Facilitating pre-operative assessment guidelines representation using SNOMED CT

A State-of-the Art Review of SNOMED CT Terminology Binding and Recommendations for Practice and Research

BACKGROUND

Unambiguous sharing of data requires information models and terminology in combination, but there is a lack of knowledge as to how they should be combined, leading to impaired interoperability.

OBJECTIVES

To facilitate creation of guidelines for SNOMED CT terminology binding we have performed a literature review to find existing recommendations and expose knowledge gaps. The primary audience is practitioners and researchers working with terminology binding.

METHODS

PubMed, Scopus, and Web of Science were searched for papers containing "terminology binding," "subset," "map," "information model" or "implement" and the term "SNOMED."

RESULTS

The search yielded 616 unique papers published from 2004 to 2020, from which 55 papers were selected and analyzed inductively. Topics described in the papers include problems related to input material, SNOMED CT, information models, and lack of appropriate tools as well as recommendations regarding competence.

CONCLUSION

Recommendations are given for practitioners and researchers. Many of the stated problems can be solved by better co-operation between domain experts and informaticians and better knowledge of SNOMED CT. Settings where these competences either work together or where staff with knowledge of both act as brokers are well equipped for terminology binding. Tooling is not thoroughly researched and might be a possible way to facilitate terminology binding.

Designing Data Elements and Minimum Data Set (MDS) for Creating the Registry of Patients with Gestational Diabetes Mellitus

The prevalence of gestational diabetes mellitus (GDM) is increasing in Iran. Collection of patients’ data is commonly conducted through using medical records. However, for providing a structured reporting based on the information needs, a minimum data set is a fast, inexpensive, and suitable method. For exchanging high-quality data between different healthcare centers and health monitoring organization, the data are required to be uniformly collected and registered. The present study aims at designing an MDS for creating the registry of GDM. The present study is an applied one, conducted in two stages, with a qualitative Delphi method in 2018. In the first stage of the study, it was attempted to extract the data elements of mothers with GDM, through reviewing the related studies and collecting these patients’ data from the medical records. Then, based on the results of the first stage, a questionnaire including demographic, clinical, and pharmaceutical data was distributed among 20 individuals including gynecologists, pharmacists, nurses, and midwives. The validity of the questionnaire was examined by a team of experts and its reliability was examined by using Cronbach’s alpha. Data analysis was conducted using descriptive statistics (frequency, percentage, and mean) and excel. An MDS of gestational diabetes mellitus was developed. This MDS divided into three categories: administrative, clinical, and pharmaceutical with 4, 18, and 2 sections and 35, 199, and 12 data elements, respectively. Determining the minimum data sets of GDM will be an effective step toward integrating and improving data management of patients with GDM. Moreover, it will be possible to store and retrieve the data related to these patients.

Investigation of Data Representation Issues in Computerizing Clinical Practice Guidelines in China

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