Abstract
Background: Routine clinical coding of clinical outcomes in outpatient consultations still lags behind the coding of episodes of inpatient care. Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) offers an opportunity for standardised coding of key clinical information. Identifying the most commonly required SNOMED terms and grouping these into a reference set will aid future adoption in routine clinical care. Objective: To create a common endocrinology reference set to standardise the coding for outcomes of outpatient endocrine consultations, using a semi-automated extraction of information from existing clinical correspondence. Methods: Retrospective review of data from an adult tertiary outpatient endocrine clinic between 2018 and 2019. A total of 1870 patients from postcodes within two regional areas of NHS Grampian (Aberdeen City and Aberdeenshire) attended the clinic. Following consultation, an automated script extracted each problem statement which was manually coded using the ‘disorder’ concepts from SNOMED CT (UK edition). Results: The review identified 298 relevant endocrine diagnoses, 99 findings and 142 procedures. There were a total of 88 (29.5%) commonly seen endocrine conditions (e.g., Graves' disease, anterior hypopituitarism and Addison's disease) and 210 (70.5%) less commonly seen endocrine conditions. Subsequently, consultant endocrinologists completed a survey regarding the common endocrine conditions; 28 conditions have 100% agreement, 25 have 90%–99% agreement, 31 have 50%–89% agreement and 4 have less than 59% agreement (which were excluded). Conclusion: Automated text parsing of structured endocrine correspondence allowed the creation of a SNOMED CT reference set for common endocrine disorders. This will facilitate funding and planning of service provision in endocrinology by allowing more accurate characterisation of the patient cohorts needing specialist endocrine care.
| Original language | English |
|---|---|
| Pages (from-to) | 343-349 |
| Number of pages | 7 |
| Journal | Clinical Endocrinology |
| Volume | 100 |
| Issue number | 4 |
| Early online date | 9 Aug 2023 |
| DOIs | |
| Publication status | E-pub ahead of print - 9 Aug 2023 |
Bibliographical note
We are grateful to the staff and patients of the endocrine clinic at Aberdeen Royal Infirmary (ARI) for the survey responses and provision of data used in this study. We are also thankful to Dr Charlotte Lee and Dr Wendy Yap for their help with data analysis. No external funding was sought or obtained for this study.Data Availability Statement
Research data are not shared except for the reference set made.Additional supporting information can be found online in the Supporting Information section at the end of this article.
Keywords
- clinical problem lists
- endocrinology
- medical coding
- ontology
- outpatient consultation
- pituitary
- reference set
- Refset
- SNOMED CT
- thyroid
Access to Document
- Yap_etal_CE_Creating__a_Snomed_VOR
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