title: An applied evaluation of SNOMED CT as a clinical vocabulary for the computerized diagnosis and problem list.
abstract: The use of a standardized controlled terminology allows diverse systems and applications throughout the enterprise to translate data. In developing a customized enterprise-wide vocabulary for clinical terminology, we implemented SNOMED CT as a base vocabulary, while facilitating the addition of site-specific clinical terms or concepts not represented in SNOMED CT. In this paper, we evaluate the breadth of SNOMED CT terms and concepts for the coding of diagnosis and problem lists by clinicians within a computerized physician order entry (CPOE) system. Clinicians selected diagnosis and problem list terms from a lexicon based on SNOMED CT, submitting requests for clinical terms that were not found in the controlled vocabulary. For each "missing" term, we assigned one of four mapping types, representing the relationship of this new terminology entry to the SNOMED CT reference terminology. Our results show that the majority of diagnosis/problem list terms (88.4%) were found in SNOMED CT. Of the 145 missing terms, only 20 represented significant concepts missing from SNOMED CT, resulting in concept coverage of 98.5%. Our results show that SNOMED CT is a relatively complete standardized terminology on which to base a vocabulary for the clinical problem list.
authors.affiliation: Enterprise Information Services, Cedars-Sinai Health System, Los Angeles, California, USA.
authors.forename: Henry
authors.initials: H
authors.lastname: Wasserman
authors.forename: Jerome
authors.initials: J
authors.lastname: Wang
mesh_terms: D000004:Abbreviations as Topic; D015510:Clinical Medicine; D003933:Diagnosis; D005568:Forms and Records Control; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000145:classification*; D008501:Medical Records, Problem-Oriented; D039061:Systematized Nomenclature of Medicine; D014584:User-Computer Interface; D018875:Vocabulary, Controlled