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Related Experiment Videos

Reliability of SNOMED-CT coding by three physicians using two terminology browsers.

Michael F Chiang1, John C Hwang, Alexander C Yu

  • 1Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, NY, USA.

AMIA ... Annual Symposium Proceedings. AMIA Symposium
|January 24, 2007
PubMed
Summary
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SNOMED-CT coding reliability is imperfect, with physicians achieving only 44-53% agreement. Browsing methods significantly impact consistent electronic health record (EHR) concept coding.

Area of Science:

  • Medical Informatics
  • Health Information Systems
  • Clinical Terminology

Background:

  • SNOMED-CT is promoted as a standard reference terminology for electronic health record (EHR) systems.
  • Consistent coding of medical concepts is crucial for many EHR functionalities.
  • Variability in coding can impede data interoperability and analysis.

Purpose of the Study:

  • To measure inter-coder and intra-coder reliability of SNOMED-CT coding.
  • To assess the impact of different SNOMED-CT terminology browsers on coding consistency.
  • To evaluate the reproducibility of SNOMED-CT coding in ophthalmology.

Main Methods:

  • Three physicians coded 242 ophthalmology concepts from case presentations.
  • Two different SNOMED-CT terminology browsers were utilized.

Related Experiment Videos

  • Inter-coder reliability (exact match) and intra-coder reliability were calculated.

    • Main Results:

    • Inter-coder reliability ranged from 44% to 53% between the two browsers.
    • Intra-coder reliability showed up to 55% variation when one user employed both browsers.
    • Coding consistency was influenced by the terminology browsing methodology.

    Conclusions:

    • SNOMED-CT coding reliability is not absolute and can be influenced by the tools used.
    • Improvements in physician training, SNOMED-CT terminology, and browser design are recommended.
    • Enhancing reproducibility is key for effective EHR system utilization.