Comparison of Knowledge Levels Required for SNOMED CT Coding of Diagnosis and Operation Names in Clinical Records

김신영; 김형회; 신경화; 김화선; 이재일; 최병관

추천

검색

자료유형: 학술저널

저자정보: 김신영 김형회 신경화 김화선 이재일 최병관

저널정보: 대한의료정보학회 Healthcare Informatics Research Healthcare Informatics Research 제18권 제3호

발행연도: 2012.1

수록면: 186 - 190 (5page)

이용수

📌

연구주제

📖

연구배경

🔬

연구방법

🏆

연구결과

초록· 키워드

오류제보하기

Objectives: Coding Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) with complex and polysemy clinical terms may ask coder to have a high level of knowledge of clinical domains, but with simpler clinical terms, coding may require only simpler knowledge. However, there are few studies quantitatively showing the relation between domain knowledge and coding ability. So, we tried to show the relationship between those two areas. Methods: We extracted diagnosis and operation names from electronic medical records of a university hospital for 500 ophthalmology and 500 neurosurgery patients. The coding process involved one ophthalmologist, one neurosurgeon, and one medical record technician who had no experience of SNOMED coding, without limitation to accessing of data for coding. The coding results and domain knowledge were compared. Results: 705 and 576 diagnoses, and 500 and 629 operation names from ophthalmology and neurosurgery, were enrolled, respectively. The physicians showed higher performance in coding than in MRT for all domains; all specialist physicians showed the highest performance in domains of their own departments. All three coders showed statistically better coding rates in diagnosis than in operation names (p < 0.001). Conclusions: Performance of SNOMED coding with clinical terms is strongly related to the knowledge level of the domain and the complexity of the clinical terms. Physicians who generate clinical data can be the best potential candidates as excellent coders from the aspect of coding performance.

#Systematized Nomenclature of Medicine #Clinical Coding #Diagnosis #Operations #Knowledge

참고문헌 (8)

참고문헌 신청

Alecu I / 2008 / A case report: using SNOMED CT for grouping Adverse Drug Reactions Terms / BMC Med Inform Decis Mak 8 (Suppl 1) : S4 ~

Andrews JE / 2007 / Variation of SNOMED CT coding of clinical research concepts among coding experts / J Am Med Inform Assoc 14 (4) : 497 ~ 506

Andrews JE / 2008 / Comparing heterogeneous SNOMED CT coding of clinical research concepts by examining normalized expressions / J Biomed Inform 41 (6) : 1062 ~ 1069

Chiang MF / 2006 / Reliability of SNOMED-CT coding by three physicians using two terminology browsers / AMIA Annu Symp Proc : 131 ~ 135

Mantena S / 2007 / Evaluation of the VA/KP problem list subset of SNOMED as a clinical terminology for electronic prescription clinical decision support / AMIA Annu Symp Proc : 498