Developing a SNOMED CT-Based Value Set to Document Symptoms and Diagnoses for Adverse Drug Events: Mixed Methods...

Area of Science:

• Health Informatics
• Clinical Terminology
• Pharmacovigilance

Background:

• Adverse drug events (ADEs) cause significant patient harm and healthcare costs in Canada, with over 2 million emergency department visits annually.
• Effective documentation and sharing of ADE information via electronic medical records (EMRs) are crucial for patient safety.
• Current EMR systems often lack standardized value sets for comprehensive ADE documentation.

Purpose of the Study:

• To develop a SNOMED CT value set for standardizing the documentation of ADE symptoms and diagnoses.
• To improve ADE data integration into EMRs for better patient care and safety.

Main Methods:

• Utilized ADE data from the prospective ActionADE reporting system across 9 British Columbia hospitals.
• Mapped 827 unique ADE terms to SNOMED CT concepts using automated and manual approaches.
• Validated mappings with clinical experts and a quality assurance team, resolving discrepancies through consensus.

Main Results:

• Successfully mapped 98.4% of source terms to SNOMED CT concepts, creating a final value set of 813 concepts.
• Achieved strong interrater reliability (κ=0.87-0.88) during mapping and validation.
• The final value set consists of 95.7% semantically equivalent and 4.3% semantically similar SNOMED CT concepts.

Conclusions:

• Developed a standardized SNOMED CT value set for documenting adult ADE symptoms and diagnoses in EMRs.
• Adoption of this value set can enhance consistency, accuracy, and interoperability of ADE documentation, reducing repeat events and improving patient safety.
• Ongoing refinement and usability assessments are vital for widespread adoption; future research should evaluate its impact on ADE reporting and patient outcomes.