Ziekenhuis Aan De Stroom (1 of 2)

The Belgian authorities have articulated a clear policy vision to adopt SNOMED CT as the national standard for clinical terminology across the healthcare system, including hospital settings. As of January 2029, all Belgian hospitals will be required to record diagnoses, elements of medical history, and procedures in a structured format within their EHRs, using SNOMED CT.

Although still a minority, some large Belgian hospitals—including university hospitals—have already started implementing SNOMED CT, primarily for the structured capture of diagnoses, medical history, and procedures. These early implementations have demonstrated that success requires more than technical EHR preparedness and sound governance; clinician buy-in for structured documentation is essential. In reality, the greatest challenge lies in achieving sufficient clinician buy-in to transition toward SNOMED CT-based structured documentation in daily workflows. Currently, free-text entry is not just the default documentation method—it is deeply embedded in clinical routines precisely because of its (perceived) advantages in flexibility and contextual expressiveness. This makes the shift to structured registration particularly complex, as it demands changes not only in tooling but also in mindset and workflow integration.

Ziekenhuis aan de Stroom (ZAS) is one of the (few) Belgian hospitals that made an early strategic decision to implement SNOMED CT for its hospital-wide problem list. Over a period of just two years, the hospital successfully registered approximately 5 million structured diagnoses, resulting in around 80% of all problem list entries being SNOMED CT-coded. While this quantitative result demonstrates technical feasibility and operational commitment, a retrospective evaluation has revealed a sobering insight: despite this level of adoption, the theoretical benefits of semantic interoperability and meaningful use both in primary and secondary contexts—remain largely unrealized in daily clinical practice. Notably, the implementation has not yet translated into effective interoperability within the hospital (across departments), nor into interoperability with external institutions and systems. Clinicians at ZAS, like elsewhere, often lack a clear answer to the question "what's in it for me?", especially when it comes to primary use. This gap in perceived clinical value risks undermining the long-term sustainability of SNOMED CT in institutions that have already implemented it and forms an even greater barrier for hospitals that are still SNOMED CT-naive

In response to these findings, Ziekenhuis aan de Stroom (ZAS) engaged with various Belgian health authorities to raise awareness of the systemic nature of the problem. The underrealization of semantic interoperability and meaningful use in the Belgian health data ecosystem cannot be attributed to isolated technical issues‚ it stems from a complex interplay of barriers involving multiple stakeholders. A key structural shortcoming is the absence of clinicians and their representatives (such as CMIOs) in the design, governance, and evaluation of national data strategies‚Äîparticularly those related to problem list data capture and reuse.

To help address this gap, ZAS took the initiative to establish the Belgian CMIO Network, with the goal of providing a unified, clinically grounded voice in national policy discussions. The network also serves as a recognizable stakeholder within the broader Belgian health data ecosystem, helping to align digital infrastructure with real-world clinical priorities. As one response to this, Ziekenhuis aan de Stroom took the initiative to establish a Belgian CMIO network—with the aim of acting as a collective voice of clinicians in advisory bodies and as a recognizable stakeholder in the Belgian health data ecosystem.

Building on the foundation of this newly established CMIO network‚Äîand in recognition of the significant challenge that SNOMED CT implementation poses for Belgian hospitals by January 1st, 2029‚ the Federal Public Service of Health mandated Ziekenhuis aan de Stroom (ZAS) to establish and coordinate a national SNOMED CT implementation support program. The initiative is aimed at CMIOs or equivalent clinical representatives from other Belgian hospitals, as well as EHR vendors, and is designed to provide peer-based, practical guidance for achieving structured SNOMED CT documentation within hospitals EHR environments.

The overarching goal is to foster organizational readiness for SNOMED CT implementation in Belgian hospitals across governance, technical infrastructure, and human factors. While the primary focus is on enabling high-quality structured documentation for direct clinical use, the initiative explicitly acknowledges the importance of secondary use—including quality monitoring, policy development, and research without adding to the documentation burden for clinicians. The initiative also aligns with the broader ambitions of the European Health Data Space (EHDS) Regulation, which emphasizes structured and interoperable clinical data across care settings, particularly in support of primary use (while also enabling but not limited to secondary use scenarios).

A set of deliverables has been defined, which the involved parties see as key building blocks to assess and guide organizational readiness:

1. National SNOMED CT Implementation Heatmap. A baseline and progress-tracking tool that maps the maturity, breadth, and depth of SNOMED CT implementation across Belgian hospitals. The heatmap is informed by a self-assessment survey based on SNOMED International's framework, and extended with targeted questions to uncover perceived and expected barriers—not only technical but also organizational and human. By systematically identifying these barriers, the network aims to enable shared dialogue and collaborative resolution with other key stakeholders, including policy-makers, vendors, and professional organizations.
2. Technical Implementation Guidelines. Guidance for backend SNOMED CT integration in EHR systems, including transition scenarios. This includes options for automated migration or tools to support free-text-to-structure conversion at the individual patient record level.
3. Clinical Implementation Guide. A practice-oriented manual based on the real-life experiences and lessons learned from Belgian hospitals. It includes business rules related to documentation scope, completeness, and timeliness
4. EHR Vendor Requirements Guide. A specification document outlining functionality and interoperability requirements from a clinical perspective. It also includes recommendations for embedding clinical documentation improvement (CDI) tools to support structured data entry without disrupting clinical workflows.
5. Clinician-Focused Training Program. A targeted educational offering designed specifically for clinicians, addressing both the "how" and the "why" of SNOMED CT-based structured documentation. The program places strong emphasis on building awareness of semantic interoperability as a strategic enabler of better care and better data. It also clarifies the responsibility of clinicians as primary data creators for ensuring the quality and reusability of health data. The training aims to empower clinicians by helping them understand their critical role within the evolving Belgian and European health data ecosystem.
6. Engagement with Government Stakeholders. Structured collaboration with national and regional health authorities to help shape a health data ecosystem that is aligned with clinical practice and both primary and secondary reuse objectives. A key goal is to increase awareness among policymakers of the clinical realities and challenges of structured documentation, and to ensure that clinicians are recognized and supported as responsible contributors to the data value chain. This deliverable also includes the development of concrete, real-world use cases that demonstrate how high-quality, SNOMED CT-coded primary documentation can directly support secondary uses—without increasing registration burden for clinicians.
7. Value Set Development and Terminology Binding. Ongoing refinement and expansion of value sets that support intuitive, efficient, and low-threshold registration of SNOMED CT concepts within the EHR. The focus lies on enabling structured documentation without compromising clinical flexibility or expressiveness.
8. Raising Awareness of Change Requirements The initiative seeks to highlight the importance of human factors (cultural and behavioral aspects) in the successful adoption of SNOMED CT by clinicians. Through knowledge-sharing across hospitals, BE Support emphasizes that structured documentation is not just a technical (or policy) challenge, but mainly a matter of clinical culture, habits, and mindset which must be acknowledged and addressed to ensure long-term success.

The Belgian SNOMED CT implementation Support Network initiative is guided by principles that are clinically driven, practical, bottom-up, pragmatic, and EHR-vendor neutral. By working together, sharing experiences, and involving clinicians as key stakeholders while also engaging vendors, policymakers, and other actors in the health data ecosystem we believe that the enormous challenge of achieving high-quality, SNOMED CT-based structured documentation will become more manageable and that real-world collaboration can break through existing barriers. We aim not only to meet regulatory objectives, but to build a sustainable foundation for better data, better care, and meaningful reuse.