In the years since Obama became president, the words ‘electronic health care records’ have been uttered and written many times. Usually they have been used in a positive context, as a factor capable of reducing health care cost and improving efficiency. It’s hard to find anyone who want to retain handwritten paper medical records, and the poor legibility and consequential medical errors that come with it. Among other benefits, electronic health records help standardize forms and terminology; they facilitate data input as well as the collection, analysis and application of such data for the benefit of the individual patient (treatment) and the patient population (clinical studies).
The last years have shown an acceleration in the development of a powerful new tool in establishing uniformity in electronic health records. Enter SNOMED CT (Systematized Nomenclature of Medicine — Clinical Terms), a systematically organized computer-processable collection of medical terminology that covers an impressive area of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. The goal of SNOMED CT is to support the development of electronic health records systems that allow for a correct retention, processing and exchange of unambiguous clinical records. There is a need to exchange clinical information consistently between health care providers, care settings and researchers and because medical information is recorded differently from place to place (on paper or electronically), a comprehensive, unified medical terminology system is needed as part of the information infrastructure.
Clinicians and organizations use different clinical terms that mean the same thing. For example, the terms heart attack, myocardial infarction, and MI may mean the same thing to a cardiologist, but to a computer, they are all different. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world and it allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research.
Each year, avoidable deaths and injuries occur because of poor communication between healthcare practitioners. The delivery of a standard clinical language for use across the world’s health information systems can therefore be a significant step towards improving the quality and safety of healthcare. SNOMED CT aims to improve patient care through the development of systems to accurately record health care encounters. Ultimately, patients will benefit from the use of SNOMED CT, for building and facilitating communication and interoperability in electronic health data exchange.