开发基于SNOMEDCT的值集,以记录药物不良事件的症状和诊断:混合方法研究
Erica Y Lau1, Linda Bird2, Anthony Lau3
1Strategy, Planning and Implementation, BC Cancer, 601 West Broadway, Vancouver, BC, V5Z 4C2, Canada, 1 6048776000.
JMIR medical informatics
|July 8, 2025
概括
一个新的SNOMED CT值集在电子医疗记录 (EMR) 中标准化了药物不良事件 (ADE) 文档. 这通过减少重复的ADE来改善数据整合和患者安全.
科学领域:
- 医疗信息学 医疗信息学
- 临床术语学 临床术语学
- 药物监督 药物监督 药物监督
背景情况:
- 药物不良事件 (ADEs) 在加拿大造成了严重的患者伤害和医疗保健费用,每年有超过200万次急诊室访问.
- 通过电子病历 (EMR) 有效地记录和共享ADE信息对于患者安全至关重要.
- 当前的EMR系统往往缺乏用于全面的ADE文档的标准化值集.
研究的目的:
- 开发一个SNOMED CT值集,用于标准化ADE症状和诊断的文档.
- 改进ADE数据集成到EMR中,以改善患者护理和安全.
主要方法:
- 利用了来自9家不列颠哥伦比亚省医院的未来ActionADE报告系统的ADE数据.
- 使用自动化和手动方法将827个独特的ADE术语映射到SNOMED CT概念中.
- 与临床专家和质量保证团队一起验证了映射,通过共识解决了差异.
主要成果:
- 成功将98.4%的源术语映射到SNOMED CT概念中,创建了一个由813个概念组成的最终价值集.
- 在绘图和验证过程中实现了强大的分层间可靠性 (κ=0.87-0.88).
- 最终的值集包括95.7%的语义等同和4.3%的语义相似的SNOMED CT概念.
结论:
- 开发了一个标准化的SNOMED CT值集,用于记录EMR中的成人ADE症状和诊断.
- 采用这种价值组可以提高ADE文档的一致性,准确性和互操作性,减少重复事件和提高患者安全.
- 持续的改进和可用性评估对于广泛采用至关重要;未来的研究应该评估其对ADE报告和患者结果的影响.
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