Gain Data Driven Insights with Effective Clinical Coding
Globally health professionals work hard to provide high quality care to a growing population with an ever-wider range of health needs. To support healthcare providers in the delivery of these critical care services should be robust systems and platforms. The use of an Electronic Health Record (EHR) was once a significant step forward, not only did this improve communication between clinical teams, but it also increased the availability of patient information.
Many NHS Trusts are now rapidly transitioning to deliver integrated methods of patient care records, through existing document management systems or electronic patient record platforms. This information should be consistent and transferable across all healthcare settings where a patient may be treated. By standardising the language and method of communication between healthcare professionals and platforms, it is hugely important from a patient safety point of view as it negates any problems in translating the actual diagnosis.
Personalised Health and Care 2020: A Framework for Action indicated that secondary care, acute care, mental health, community systems, dentistry and other systems used in direct patient care must use SNOMED CT as the clinical terminology, by 1st April 2020. SNOMED CT was implemented across primary care in England and began to be deployed to GP practices in a phased approach from April 2018. The systems used by GP service providers were required to adopt SNOMED CT which must be used in place of Read Codes as specified by NHS - https://www.england.nhs.uk/digitaltechnology/digital-primary-care/snomed-ct/
There are other systems that can be used by healthcare institutions, the most commonly known being ICD-10; such systems group together similar diseases and procedures, structuring related entities for easy retrieval. As “output” systems they are not intended or designed for the primary documentation of clinical care. SNOMED-CT is classified as a Reference System and is designed as an “input” mechanism, coding the clinical information captured in an EHR during the course of patient care - Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems.
SNOMED CT gives clinical IT systems a single shared language, making the exchange of information between systems easier, safer and more accurate. SNOMED CT was selected as the main clinical terminology of choice as it contains all the clinical terms needed for the whole NHS, from procedures and symptoms through to clinical measurements, diagnoses and medications allowing a more comprehensive and accurate way of collecting patient data. This is now increasingly being used to link clinical knowledge and contributes to the quality, consistency and safety of healthcare delivery.
There are many perceived benefits of using a unified language across healthcare systems, some of these have been mentioned above. Additional benefits of using a universal language such as SNOMED CT include:
Reporting and Business Intelligence
Enabling accurate access to relevant information, reducing costly duplication's and errors
Enabling links between clinical records and clinical guidelines
Removing language barriers – SNOMED CT enables multilingual use
Enhancing audits of care delivery with options for detailed analysis of clinical records to investigate outliers and exceptions
SNOMED CT allows clinical data to be recorded in a human recognisable way and a computer ‘recognisable’ way and supports efficient coding of information. This paves the way for making the most of Big Data and development of AI algorithms supporting and provisioning for service improvement initiatives.
All Pathpoint platforms are engineered and built upon SNOMED CT coding, allowing systems to communicate effectively with one another in a universal language, enhancing patient care and delivering true interoperability. For more information about how we adopted SNOMED CT into all our solutions email info@openmedical.co.uk.