Mapping Equivalence of German Emergency Department Medical Record Concepts with SNOMED CT After Implementation with HL7 CDA.

INTRODUCTION: The German Emergency Department Medical Record (GEDMR) was created by medical domain experts and healthcare providers providing a dataset as well as a form. The trauma module of GEDMR was syntactically standardized using HL7 CDA and semantically standardized using different terminologies including SNOMED CT, LOINC and proprietary coding systems. This study depicts the mapping accuracy with aforementioned syntactical and semantical standards in general and especially the content coverage of SNOMED CT. METHODS: The specification of GEDMR (V2015.1) concepts with eHealth-standards HL7-CDA, LOINC, SNOMED CT was analyzed. A content coverage assessment was made using the ISO TR 12300 rating scheme, following descriptive analysis. RESULTS: The trauma module of GEDMR contains 489 concepts, with 202 concepts expressed via HL7 CDA structure. It is possible to code 89 % of the remaining concepts via SNOMED CT. 79 % provide an advanced level of semantic interoperability, as they represent the source information either lexically or as an approved synonym. DISCUSSION: The terminology binding problem is relevant when combining different standards for syntactic and semantic interoperability with best practice documents and reference specifications providing guidance. A national license and extension for SNOMED CT in Germany as well as an ongoing effort in contributing to the International Version of SNOMED CT would be necessary to gain full coverage for concepts in German Emergency Medicine and to leverage the associated standardization process.