CHU St Pierre

EMEA

Electronic health record

SNOMED CT terminology will be used for the capture of medical information (diseases, procedures, complaints,..) in our EHR in structured fields as well as in free text (through a parsing application).

Further reuse of these SNOMED CT “smart” medical data will then be implemented along the following axes: Location: Rue Haute 322, Brussels, Belgium

communication of medical information with other hospitals
(semi-)automated coding of health data for fulfillment of national registration obligations
creation of automatic medical alerts (allergies, drug interactions,..) and suggestions of clinical pathways “as-you type”
linkage to knowledge databases
health statistics for quality control and epidemiological surveillance inside the institution and beyond

Description

These developments form part of a larger initiative regrouping Belgian hospitals and software vendors who wish to promote implementation of the SNOMED CT terminology in their EHRs.

For more information about this Consortium, please visit the CSCT website at http://www.csct.be.

Scope

SNOMED CT will be used to capture the clinical meaning at the point of care either through structured fields or after parsing and recognition of medial expressions in free text zones. The primary targets will be the discharge summary, problem list and allergies. Language refsets will be used, both for capture and display, as we are a French/Dutch speaking country. The data will be captured both with pre-coordinated concepts and if needed with post-coordinated expressions.

Creation of local SNOMED CT content (namely for scales) is planned. SNOMED CT driven queries will be run against the data to provide the expected "smart" functionalities: alerts, propositions of clinical pathways, etc.

How SNOMED CT will be used

SNOMED CT was selected because it has the broadest medical terminology coverage, allows for creation of medical expressions that can be understood by a machine through post-coordination and its defined grammar) and because SNOMED CT was the terminology chosen in the Belgian e-Health roadmap.