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Published on: January 15, 2017
Using SNOMED CT codes for coding information in electronic health records for stroke patients
Judith van der Kooij1, William T F Goossen, Anneke T M Goossen-Baremans
1Acquest, Koudekerk aan den Rijn, the Netherlands. acquest@acquest.nl
Studies in Health Technology and Informatics
|November 17, 2006
Summary
Researchers sought SNOMED CT codes to replace self-made codes in Electronic Health Records for stroke patients. While 58% of concepts found a match, individual concepts were more successful (68%) than scientific scales (26%).
Area of Science:
- Health Informatics
- Medical Terminology
- Clinical Documentation
Background:
- Electronic Health Records (EHRs) require standardized codes for interoperability.
- Stroke patient care information is organized in templates, often necessitating unique concept codes.
- Existing coding systems may lack codes for specific medical concepts, leading to self-made codes.
Purpose of the Study:
- To identify SNOMED CT codes to replace self-made codes in stroke patient EHR templates.
- To assess the feasibility of using SNOMED CT for enhanced interoperability in stroke care.
- To investigate differences in SNOMED CT code availability between individual concepts and scientific scales.
Main Methods:
- Systematic search for SNOMED CT codes corresponding to self-made codes within stroke patient EHR templates.
- Comparison of SNOMED CT code replacement rates for individual concepts versus concepts within scientific scales.
- Analysis of the percentage of self-made codes successfully replaced by SNOMED CT codes.
Main Results:
- A SNOMED CT code was found for 58% of all concepts evaluated.
- 54.9% of self-made codes could be replaced with SNOMED CT codes.
- SNOMED CT code availability differed significantly: 68% for individual concepts versus 26% for scientific scales.
Conclusions:
- SNOMED CT offers potential for coding stroke patient EHR data, improving continuity of care and interoperability.
- Despite lower-than-expected replacement rates, SNOMED CT's ability to request new codes and represent scales is advantageous.
- Further development and utilization of SNOMED CT are recommended for standardized stroke EHRs.
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