Country / Region
EMEA
Tags
Clinical Practice, Data quality, Implementation
Belgium has designated the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) as the recommended clinical reference terminology for clinical information systems. The use of a common, unambiguous terminology has the potential to improve data quality and patient safety by capturing clinical data in a standardized manner.
In our academic hospital, we adopted a new electronic health system in 2020, and at the same time, we implemented SNOMED CT in various parts of our electronic health record. As a result, we transitioned overnight from a free-text system to one where data is 100% structured in certain sections. For the users, this represented a significant disruption to their clinical practices. Essential parts of the patient record, such as the problem list and medical history, could no longer be entered as free text but required selecting a term from a list of sometimes unfamiliar terms. How can we address this major shift in the use of the patient record? There is little documentation explaining how best to support users during this transformation.
We would therefore like to share our experience of this transition, the strategies we implemented, and the challenges we faced. This presentation will be structured around four key areas: communication between end-users and the terminology team, data quality, data relevance, and the importance of structured data.
Description
Our academic hospital transitioned from a free-text system to a system where data is 100% structured in specific sections, such as the problem list and medical history. This shift required users to select terms from a standardized list rather than entering free-text information. This represented a significant disruption to their clinical practices.
The scope of this abstract covers our experience with this transition, as well as the strategies we implemented to improve compliance of end-users and adapt SNOMED CT to clinical practice.
Scope
Belgium has designated SNOMED CT as the recommended clinical reference terminology for clinical information systems. In our academic hospital, we adopted a new electronic health system in 2020, and at the same time, we selected and implemented SNOMED CT as the reference terminology in various parts of our electronic health record. The use of a common, unambiguous terminology has the potential to improve data quality and patient safety by capturing clinical data in a standardized manner.
How SNOMED CT will be used
SNOMED CT is used in the problem list, medical history, family history, visit diagnosis, surgical history, and for non-drug allergies. We would like to extend its use to other domains, such as pharmacy and laboratory.
Why SNOMED CT will be used
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