Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

<p>Abstract</p> <p>Background</p> <p>Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT.</p> <p>Methods</p> <p>Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed.</p> <p>Results</p> <p>417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions.</p> <p>Conclusions</p> <p>Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.</p> <p>Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.</p

Towards a system of concepts for Family Medicine. Multilingual indexing in General Practice/ Family Medicine in the era of Semantic Web

UNIVERSITY OF LIÈGE, BELGIUM Executive Summary Faculty of Medicine Département Universitaire de Médecine Générale. Unité de recherche Soins Primaires et Santé Doctor in biomedical sciences Towards a system of concepts for Family Medicine. Multilingual indexing in General Practice/ Family Medicine in the era of SemanticWeb by Dr. Marc JAMOULLE Introduction This thesis is about giving visibility to the often overlooked work of family physicians and consequently, is about grey literature in General Practice and Family Medicine (GP/FM). It often seems that conference organizers do not think of GP/FM as a knowledge-producing discipline that deserves active dissemination. A conference is organized, but not much is done with the knowledge shared at these meetings. In turn, the knowledge cannot be reused or reapplied. This these is also about indexing. To find knowledge back, indexing is mandatory. We must prepare tools that will automatically index the thousands of abstracts that family doctors produce each year in various languages. And finally this work is about semantics1. It is an introduction to health terminologies, ontologies, semantic data, and linked open data. All are expressions of the next step: Semantic Web for health care data. Concepts, units of thought expressed by terms, will be our target and must have the ability to be expressed in multiple languages. In turn, three areas of knowledge are at stake in this study: (i) Family Medicine as a pillar of primary health care, (ii) computational linguistics, and (iii) health information systems. Aim • To identify knowledge produced by General practitioners (GPs) by improving annotation of grey literature in Primary Health Care • To propose an experimental indexing system, acting as draft for a standardized table of content of GP/GM • To improve the searchability of repositories for grey literature in GP/GM. 1For specific terms, see the Glossary page 257 x Methods The first step aimed to design the taxonomy by identifying relevant concepts in a compiled corpus of GP/FM texts. We have studied the concepts identified in nearly two thousand communications of GPs during conferences. The relevant concepts belong to the fields that are focusing on GP/FM activities (e.g. teaching, ethics, management or environmental hazard issues). The second step was the development of an on-line, multilingual, terminological resource for each category of the resulting taxonomy, named Q-Codes. We have designed this terminology in the form of a lightweight ontology, accessible on-line for readers and ready for use by computers of the semantic web. It is also fit for the Linked Open Data universe. Results We propose 182 Q-Codes in an on-line multilingual database (10 languages) (www.hetop.eu/Q) acting each as a filter for Medline. Q-Codes are also available under the form of Unique Resource Identifiers (URIs) and are exportable in Web Ontology Language (OWL). The International Classification of Primary Care (ICPC) is linked to Q-Codes in order to form the Core Content Classification in General Practice/Family Medicine (3CGP). So far, 3CGP is in use by humans in pedagogy, in bibliographic studies, in indexing congresses, master theses and other forms of grey literature in GP/FM. Use by computers is experimented in automatic classifiers, annotators and natural language processing. Discussion To the best of our knowledge, this is the first attempt to expand the ICPC coding system with an extension for family physician contextual issues, thus covering non-clinical content of practice. It remains to be proven that our proposed terminology will help in dealing with more complex systems, such as MeSH, to support information storage and retrieval activities. However, this exercise is proposed as a first step in the creation of an ontology of GP/FM and as an opening to the complex world of Semantic Web technologies. Conclusion We expect that the creation of this terminological resource for indexing abstracts and for facilitating Medline searches for general practitioners, researchers and students in medicine will reduce loss of knowledge in the domain of GP/FM. In addition, through better indexing of the grey literature (congress abstracts, master’s and doctoral theses), we hope to enhance the accessibility of research results and give visibility to the invisible work of family physicians

Evaluasi konversi icpc-2r dari icd sebagai upaya peningkatan kualitas pelayanan puskesmas

