1. SHI2010 presentation Kirstine Rosenbeck Gøeg & Anne Randorff Rasmussen

2. INTRODUCTION

3. Ambiguous documentation “Impairment of vision” Worsening of something chronic First diagnose Impairment causing change of occupation

4. A problem? Interview 2009 “Vi har nogle begreber som vi har brugt i årevis, eksempelvis tilladelig blødning..... nogen der siger, at det er 100ml, mens andre siger at det er det i hvert fald ikke. Så der opdager vi, at vi ikke har den samme opfattelse. Så der må vi blive enige om at tilladelig blødning er under 100ml, hvis moren ellers har det godt, blodtrykket holder og hun ikke besvimer. Der var så meget mere, der skulle knyttes til sådan et begreb....” Rector 1999 “ Common usage may differ from the expectations of information retrieval, e.g. it may seem odd to say that ‘The fingernail is a part of the arm’, but it would be an error not to retrieve ‘evulsion of nail’ under ‘trauma to upper extremity’.” Interview 2009: http://projekter.aau.dk/projekter/files/17651356/speciale-rapportTilUdskrift.pdf Rector 1999: Why is terminology so hard? Method Inform Med 1999; 38: 239–52

5. A problem? Increasingly possible to – Exchanging information to perform shared care – Use data for statistical purposes Characterised by – No input validation – Most likely to stay in one organisation and being used only for patient treatment purposes Semantic precision!

6. METHOD

7. Method Two cases – Tolerable bleeding/ Tilladelig blødning – Eating too little/ Småtspisende Charaterised by – Real life examples of clinical evaluations – From spring 2009 – Expressed difficulties in mapping from paper documentation to electronic documentation Three approaches to improve precision using SNOMED CT – Mapping to existing pre- coordinated SNOMED CT terms consisting of a finding and a qualifier. Map the evaluation as is, without interpretation. – Mapping by analysing the clinical situation/context in which the evaluation is obtained. – Mapping by nesting the subjective evaluation with the rationale behind the evaluation.

8. RESULTS

9. Existing pre-coordinated terms

10. Adding the context of the finding Finding: Tolerable bleeding Context: During labour Maternal blood loos within normal limits SNOMED CT mapping Finding: Eating too little Context: Screening, some time duration Inadequate dietary caloric intake, continual

11. Nesting observation and evaluation

12. DISCUSSION

13. Discussion A study with only two clinical expressions – pros and cons Choosing between the three approaches? – Mapping directly is not recommended based on the results of this study – Considering the clinical situation and consequences of different mappings – Asking clinical experts Can levels of precision be pre-specified?

14. Correspondence: Kirstine Hjære Rosenbeck PhD Fellow, Aalborg University Department of Health Science and Technology E-mail: kirse@hst.aau.dk Phone:+45 9940 8835