The content coverage of clinical classifications
The content coverage of clinical classifications
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DOI：
10.1136/jamia.1996.96310636
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发表时间：
1996-05-01
影响因子：
6.4
通讯作者：
Campbell, JR
中科院分区：
文献类型：
--
作者：
Chute, CG;Cohn, SP;Campbell, JR
背景与目的：患者病情和事件是病历内容的核心。基于计算机的记录将需要标准的词汇表来一致地表示这些数据，从而促进临床决策支持、研究和有效的护理提供。为了解决现有的主要编码系统是否可以服务于这一功能，作者评估了主要的临床分类，其内容coverage.Methods：临床文本从四个医疗中心从住院和门诊设置采样。最终的14，247个单词的语料库被解析为3，061个不同的概念。这些概念分为诊断、修饰、发现、治疗和程序以及其他。每个概念都编码到ICD-9-CM、ICD-10、CPT、SNOMED III、Read V2、UMLS 1.3和NANDA中;二级评审员确保一致性。结果：ICD-9-CM的总体平均分为0.77（满分2分），最高分为1.61（诊断）。ICD-10诊断评分为1.60，总体评分为0.62。CPT增强的ICD-9-CM的总体评分没有实质性改善，为0.82。SNOMED国际系统在包括诊断在内的各个分类中得分最高（1.90），总分为1.74。结论：尽管SNOMED系统的分类最全面，但没有一个分类能涵盖所有的概念。在美国主要使用的系统，ICD-9-CM和CPT，未能捕获大量的临床内容。ICD-10的表现并不比ICD-9-CM好。目前使用的主要临床分类不完全涵盖病历的临床内容;因此，依赖于这些系统的分析结论可能是可疑的。
Background and Objective: Patient conditions and events are the core of patient record content. Computer-based records will require standard vocabularies to represent these data consistently, thereby facilitating clinical decision support, research, and efficient care delivery. To address whether existing major coding systems can serve this function, the authors evaluated major clinical classifications for their content coverage.Methods: Clinical text from four medical centers was sampled from inpatient and outpatient settings. The resultant corpus of 14,247 words was parsed into 3,061 distinct concepts. These concepts were grouped into Diagnoses, Modifiers, Findings, Treatments and Procedures, and Other. Each concept was coded into ICD-9-CM, ICD-10, CPT, SNOMED III, Read V2, UMLS 1.3, and NANDA; a secondary reviewer ensured consistency. While coding, the information was scored: 0 = no match, 1 = fair match, 2 = complete match.Results: ICD-9-CM had an overall mean score of 0.77 out of 2; its highest subscore was 1.61 for Diagnoses. ICD-10 scored 1.60 for Diagnoses, and 0.62 overall. The overall score of ICD-9-CM augmented by CPT was not materially improved at 0.82. The SNOMED International system demonstrated the highest score in every category, including Diagnoses (1.90), and had an overall score of 1.74.Conclusion: No classification captured all concepts, although SNOMED did notably the most complete job. The systems in major use in the United States, ICD-9-CM and CPT, fail to capture substantial clinical content. ICD-10 does not perform better than ICD-9-CM. The major clinical classifications in use today incompletely cover the clinical content of patient records; thus analytic conclusions that depend on these systems may be suspect.