SNOMED CT – THE LANGUAGE FOR EHR Dr SB Bhattacharyya MBBS, MBA, FCGP Member, National EHR Standardisation Committee, MoH&FW, GoI Member, Health Informatics Sectional Committee, MHD 17, BIS Hony. State Secretary (2015), IMA Haryana President (2010 – 2011), IAMI
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SNOMED CT – THE LANGUAGE FOR
EHRDr SB Bhattacharyya
MBBS, MBA, FCGP
Member, National EHR Standardisation Committee, MoH&FW, GoI
Member, Health Informatics Sectional Committee, MHD 17, BIS
Hony. State Secretary (2015), IMA Haryana
President (2010 – 2011), IAMI
Electronic Health Record
■ A longitudinal record of the health of an individual sequentially arranged from the very first medical record to the very latest
■ Consists of all health-related records like
– Medical Records – treatment and discharge summaries
During early spring, a 45 year old male presented with complaints of fever accompanied by a runny nose, cough without expectoration along with feeling of malaise and generalised body ache for the past one day. There were no other complaints although the patient kept on insisting that he had “cold”.
The patient had a past history of infection with Koch’s bacilli for which he successfully underwent ATT. In family history, both his parents and his two siblings – elder brother and sister – all suffer from NIDDM.
On examination he was found to have an oral temperature of 38°C, bilaterally clear chest, normal heart sounds, doughy feel of abdomen, liver and spleen not enlarged, and plantar reflex negative. Based on the findings, a clinical diagnosis of seasonal influenza was made.
He was advised CBC, RBS, CXR, Mantoux Test, and Urine RE/ME. He was prescribed oral form of acetaminophen 500mg stat and PRN, oral form of diphenhydramine hydrochloride 25mg 8 hourly for three days, plenty of fluids orally and bed rest.
He reported back with his test reports the next day stating that he was feeling better. All investigation results and reports were unremarkable, except his RBS was 200 mg/dL. He was advised to consult a diabetologist without delay, complete his medications and report back only if fresh problems arose.
There were no further follow-ups by the patient for this particular episode.
■ When the patient said he had “cold”, what exactly was he trying to say?
■ What is infection with “Koch’s bacilli”?
■ How accurate was the clinical diagnosis? How likely was this diagnosis to have turned out to be a laboratory diagnosis should the appropriate tests based on evidence based medicine have been run?
■ Did the patient require to undergo all the tests as advised, particularly given the fact that most were “unremarkable”, or could some of them been safely avoided without risking the patient?
■ Were any investigation or further examination missed?
■ Based on his previous history of Koch’s infection and concomitant strong family history of NIDDM, did he merit more aggressive treatment with antibiotics?
■ Was there any delay in referring the patient to a diabetologist, particularly in view of the fact that he had such a strong family history of NIDDM and that he was already 45 years old? Was it also alright to test him only for RBS or should Fasting Blood Sugar, Postprandial Blood Sugar and Test for Glycosylated Haemoglobin tests should additionally have been carried out before referring?
■ What do these acronyms ATT, CBC, RBS, CXR, RE/ME, and NIDDM actually mean?
■ Was the treatment plan the right one for the patient or could it have been designed better and that too just for him?
■ Could the answers to the questions above been made available while the patient was sitting in front of the doctor?
■ Was it wise to have suggested to the patient that he did not need any further follow-ups for this complaint unless any fresh problems arose?
■ What if this clinical summary needs to subsequently be read in Spanish by someone who does not know a word of English? Can this be done without any loss in meaning?
■ Based on the concept-based approach, SNOMED CT considers every clinical term to relate to a clinical concept like fever, which
– is a body temperature above reference range, and
– interprets body temperature
■ SNOMED CT is a semantically interoperable polyhierarchical subtype multi-lexical clinical terminology system that is able to deliver robust benefits to the health care services
■ Provides clinical content and expressivity for clinical documentation and reporting.
■ Used to code, retrieve, and analyze clinical data.
■ The terminology is comprised of concepts, terms and relationships with the objective of precisely representing clinical information across the entire spectrum of health care.
– This could be the very first time ever the patient has experienced such a sensation in the affected body part or it could a recurrent phenomenon
– It will have a clinical course like “gradual onset”, “cyclical”, “non-progressive”, etc.
■ Other than some clinicians who deal with pain findings either on a regular basis or often enough, it can safely be assumed that most will fail to note and consequently not capture all the details associated with pain. EHR systems using SNOMED CT can consequently help all clinicians in this regard irrespective of the care setting, specialisation or ability and experience thereby improving quality of care overall.
■ Analyse every part of a record: from history to treatment
■ Support for
– Conducting outcomes research
– Evaluating the quality and cost of care
– Designing effective treatment guidelines
■ Providing more easily accessible and complete information pertaining to the health care process (medical history, illnesses, treatments, laboratory results, etc.), thereby resulting in improved patient outcomes
■ No challenge in migrating from one version to another – it is seamless and most often an automated process
Introduction to SNOMED CT by Dr SB Bhattacharyya available at
■ http://www.amazon.com/Introduction-SNOMED-CT-S-B-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269681&sr=8-1&keywords=introduction+to+snomed+ct – hardcopy only
■ http://www.amazon.in/Introduction-SNOMED-CT-2016-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269722&sr=8-1&keywords=introduction+to+snomed+ct – hardcopy only
■ http://www.springer.com/gp/book/9789812878939 – ebook and hardcopy
■ http://link.springer.com/book/10.1007/978-981-287-895-3 – chapter-wise online access only