Description

Since October 2015 we have deployed a home-made EMR entirely based on SNOMED CT in our academic institution. A French speaking extension has been created with the help of our NRC and is improving day by day. We use mostly precoordinated expressions, but postcoordination is already available in specific templates. Free text is allowed only when a structured item has been recorded to improve its granularity.

Artifacts covered are: reason for admission, risk factors (allergies, implants, nutritional, addictions, social factors…), systematic review of systems, physical examination (usual and some more specific: neurology and vascular), past history (personal and family) of diseases and procedures, active problems, procedures performed, staging and scales. Admission and discharge reports can be generated and sent electronically to referring physician.

At the present time (March 2017), about 70% of the inpatient activity is covered by the system and more than 2 millions concepts have been recorded.

Location: Hoptial Ersasme - Cliniques Universitaires de Bxl, Boulevard Baudouin, Bruxelles, Belgique


Scope

The scope will be extended to paramedical and nursing activities.

How SNOMED CT will be used

As stated before, precoordination is currently predominantly used but we plan an increasing use of postcoordination through the use of specific templates.

Why SNOMED CT was selected

For its granularity as a clinical terminology and the potential power of exploitation in conjunction with a terminology server and constraint language. In an academic hospital SNOMED CT fits very well with its missions: Education, Quality of Care and Research.

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