Testing Three Problem List Terminologies in a simulated data entry environment

AMIA Annu Symp Proc. 2011;2011:445-54. Epub 2011 Oct 22.

Abstract

Three Problem List Terminologies (PLT) were tested using a web-based application simulating a clinical data entry environment to evaluate coverage and coding efficiency. The three PLTs were: the CORE Problem List Subset of SNOMED CT, a clinical subset extracted from the full SNOMED CT and the PLT currently used at the Mayo Clinic. Candidate problem statements were randomly extracted from free text problem list entries contained in two electronic medical record systems. Physician reviewers searched for concepts in one of the three PLTs that most closely matched a problem statement. Altogether 45 reviewers reviewed 15 problems each. The coverage of the much smaller CORE Subset was comparable to Clinical SNOMED for combined exact or partial matches. The CORE Subset required the shortest time to find a concept. This may be related to the smaller size of the pick lists for the CORE Subset.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Intramural

MeSH terms

  • Clinical Coding / methods*
  • Electronic Health Records*
  • Medical Records, Problem-Oriented*
  • Systematized Nomenclature of Medicine*
  • Vocabulary, Controlled*