Inter-rater agreement in physician-coded problem lists. 2005

Adam S Rothschild, and Harold P Lehmann, and George Hripcsak
Department of Biomedical Informatics, Columbia University, New York, NY, USA.

Coded problem lists will be increasingly used for many purposes in healthcare. The usefulness of coded problem lists may be limited by 1) how consistently clinicians enumerate patients' problems and 2) how consistently clinicians choose a given concept from a controlled terminology to represent a given problem. In this study, 10 physicians reviewed the same 5 clinical cases and created a coded problem list for each case using UMLS as a controlled terminology. We assessed inter-rater agreement for coded problem lists by computing the average pair-wise positive specific agreement for each case for all 10 reviewers. We also standardized problems to common terms across reviewers' lists for a given case, adjusting sequentially for synonymy, granularity, and general concept representation. Our results suggest that inter-rater agreement in unstandardized problem lists is moderate at best; standardization improves agreement, but much variability may be attributable to differences in clinicians' style and the inherent fuzziness of medical diagnosis.

UI MeSH Term Description Entries
D007388 Internal Medicine A medical specialty concerned with the diagnosis and treatment of diseases of the internal organ systems of adults. General Internal Medicine,Medicine, Internal,Internal Medicine, General,Medicine, General Internal
D008501 Medical Records, Problem-Oriented A system of record keeping in which a list of the patient's problems is made and all history, physical findings, laboratory data, etc. pertinent to each problem are placed under that heading. Problem-Oriented Medical Records,Medical Record, Problem-Oriented,Medical Records, Problem Oriented,Record, Problem-Oriented Medical,Records, Problem-Oriented Medical,Medical Record, Problem Oriented,Problem Oriented Medical Records,Problem-Oriented Medical Record,Record, Problem Oriented Medical,Records, Problem Oriented Medical
D005568 Forms and Records Control A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records. Records Control,Forms Control,Records Management,Controls, Records,Management, Records,Records Controls
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D015588 Observer Variation The failure by the observer to measure or identify a phenomenon accurately, which results in an error. Sources for this may be due to the observer's missing an abnormality, or to faulty technique resulting in incorrect test measurement, or to misinterpretation of the data. Two varieties are inter-observer variation (the amount observers vary from one another when reporting on the same material) and intra-observer variation (the amount one observer varies between observations when reporting more than once on the same material). Bias, Observer,Interobserver Variation,Intraobserver Variation,Observer Bias,Inter-Observer Variability,Inter-Observer Variation,Interobserver Variability,Intra-Observer Variability,Intra-Observer Variation,Intraobserver Variability,Inter Observer Variability,Inter Observer Variation,Inter-Observer Variabilities,Inter-Observer Variations,Interobserver Variabilities,Interobserver Variations,Intra Observer Variability,Intra Observer Variation,Intra-Observer Variabilities,Intra-Observer Variations,Intraobserver Variabilities,Intraobserver Variations,Observer Variations,Variabilities, Inter-Observer,Variabilities, Interobserver,Variabilities, Intra-Observer,Variabilities, Intraobserver,Variability, Inter-Observer,Variability, Interobserver,Variability, Intra-Observer,Variability, Intraobserver,Variation, Inter-Observer,Variation, Interobserver,Variation, Intra-Observer,Variation, Intraobserver,Variation, Observer,Variations, Inter-Observer,Variations, Interobserver,Variations, Intra-Observer,Variations, Intraobserver,Variations, Observer
D016247 Information Storage and Retrieval Organized activities related to the storage, location, search, and retrieval of information. Information Retrieval,Data Files,Data Linkage,Data Retrieval,Data Storage,Data Storage and Retrieval,Information Extraction,Information Storage,Machine-Readable Data Files,Data File,Data File, Machine-Readable,Data Files, Machine-Readable,Extraction, Information,Files, Machine-Readable Data,Information Extractions,Machine Readable Data Files,Machine-Readable Data File,Retrieval, Data,Storage, Data
D016347 Medical Records Systems, Computerized Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record. Automated Medical Records Systems,Computerized Medical Records Systems,Automated Medical Record System,Automated Medical Record Systems,Automated Medical Records System,Computerized Medical Record System,Computerized Medical Record Systems,Computerized Medical Records System,Computerized Patient Medical Records,Medical Record System, Automated,Medical Record System, Computerized,Medical Record Systems, Automated,Medical Record Systems, Computerized,Medical Records System, Automated,Medical Records System, Computerized,Medical Records Systems, Automated
D017432 Unified Medical Language System A research and development program initiated by the NATIONAL LIBRARY OF MEDICINE to build knowledge sources for the purpose of aiding the development of systems that help health professionals retrieve and integrate biomedical information. The knowledge sources can be used to link disparate information systems to overcome retrieval problems caused by differences in terminology and the scattering of relevant information across many databases. The three knowledge sources are the Metathesaurus, the Semantic Network, and the Specialist Lexicon. Metathesaurus,UMLS
D039061 Systematized Nomenclature of Medicine Controlled vocabulary of clinical terms produced by the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED,SNOMED CT,SNOMED Clinical Terms,SNOMED RT,SNOMED Reference Terminology,Clinical Term, SNOMED,Clinical Terms, SNOMED,Reference Terminology, SNOMED,SNOMED Clinical Term

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