Registration in practice: Comparing free-text and compositional terminological-system-based registration of ICU reasons for admission

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Abstract

Reusability of patient data for clinical research or quality assessment relies on structured, coded data. Terminological systems (TS) are meant to support this. It is hardly known how compositional TS-based registration affects the correctness and specificity of information, as compared to free-text registration. In this observational study free-text reasons for admission (RfA) in intensive care were compared to RfAs that were composed using a compositional TS. Both RfAs were registered in the Patient Data Management System by clinicians during care practice. Analysis showed that only 11% of the concepts matched exactly, 79% of the concepts matched partially and 10% of the concepts did not match. TS-based registration results in more details for almost half of the partial matches and in less details for the other half. This study demonstrates that the quality of TS-based registration is influences by the terminological system's content, its interface, and the registration practice of the users.

Original languageEnglish
Title of host publicationComparing free-text and compositional terminological-system-based registration of ICU reasons for admission
Pages3-9
Number of pages7
Volume222
Publication statusPublished - 2006
Event2nd International Workshop on Formal Biomedical Knowledge Representation, KR-MED 2006, Collocated with the 4th International Conference on Formal Ontology in Information Systems, FOIS 2006 - Baltimore, MD, United States
Duration: 8 Nov 20068 Nov 2006

Publication series

NameCEUR Workshop Proceedings

Conference

Conference2nd International Workshop on Formal Biomedical Knowledge Representation, KR-MED 2006, Collocated with the 4th International Conference on Formal Ontology in Information Systems, FOIS 2006
Country/TerritoryUnited States
CityBaltimore, MD
Period8/11/20068/11/2006

Keywords

  • Evaluation
  • Information storage and retrieval
  • Medical records
  • Terminological system

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