LatarBelakang: ICD merupakan klasifikasi penyakit dan masalah kesehatan dalam bentuk huruf dan angka (WHO 2011). Kode ICD dirasa belum dapat memenuhi kebutuhan informasi koding morbiditas, karena untuk Puskesmas masih terdapatnya masalah 63,16% pada 12 Bab yang digunakan (Wockenfuss et al., 2009). Puskesmas lebih tepat menggunakan ICPC-2R, dengan konsep episode pelayanan pasien/ RFE yang juga tercakup dalam sistem PCARE. Diperlukan konversi antara ICD ke ICPC-2R agar keduanya dapat terbaca dari mapping terminologi medis yang sama untuk menyatukan dua prinsip koding tersebut.Tujuan: 1). Mengetahui hasil mapping konversi ICPC-2R dari ICD pada SIMPUS; 2). Mengetahui dimensi mutu yang mempengaruhi kualitas pelayanan dari penerapan konversi; dan 3). Melakukan evaluasi hasil penerapan konversi.Metode:Penelitian diskriptif analitik dengan rancangan bersifat observasional. Indept interview pada subyek penelitian 18 responden data SIMPUS Puskesmas Sukoharjo dan Puskesmas Mojolaban. Data dianalisis secara deskriptif dan kualitatif pada konversi SIMPUS web based dan tanpa konversi SIMPUS single user dari software standard ICPC-2R bahasa Indonesia sesuai lisensi WONCA.Hasil: Mapping konversi ICPC-2R dari ICD pada SIMPUS berhasil dilakukan. Sebelum konversi, dilakukan identifikasi 431 kode ICD pada SIMPUS. 261 (57,62%) sesuai, 192 (42,38%) tidak sesuai. Dilakukan desain ulang data base, dan memasukkan konversi ICPC-2R dalam SIMPUS. Pengaturan ulang koding juga dilakukan menggunakan ICPC-2R. Berdasarkan ijin dan kebijakan DKK maka dari standard 3801 kode, yang bisa dipakai 190 (4,99%) sedangkan yang tidak dipakai 3611 (95,01%). Hasil koding yang benar meningkat 94,92% dan koding salah 5,08%. Perbaikan koding data base, upgrade, dan ujicoba semakin lengkap dengan dimasukkannya data bayar dan query. Bahasa terminologi medis dari diagnosis pasien diperbaiki sebanyak 117. Dari segi penggunaan setelah konversi, SIMPUS dirasakan efektif (53,7%). Pemeriksaan sakit perut dan pengambilan test hasil golongan darah, ICPC-2R dimasukkan dalam koding B60, tetapi tidak ada padanan konversi ini di ICD-10. Hasil koding ICPC-2R tertinggi R74 untuk Infeksi Saluran Napas Akut. Dibutuhkan Man, Money, Material, Method yang handal untuk implementasinya secara maksimal.Kesimpulan: ICPC-2R sangat layak untuk diterapkan di Puskesmas sebagai pengganti/pelengkap ICD-10 dan lebih sesuai karena berbasis episode pelayanan. ICPC-2R akan mampu mendukung upaya peningkatan pelayanan kesehatan. Jika dapat dilaksanakan secara utuh dalam electronic medical record dalam SIMPUS, dapat diketahui status data kesakitan (severity illness) dan status kondisi pasien. Dijalankannya secara konsisten dan reliable, akan sangat mendukung program monitoring dan evaluasi program Puskesmas. Konsep ini dapat digunakan untuk mengetahui riwayat kesehatan pasien secara menyeluruh, kondisi epidemiologi dari kasus penyakit dan pengobatan pasien secara berkesinambungan. Jika konversi diterapkan 100%, dapat membantu konsep data PCARE sebagai pemantauan pembiayaan kesehatan dari Badan Penyelenggara Jaminan Sosial (BPJS) di pelayanan kesehatan primer. Episode of care yang terpola dalam ICPC-2R, merupakan implementasi dari PCARE di Puskesmas. ICPC-2R sangat memungkinkan diterapkan dalam P-Care untuk membantu status pelayanan pasien secara berkesinambungan dengan pembiayaan sesuai tindakan

Foundation, Implementation and Evaluation of the MorphoSaurus System: Subword Indexing, Lexical Learning and Word Sense Disambiguation for Medical Cross-Language Information Retrieval

Im medizinischen Alltag, zu welchem viel Dokumentations- und Recherchearbeit gehört, ist mittlerweile der überwiegende Teil textuell kodierter Information elektronisch verfügbar. Hiermit kommt der Entwicklung leistungsfähiger Methoden zur effizienten Recherche eine vorrangige Bedeutung zu. Bewertet man die Nützlichkeit gängiger Textretrievalsysteme aus dem Blickwinkel der medizinischen Fachsprache, dann mangelt es ihnen an morphologischer Funktionalität (Flexion, Derivation und Komposition), lexikalisch-semantischer Funktionalität und der Fähigkeit zu einer sprachübergreifenden Analyse großer Dokumentenbestände. In der vorliegenden Promotionsschrift werden die theoretischen Grundlagen des MorphoSaurus-Systems (ein Akronym für Morphem-Thesaurus) behandelt. Dessen methodischer Kern stellt ein um Morpheme der medizinischen Fach- und Laiensprache gruppierter Thesaurus dar, dessen Einträge mittels semantischer Relationen sprachübergreifend verknüpft sind. Darauf aufbauend wird ein Verfahren vorgestellt, welches (komplexe) Wörter in Morpheme segmentiert, die durch sprachunabhängige, konzeptklassenartige Symbole ersetzt werden. Die resultierende Repräsentation ist die Basis für das sprachübergreifende, morphemorientierte Textretrieval. Neben der Kerntechnologie wird eine Methode zur automatischen Akquise von Lexikoneinträgen vorgestellt, wodurch bestehende Morphemlexika um weitere Sprachen ergänzt werden. Die Berücksichtigung sprachübergreifender Phänomene führt im Anschluss zu einem neuartigen Verfahren zur Auflösung von semantischen Ambiguitäten. Die Leistungsfähigkeit des morphemorientierten Textretrievals wird im Rahmen umfangreicher, standardisierter Evaluationen empirisch getestet und gängigen Herangehensweisen gegenübergestellt

Medical Informatics

Information technology has been revolutionizing the everyday life of the common man, while medical science has been making rapid strides in understanding disease mechanisms, developing diagnostic techniques and effecting successful treatment regimen, even for those cases which would have been classified as a poor prognosis a decade earlier. The confluence of information technology and biomedicine has brought into its ambit additional dimensions of computerized databases for patient conditions, revolutionizing the way health care and patient information is recorded, processed, interpreted and utilized for improving the quality of life. This book consists of seven chapters dealing with the three primary issues of medical information acquisition from a patient's and health care professional's perspective, translational approaches from a researcher's point of view, and finally the application potential as required by the clinicians/physician. The book covers modern issues in Information Technology, Bioinformatics Methods and Clinical Applications. The chapters describe the basic process of acquisition of information in a health system, recent technological developments in biomedicine and the realistic evaluation of medical informatics