Country / Region
APAC
Tags
Clinical Practice, Mapping, Translation
The Dental Information System (DIS) was developed internally by the Oral Health Programme, Ministry of Health Malaysia (OHP) spearheaded by a specialized team of dental professionals as part of the broader National Electronic Medical Record (EMR) initiative. Early DIS iterations primarily emphasized disease incidence analytics and clinician workload tracking. SNOMED CT was integrated during initial development phases, demonstrating an early commitment to adopting standardized terminologies for enhanced interoperability, effective implementation of the International Patient Summary (IPS) and streamlined integration with other health information systems.
Valuable experiences were accrued through the development of eReporting V2.0 Oral Health within the Malaysian Health Data Warehouse (MyHDW), particularly from integrating MyHarmony for the analysis of unstructured data using SNOMED CT. The Health Informatics Centre (HIC), as a crucial stakeholder in the national deployment of SNOMED CT, is now focused on systematically mapping DIS data variables to SNOMED CT concepts. This mapping effort aims to establish a foundational standardized Dentistry IPS framework, thereby promoting interoperability on national and international scales.
Description
The DIS developed in-house by the Ministry of Health Malaysia, comprises four submodules designed to support various aspects of oral healthcare services. One of the key modules, DIS:Clinical, functions as an EMR system for primary oral healthcare by capturing patient data during each clinical encounter. It also records non-patient-based data, such as health promotion and program-specific activities. These data are subsequently used to generate reports on disease incidence and clinician workload. A small portion of DIS variables has incorporated SNOMED CT to enhance data standardization and interoperability.
To further support international use in dentistry particularly in generating an International Patient Summary (IPS), which Malaysia successfully implemented during the Haj pilgrimage, most clinical variables within DIS were mapped to SNOMED CT concepts, referencing a 2021 local reference set. A mapping document containing Fully Specified Names (FSNs), SNOMED CT codes, synonyms, and local terminology proved essential, especially since many data elements were originally documented in the Malay language. The terminology alignment was validated using the SNOMED CT International Edition (September 2024), which has since been integrated into the DIS to ensure semantic consistency and broader interoperability.
Preliminary results indicate that the majority of DIS:Clinical variables align with SNOMED CT hierarchies, particularly under Clinical Findings and Procedures. Most clinical notes were successfully mapped to the pre-existing reference set, with a high proportion of variables demonstrating either one-to-one or post-coordinated concept mapping. The next step involves developing a consensus-based data sharing format aligned with the IPS structure to support both national and international interoperability.
Scope
Malaysia has been a subscriber to SNOMED CT for many years. Its introduction to the Oral Health Programme began in 2018, with an initial focus on supporting disease and service analysis within the Malaysian Health Data Warehouse (MyHDW). Building on this foundation, the use of SNOMED CT is now being expanded to the front end, specifically in the Electronic Medical Record (EMR) system used during patient encounters.
How SNOMED CT will be used
In Malaysia's Dental Information System (DIS), SNOMED CT helps to enhance data standardization and support interoperability. Some clinical variables in the DIS Clinical module have been linked to SNOMED CT terms, especially from the Clinical Findings and Procedures categories. This mapping allows clinical notes and patient data, often documented in the Malay language, to be standardized using internationally recognized terminology.
Why SNOMED CT will be used
Contact
