A SNOMED CT Mapping Guideline for the Local Terms Used to Document Clinical Findings and Procedures in Electronic Medical Records in South Korea: Methodological Study

Abstract

BackgroundSouth Korea joined SNOMED International as the 39th member country. To ensure semantic interoperability, South Korea introduced SNOMED CT (Systemized Nomenclature of Medicine–Clinical Terms) in 2020. However, there is no methodology to map local Korean terms to SNOMED CT. Instead, this is performed sporadically and independently at each local medical institution. The quality of the mapping, therefore, cannot be guaranteed. ObjectiveThis study aimed to develop and introduce a guideline to map local Korean terms to the SNOMED CT used to document clinical findings and procedures in electronic health records at health care institutions in South Korea. MethodsThe guidelines were developed from December 2020 to December 2022. An extensive literature review was conducted. 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 experiences of the committee members. The developed guidelines were validated by a guideline review panel. ResultsThe SNOMED CT mapping guidelines developed in this study recommended the following 9 steps: define the purpose and scope of the map, extract terms, preprocess source terms, preprocess source terms using clinical context, select a search term, use search strategies to find SNOMED CT concepts using a browser, classify mapping correlations, validate the map, and build the final map format. ConclusionsThe guidelines developed in this study can support the standardized mapping of local Korean terms into SNOMED CT. Mapping specialists can use this guideline to improve the mapping quality performed at individual local medical institutions.