SNOMED CT: The Key to Unlocking EHR Vital Data
Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) play an important role in clinical documentation and patient care management in today's medical practice. While the front end of these systems presents a user-friendly interface for doctors to chart patient histories, order tests and make notes, the back end is supported by sophisticated coding systems like SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms).
When doctors enter patient information in the EMR, the data is often captured in a mix of free text, dropdown selections and checkboxes. In the background, SNOMED CT codes are assigned to the entered terms. This process can be either direct, where structured fields link to pre-defined SNOMED terms or assisted by Natural Language Processing (NLP) algorithms, which extract relevant terms from unstructured text and map them to SNOMED codes.
This standardized clinical terminology is embedded in EMRs/EHRs to ensure that clinical data is captured consistently and accurately, providing a unified language that enhances interoperability, analytics, and patient care quality.
So, what's behind these codes?
SNOMED CT, or the Systematized Nomenclature of Medicine - Clinical Terms, is a universal coding system used in healthcare. Think of it as a giant dictionary that healthcare providers use to describe everything from diseases, symptoms, treatments and surgeries. One of the most powerful tools that will change how you document patient information in your electronic health records.
Instead of using long, complicated medical terms, each medical concept (eg: "diabetes" or "fever") is assigned a unique code in SNOMED. Here's a simple breakdown of how SNOMED codes are created and the logical structure behind them.
1.Concepts: The Building Blocks
In SNOMED, each concept represents something in healthcare - a disease, symptom, procedure or body part.
Example: "diabetes" is a concept, "fever" and "blood test" are all also concepts. Each of these concepts will be assigned an unique identifier called the SNOMED code.
2.Hierarchical Structure
SNOMED CT organizes the concepts into a hierarchy, with more general concepts higher the hierarchy and more specific ones are found lower. This structure makes it easy to find related conditions or terms.
3.Association Among Concepts
SNOMED CT doesn’t just organize concepts based on hierarchy. It also connects them using relationships. These relationships help describe complex medical scenarios accurately.
4.Unique Codes
Each SNOMED code is inherently tied to a single concept. The numbers are not meaningful on their own like other coding systems (eg: ICD-10 codes, where the digits tell you about the disease category). Instead, SNOMED uses the concepts, relationships and hierarchy to give the codes medical meaning.
SNOMED CT is maintained by SNOMED International, a global organization that ensures the system is up-to-date and relevant worldwide. This helps ensure that no matter where a patient is, their medical data is understandable by doctors across different countries. SNOMED is constantly updated as new medical knowledge is discovered. New concepts (like new diseases or treatments) are added to the system.
For example : The SNOMED concept for Gestational Diabetes Mellitus is shown below
Key advantages SNOMED CT powered EMR/EHR include,
Using coded databases by Incorporating SNOMED CT into EHRs enhances clinical documentation quality, empowers clinicians to save time, improve patient care and stay up-to-date with medical advancements.
