JMIR Publications

ABSTRACT

Background:

To ensure semantic interoperability, South Korea joined SNOMED International as the 39th official member country and introduced the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) in 2020. However, no methodology exists for mapping local codes to SNOMED CT, with instead this being performed at each local medical institution sporadically and independently. The quality of the mapping therefore cannot be guaranteed.

Objective:

This study aimed to develop and introduce SNOMED CT mapping guidelines for local terms used to document clinical findings and procedures in electronic health records at local institutions in South Korea.

Methods:

The overall structures and contents of the guidelines with diverse use cases were developed by referencing the existing SNOMED CT mapping guidelines, previous studies related to SNOMED CT mapping, and the mapping and teaching experiences of the authors.

Results:

The SNOMED CT mapping guidelines developed in this study consisted of the nine sections of ‘define purpose and scope of the map,’ ‘term extraction,’ ‘preprocess source terms syntactically,’ ‘preprocess source terms semantically,’ ‘select a search term,’ ‘search strategies to find SNOMED CT concept using browser,’ ‘classify mapping correlation,’ ‘validation of the map,’ and ‘build the final map format.’

Conclusions:

The guidelines developed in this study can support local medical institutions in standardizing their local terms into SNOMED CT. The use of these guidelines by map developers working at local hospitals can improve the mapping quality performed at individual medical institutions.