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The connection between terms used in medical records and coding system: a study on Swedish primary health care data
Linköping University, Department of Biomedical Engineering, Medical Informatics. Linköping University, The Institute of Technology.
Family Medicine Stockholm, Karolinska institutet, Stockholm.
Family Medicine Stockholm, Karolinska institutet, Stockholm.
Linköping University, Department of Biomedical Engineering, Medical Informatics. Linköping University, The Institute of Technology.
2001 (English)In: Medical informatics and the Internet in medicine (Print), ISSN 1463-9238, E-ISSN 1464-5238, Vol. 26, no 2, 87-99 p.Article in journal (Refereed) Published
Abstract [en]

Implementation of problem lists and their relation to standardized coding systems have been approached and analysed in different ways. Most evaluations concern quantitative aspects such as content coverage in a specific domain. In order to reveal the qualitative aspects of diagnostic coding, medical record texts from primary health care encounters were compared with terms from a coding system that was used for describing them statistically. The records were coded by six general practitioners, and in some cases, an applied diagnostic term was found within the text, while other record text-coding system relationships were categorized as synonyms, alternative terms, and interpretations. Thus, the categories roughly corresponded to a measure of semantic distance between the terms in the record text and the rubrics of the coding system, and there was a correlation between semantic distance and inter-rater agreement. The subcategories of this scheme corresponded fairly well to recently published desiderata for clinical terminology servers, including functionality such as word normalization and spelling correction. However, not all problems could have been automatically coded by means of lexical methods, which can be partly explained by the fact that diagnostic coding also relies on clinical knowledge. In addition, proper automation relies on context representation within the records.

Place, publisher, year, edition, pages
2001. Vol. 26, no 2, 87-99 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-29002PubMedID: 11560294Local ID: 14235OAI: oai:DiVA.org:liu-29002DiVA: diva2:249814
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2013-02-20
In thesis
1. On information quality in primary health care registries
Open this publication in new window or tab >>On information quality in primary health care registries
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Data compilation has a long history in the field of medicine, and domains for which data are pooled include, among others, epidemiological studies and quality assessment. Unfortunately, data may be of low quality with poor validity and reliability, and consequently, decisions based on statistics may be unreliable. The range of applications of information use and reuse is expected to extend from aggregation of information to retrieval of specific cases, which further emphasizes the importance of high quality data. The present thesis deals with aspects of information quality in Swedish primary health care registries. Such information is commonly encoded according to standardized coding systems.

In order to improve coding quality, it is necessary to study the content, structure, and semantics of the coding systems, as well as the functionality of the tools used to access them. In particular, the thesis discusses the effect of the coding system structure - as an instrument for code retrieval as well as data aggregation - on the reliability of coding. In summary, the functionality of a tool that supports coding of medical problems must meet numerous requirements. Flexible structures for browsing the coding system and different types of lexical tools are needed, as are rules for guiding the correct choice of code with respect to a particular medical problem. As an instrument for data compilation, the structure of the coding system may support aggregation in ways that reflect dimension with low variability.

The main contribution of this thesis is to increase understanding of the complexity of disease concepts and the coding systems used for representing them. In addition, it also encompasses the measurements of reliability in coded Swedish primary health care data that were carried out in both a smaller prospective and a larger retrospective study. Further, the thesis proposes a metric for retrospective reliability studies. Finally, the presented coding tool - the Classification Browser - is in itself a platform for further discussion and development in the domain of diagnostic coding.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet, 2003. 65 p.
Series
Linköping Studies in Science and Technology. Dissertations, ISSN 0345-7524 ; 805
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24499 (URN)6623 (Local ID)91-7373-612-0 (ISBN)6623 (Archive number)6623 (OAI)
Public defence
2003-04-11, Patologsalen, Universitetssjukhuset, Linköping, 09:15 (Swedish)
Opponent
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2013-02-20

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Petersson, HåkanÅhlfeldt, Hans

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