Health Informatics Centre, Planning Division, Ministry of Health Malaysia

This use case describes the automation of monitoring obstetric clinical indicators using SNOMED CT encoded clinical notes. The semi-structured clinical notes were extracted and encoded with SNOMED CT using a natural language processing system called MyHarmony. A tri-partite arrangement was established, which involved the informaticians at the Health Informatics Centre (Pusat Informatik Kesihatan, PIK) in the Ministry of Health Malaysia, the clinicians headed by the head of Malaysia’s obstetric speciality, and the Information Technology (IT) engineers of the hospitals involved. Each party has specific roles and responsibilities. There were four benefits identified with using this approach: (1) No data entry required. (2) Saved time and resources due to the automation process for data submission, codification, and reporting. Hence, there is no effect on clinical workflow or requires additional workload. (3) Richer analysis due to the granularity of the data written in free text. (4) Timely result which enables clinicians to monitor and intervene faster. However, there were several expected challenges during this project. First is the incompleteness of the documentation by the doctors which need can be improved with continuous awareness. the documentation and the resulting reports. Secondly, the team must standardize the semi-structured clinical notes from different hospitals. Therefore, it is important that the informatician understand the clinical requirement to ensure the right data are extracted by the IT engineers. This approach will be introduced to other clinical specialities so they can experience the same benefit when using SNOMED CT.