Int J Med Inform - Content analysis of physical examination templates in electronic health records using SNOMED CT.

Tópicos

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Resumo

JECTIVES: Most electronic health record (EHR) systems are built on proprietary information models and terminology, which makes achieving semantic interoperability a challenge. Solving interoperability problems requires well-defined standards. In contrast, the need to support clinical work practice requires a local customization of EHR systems. Consequently, contrasting goals may be evident in EHR template design because customization means that local EHR organizations can define their own templates, whereas standardization implies consensus at some level. To explore the complexity of balancing these two goals, this study analyzes the differences and similarities between templates in use today.METHODS: A similarity analysis was developed on the basis of SNOMED CT. The analysis was performed on four physical examination templates from Denmark and Sweden. The semantic relationships in SNOMED CT were used to quantify similarities and differences. Moreover, the analysis used these identified similarities to investigate the common content of a physical examination template.RESULTS: The analysis showed that there were both similarities and differences in physical examination templates, and the size of the templates varied from 18 to 49 fields. In the SNOMED CT analysis, exact matches and terminology similarities were represented in all template pairs. The number of exact matches ranged from 7 to 24. Moreover, the number of unrelated fields differed a lot from 1/18 to 22/35. Cross-country comparisons tended to have more unrelated content than within-country comparisons. On the basis of identified similarities, it was possible to define the common content of a physical examination. Nevertheless, a complete view on the physical examination required the inclusion of both exact matches and terminology similarities.CONCLUSIONS: This study revealed that a core set of items representing the physical examination templates can be generated when the analysis takes into account not only exact matches but also terminology similarities. This core set of items could be a starting point for standardization and semantic interoperability. However, both unmatched terms and terminology matched terms pose a challenge for standardization. Future work will include using local templates as a point of departure in standardization to see if local requirements can be maintained in a standardized framework.

Resumo Limpo

jectiv electron health record ehr system built proprietari inform model terminolog make achiev semant interoper challeng solv interoper problem requir welldefin standard contrast need support clinic work practic requir local custom ehr system consequ contrast goal may evid ehr templat design custom mean local ehr organ can defin templat wherea standard impli consensus level explor complex balanc two goal studi analyz differ similar templat use todaymethod similar analysi develop basi snome ct analysi perform four physic examin templat denmark sweden semant relationship snome ct use quantifi similar differ moreov analysi use identifi similar investig common content physic examin templateresult analysi show similar differ physic examin templat size templat vari field snome ct analysi exact match terminolog similar repres templat pair number exact match rang moreov number unrel field differ lot crosscountri comparison tend unrel content withincountri comparison basi identifi similar possibl defin common content physic examin nevertheless complet view physic examin requir inclus exact match terminolog similaritiesconclus studi reveal core set item repres physic examin templat can generat analysi take account exact match also terminolog similar core set item start point standard semant interoper howev unmatch term terminolog match term pose challeng standard futur work will includ use local templat point departur standard see local requir can maintain standard framework

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