Description

Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic operative report templates also provide the optimum goal of enriching personalized health information of a given patient at the point of care so as to support the exchange of clinical information across the continuum of multiple healthcare providers. However, most of the available synoptic operative report templates in many clinical settings do not incorporate interoperable standards in their design and implementation.

This project implemented a template (i.e., eSOR-SCI) that uses interoperable standards for its design and implementation. The implementation of the eSOR-SCI template was completed in September 2012. It was designed to be conformant with the HL7 Clinical Document Architecture (CDA) Implementation Guide for the Operative Note and to represent clinical activity using the HL7 Clinical Statement pattern encoded with Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) terminology.

Location: Halifax, Nova Scotia, Canada


Scope

Electronic synoptic operative reports are dependent upon predefined templates for individual procedures. Such templates are based on synoptic methodology, which on its own refers to the creation of a library of keywords and phrases to show a preferred way to communicate a clinical concept in an operative report.

There were 402 clinical data elements in the eSOR-SCI template. The sensitivity and positive predictive value (PPV) metrics were respectively 97% and 99% using pre and post coordinated SNOMED CT terms. Almost 3% of the clinical data elements were considered to be difficult to encode using the SNOMED CT expressions in either pre or post-coordinated form. All section names were expressed using LOINC codes as per conformance criteria in the HL7 CDA Implementation Guides. There were 17 HL7 CDA Operative Note Sections implemented.


How SNOMED CT will be used

Subjects recruited for a pilot study completed recruitment and feedback questionnaires, and produced both an electronic synoptic operative report for spinal cord injury report and a dictated narrative operative report for an actual patient case. SNOMED CT codes ensure consistent data across institutions, but each institution can tailor their interface to the terminology used by clinicians at a particular institution. This facilitates coding at the point of data entry while improving data quality and reuse for researchers and administrators.

Why SNOMED CT was selected

The methods were primarily based on the principles of health interoperability using HL7 V3 CDA R2, SNOMED-CT, and Logical Observation Identifiers Names and Codes (LOINC).

Drawing upon the work of Rector, Qamar, and Marley, Benson asserted that electronic information systems operate at two different levels: Model of Use and Model of Meaning. Whereas Model of Use is defined as the human interface that describes how the system is actually used, Model of Meaning is defined as the representation for reporting and analysis that supports data processing and reasoning. These two distinct levels of system operation are necessary because each “model of use needs to be convertible into a model of meaning to make it computable” [Benson]. This study extended the work of Rector et al. by adding another level (i.e., Model of Design) to the methodology to describe how electronic information systems are designed.

The eSOR-SCI template was implemented using a model of meaning methodology to ensure that data can be aggregated and analyzed for research purposes. The binding of the SNOMED-CT with the HL7 V3 CDA R2 template structure depicts how the model of meaning was achieved. In the case of the eSOR-SCI template, the clinical document is the synoptic operative report generated by the system.

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