Introduction of systematized nomenclature of medicine-clinical terms coding Into an electronic health record and evaluation of its impact: qualitative and quantitative study
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Journal Article
Abstract
Background:
This study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations.
Objective:
The aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable remodeling of medical pathways.
Methods:
The study used qualitative and quantitative data to understand the successes and gaps in the project, clinician attitudes toward the new tool, and the future use of the tool.
Results:
The new coding system (tool) was well received and immediately widely used in all specialties. This resulted in increased, accurate, and clinically relevant data collection. Clinicians appreciated the increased depth and detail of the new coding, welcomed the potential for both data sharing and research, and provided extensive feedback for further development.
Conclusions:
Successful implementation of the new system aligned the University Hospitals Birmingham NHS Foundation Trust with national strategy and can be used as a blueprint for similar projects in other health care settings.
JMIR Med Inform 2021;9(11):e29532
This study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations.
Objective:
The aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable remodeling of medical pathways.
Methods:
The study used qualitative and quantitative data to understand the successes and gaps in the project, clinician attitudes toward the new tool, and the future use of the tool.
Results:
The new coding system (tool) was well received and immediately widely used in all specialties. This resulted in increased, accurate, and clinically relevant data collection. Clinicians appreciated the increased depth and detail of the new coding, welcomed the potential for both data sharing and research, and provided extensive feedback for further development.
Conclusions:
Successful implementation of the new system aligned the University Hospitals Birmingham NHS Foundation Trust with national strategy and can be used as a blueprint for similar projects in other health care settings.
JMIR Med Inform 2021;9(11):e29532
Date Issued
2021-11-01
Date Acceptance
2021-11-01
Citation
JMIR Medical Informatics, 2021, 9 (11), pp.1-18
ISSN
2291-9694
Publisher
JMIR Publications
Start Page
1
End Page
18
Journal / Book Title
JMIR Medical Informatics
Volume
9
Issue
11
Copyright Statement
©Tanya Pankhurst, Felicity Evison, Jolene Atia, Suzy Gallier, Jamie Coleman, Simon Ball, Deborah McKee, Steven Ryan, Ruth
Black. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 23.11.2021. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR
Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on
https://medinform.jmir.org/, as well as this copyright and license information must be included.
Black. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 23.11.2021. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR
Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on
https://medinform.jmir.org/, as well as this copyright and license information must be included.
License URL
Identifier
http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000744229000001&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=1ba7043ffcc86c417c072aa74d649202
Subjects
Science & Technology
Life Sciences & Biomedicine
Medical Informatics
coding standards
clinical decision support
Clinician led design
clinician reported experience
clinical usability
data sharing
diagnoses
electronic health records
electronic health record standards
health data exchange
health data research
International Classification of Diseases version 10 (ICD-10)
National Health Service Blueprint
patient diagnoses
population health
problem list
research
Systematized Nomenclature Of Medicine-Clinical Terms (SNOMED-CT)
use of electronic health data
user-led design
SNOMED CT
STANDARDS
Publication Status
Published
Article Number
ARTN e29532
Date Publish Online
2021-11-23