Accepted for/Published in: JMIR Medical Informatics
Date Submitted: Apr 11, 2021
Date Accepted: Jun 17, 2021
Date Submitted to PubMed: Nov 24, 2021
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Introducing SNOMED-CT* Coding into an Electronic Health Record: Impact on Clinicians, Data Sharing and Research potential *Systemised Nomenclature of Medicine Clinical Terminology
ABSTRACT
Background:
This study describes the conversion within an existing Electronic Health Record (EHR) from the coding system International Classification of Diseases version 10 (ICD-10) to the Systematized Nomenclature Of MEDicine - Clinical Terms (SNOMED-CT), for collection of patients’ history and diagnoses. The setting is a large acute hospital, designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection which can be utilised in Clinical Decision Support rules to drive patient safety. Collected data can be exchanged across healthcare systems to support patients in all healthcare settings. Data can be used for research to prevent disease and protect future populations.
Objective:
To migrate a current electronic health record, with all relevant patient data, to the coding system, Systematized Nomenclature of Medicine - Clinical Terms, to optimise clinical utilisation and clinical decision support, and facilitate data sharing across organisational boundaries for national programmes, and remodelling of medical pathways.
Methods:
The study used qualitative and quantitative data to understand the successes and gaps in the project, clinician attitudes to the new tool, and future use.
Results:
The new coding system (“tool”) was well received and immediately widely used in all specialities. It resulted in increased, accurate and clinically relevant data collection. Clinicians appreciated the increased depth and detail of the new coding, welcomed the potential for both data sharing and research, and gave extensive feedback for further development.
Conclusions:
Successful implementation aligned the Trust with national strategy and can be used as a Blueprint for similar projects in other healthcare settings. Clinical Trial: NA
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