Date

May 2007

Document Type

Capstone

Degree Name

M.B.I.

Department

Dept. of Medical Informatics and Clinical Epidemiology

Institution

Oregon Health & Science University

Abstract

Background: The Systematized Nomenclature of Medicine Clinical Terms® (SNOMED CT) is the most sophisticated reference terminology currently available for the representation of health care. In several countries it is being adopted as the terminology for the documentation of clinical care. SNOMED CT has evolved from the Systematized Nomenclature of Pathology [SNOP, 1965] into the current Systematized Nomenclature ofMedicine [SNOMED, 2002] over forty years. The content of the terminology has been determined largely by the voluntary contributions of many, diverse clinical groups. An unforeseen consequence of this evolutionary process may be that some unique, clinically relevant concepts of highly specialized clinical domains are not represented as SNOMED CT concepts. The purpose of this project was to assess the performance of SNOMED CT as the terminology for the representation of the clinical care of the newborn infant. Methods: The SNOMED CT July 2006 release was systematically examined using the CliniClue 2006 Terminology Browser available for this release to determine the degree of representation for 881 terms that are relevant for the clinical care of the newborn infant by SNOMED CT concepts. The 881 terms were extracted from the Clinical Information Management System (CIMS) used in the Neonatal Intensive Care Unit at the Hospital for Sick Children, Toronto, Ontario, Canada. The CIMS terms were categorized as an observation, diagnosis, procedure or drug. The representation for each CIMS term by a SNOMED CT concept was assessed as absent, partial or complete representation by a single clinician. Results: Ninety-six percent of the 881 CIMS terms that describe an observation, diagnosis, procedure or drug are represented within the SNOMED CT July 2006 release. There is complete representation for 86.4% of the terms, partial representation for 10.2% of the terms and no representation for 3.4% of the terms. Ninety-seven percent of the 761 CIMS terms that are completely represented by a SNOMED CT concept are represented by a single, pre-coordinated SNOMED CT expression. Ninety-three percent of the SNOMED CT concepts that completely represent CIMS terms have a current Concept Status. Twenty-eight percent of the SNOMED CT concepts are fully defined SNOMED CT concepts and 49.4% of the SNOMED CT concepts have one or more synonyms. Conclusion: SNOMED CT is a comprehensive reference terminology that provides robust, structured representation based on description logic for the majority of the CIMS terms that are relevant for the clinical care of the newborn infant.

Identifier

doi:10.6083/M43R0QWP

School

School of Medicine

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