latent tuberculosis infection (LTBI) and tuberculosis (TB), we assessed the agreement between diagnosis codes for TB or LTBI in electronic health records (EHRs) and insurance claims for the same person. In a US population-based, retrospective cohort study, we matched TB-related Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) EHR codes and (ICD-10-CM) claims codes. Furthermore, LTBI was identified using a published ICD-based algorithm and all LTBI- and TB-related SNOMED CT codes. Of people with the 10 most frequent TB-related claim codes, 50% did not have an exact-matched EHR code. was the most frequent unmatched EHR code and people with the 10 most frequent TB EHR codes, 40% did not have an exact-matched claim code. The most frequent unmatched claim code was . EHR codes for LTBI matched to claims codes for ; ; and or . TB-related EHR codes and claims diagnostic codes often disagree, and people with claims codes for LTBI have unexpected EHR codes, indicating the need to reconcile these coding systems.
为了衡量与潜伏性结核感染（LTBI）和结核病（TB）相关疾病的频率，我们评估了电子健康记录（EHR）中用于 TB 或 LTBI 的诊断代码与同一人的保险索赔之间的一致性。在一项基于美国人群的回顾性队列研究中，我们匹配了与 TB 相关的系统医学术语临床术语（SNOMED CT）EHR 代码和国际疾病分类第 10 次修订版-临床修正（ICD-10-CM）索赔代码。此外，使用已发表的基于 ICD 的算法和所有 LTBI 和 TB 相关的 SNOMED CT 代码来识别 LTBI。在具有 10 种最常见 TB 相关索赔代码的人群中，有 50%的人没有确切匹配的 EHR 代码。是最常见的不匹配 EHR 代码，而在具有 10 种最常见 TB EHR 代码的人群中，有 40%的人没有确切匹配的索赔代码。最常见的不匹配索赔代码是。与索赔代码匹配的 LTBI 的 EHR 代码为；；和 或 。TB 相关的 EHR 代码和索赔诊断代码经常不一致，并且具有 LTBI 索赔代码的人会出现意外的 EHR 代码，这表明需要协调这些编码系统。
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