Country / Region
EMEA
Tags
Clinical Practice, Data quality, Implementation, Innovation, Pre/postcoordination
The department of neurosurgery at University Hospitals Leuven, in collaboration with a terminologist, established a standardized complication registration system through an iterative consensus process. Following rigorous clinical review, 102 complications were selected, resulting in a final list of 100 concepts (91 unique SNOMED CT identifiers). Complications were categorized as: intraoperative, postoperative surgical, postoperative medical. To enable tracking the absence of complications and the proportion of completed registrations, a 'no complication' category was also included.
Our standardized complication registry has been clinically operational since February 1, 2023. It documents all neurosurgical procedures (N=3501) with SNOMED CT-coded complications (or their absence) linked to surgical procedures (using local codes) in the electronic patient record (EPR) problem list and covers the period from surgery through 6 weeks of postoperative follow-up. Analysis through April 21, 2025 shows 92% coverage.
Our datawarehouse integrates these procedures and complications with laboratory results, imaging reports, medications, readmissions, and survival data - providing clinicians with comprehensive patient overviews and enabling the identification of clinically relevant patterns over time
Key features
1. Clinical utility: Surgeons register the complications directly in workflow using EPR templates
2. Terminology flexibility: Light version of post-coordination when needed (MRCM-compliant)
3. Future-ready:
* Architecture permits eventual Clavien-Dindo integration (Grade I-V severity scoring)
* Technical foundations exist for SNOMED CT procedural coding (requiring future IT development)
This implementation demonstrates how SNOMED CT can support surgical outcome monitoring while pragmatically accommodating existing systems. The multidimensional linkage will enable both quality benchmarking and research applications in the future.
Description
This implementation project has dual clinical and research objectives with direct patient care impact:
Primary: Clinical Quality Improvement
* Real-time monitoring of postoperative complications through standardized SNOMED CT documentation
* Supports clinical decision support: triggered alerts for abnormal values (lab/imaging)
Secondary: Research Enablement
Provides structured outcome data for:
* Service-level quality benchmarking
* Postoperative recovery trajectory analysis
Scalable Architecture:
Designed for future expansion to:
* Ranking the severity of the complication (Clavien-Dindo)
* Procedure coding standardization
* Multidisciplinary complication management
This scope reflects our "quality-first" approach where research benefits emerge from clinically relevant, caregiver-driven data collection.
Scope
SNOMED CT was selected for this initiative based on both clinical-technical merits and alignment with Belgian healthcare policy:
* Mandated National Standard
* Implements the Belgian government's strategic choice for SNOMED CT as the preferred clinical terminology
* Complies with recommendations from Belgian healthcare agencies (e.g., eHealth Platform)
* Clinical Precision for Neurosurgery
* Provides granular concepts tailored to neurosurgical complications
* Enables accurate distinction between similar conditions (e.g., different locations of nerve injury’s)
* Future-Proof Infrastructure
* Allows integration with other SNOMED CT-coded data across the healthcare continuum
* Facilitates compliance with evolving Belgian digital health regulations
How SNOMED CT will be used
Clinical Registration Process:
* Neurosurgeons directly record complications (or their absence) as SNOMED CT-coded diagnoses/findings in the patient's problem list using drop-down menus or a grid of tiles (EPR)
* Critical implementation detail:
* The surgical procedures remain coded using the hospital's local procedure coding system (non-SNOMED)
* The association between complication and procedure is established through the EPR's native relationship mechanism (non-SNOMED link)
* This hybrid approach ensures clinical workflow compatibility while maintaining semantic precision for complications
Post-Coordination Approach:
* When required concepts aren't available as precoordinated terms, we employ a light post-coordination method using EPR templates
* Methodology:
* Start with the most specific available parent concept
* Add clinical meaning through attribute relationships
* Strictly follow MRCM (Reference Set Member) rules for valid concept composition
* Example: If a specific complication isn't available, we might:
* Select the broader SNOMED concept (e.g., "Complication associated with nervous system implant")
* Add attributes like:
* Associations with devices (e.g., "Intrathecal implantable infusion pump")
* Temporal context (e.g., "intraoperative during surgery")
Why SNOMED CT will be used
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