创建一个SNOMEDCT参考集,用于常见的内分泌疾病,基于常规的诊所通信
Shao Hao Alan Yap1, Sam Philip1, Alex J Graveling1
1JJR Macleod Centre for Diabetes & Endocrinology, Aberdeen Royal Infirmary, Aberdeen, UK.
Clinical endocrinology
|August 9, 2023
概括
标准化门诊内分泌护理编码至关重要. 这项研究为常见的内分泌疾病创建了一个医学临床术语系统化命名法 (SNOMED CT) 参考集合,改进了患者队列表征和服务规划.
科学领域:
- 内分泌学 在内分泌学.
- 医疗信息学 医疗信息学
- 医疗保健服务研究 医疗服务研究
背景情况:
- 在门诊环境中编码临床结果落后于住院护理.
- 医学临床术语的系统化命名法 (SNOMED CT) 提供了标准化的临床信息编码.
- 开发一套常见SNOMED CT术语的参考集合将有助于在常规护理中采用.
研究的目的:
- 为门诊内分泌咨询建立一个标准化的SNOMED CT参考套件.
- 通过从信件中提取半自动信息来促进临床结果的编码.
主要方法:
- 对成人三级门诊内分泌诊所数据 (2018-2019) 的回顾性审查.
- 从临床信件中自动提取问题陈述.
- 使用SNOMED CT"障碍"概念,手动编码提取的信息.
主要成果:
- 确定了298个内分泌诊断,99个发现和142个程序.
- 发现了88种 (29.5%) 常见的内分泌疾病和210种 (70.5%) 不太常见的内分泌疾病.
- 顾问对共同条件的同意有所不同,28个显示100%的同意.
结论:
- 结构化内分泌对应的自动解析使SNOMED CT参考集的创建成为可能.
- 这一参考集有助于描述专业内分泌护理的患者队列.
- 有助于改善内分泌学服务规划和资金.
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