Balancing centralised and decentralised EHR approaches to manage standardisation.

Balancing regional and national electronic health record (EHR) approaches requires cooperation between clinical and technical experts at different organisational levels. Bridging is necessary to achieve interoperability between regional EHR systems, without neglecting the clinical usefulness. This study has investigated the approaches chosen in modelling the clinical content of EHRs in two out of five regions in Denmark. Based on the knowledge obtained in these studies a 'clinical content format' was developed to facilitate the work of the regions, where the clinical content of EHR systems is modelled. The objective of the clinical content format is to enable share and reuse across organisations, furthermore an objective is to gradually introduce standards. The results of the first iteration of a 'clinical content format' are presented and future adjustments are discussed based on the results.

SNOMED CT as Reference Terminology in the Danish National Home Care Documentation Standard.

In Danish home care, multiple professions deliver services to citizens. FSIII is a national home care documentation standard, where one of the goals is to share documentation to improve coordination between these professional groups and avoid double documentation. The aim of this study was to develop a SNOMED-CT based navigation hierarchy to ensure that professions could preserve their documentation practice, to help avoid double documentation, and to ensure that the technical implementation did not require sophisticated semantic tools. The method involved mapping of non-SNOMED-CT content to SNOMED CT, visualization of merged graphs, identification of reference concepts, relating reference concepts to the documentation models of each profession, and representation of the navigation hierarchy in a reference set. The navigation hierarchy ensures that citizen conditions appear in a relevant context, regardless of which profession entered the data. Our approach paves the way for incremental standardization projects, where an implementation artefact, such as the navigation hierarchy, highlights the semantic features of SNOMED CT that can be used to reach specific business goals; in this case, sharing data across professional groups.

Terminology-Based Recording of Clinical Data for Multiple Purposes Within Oncology.

INTRODUCTION: Collecting clinical data once for the use in both electronic health record (EHR) and registries requires semantic interoperability. This paper presents the results of a systematic semantic analysis of similarities and differences in clinical documentation across regional EHR and a national oncology registry to assess options for an integration of recording templates. METHODS: A comparison of current clinical information in EHR and the national registry was carried out, using SNOMED CT as frame of reference to find exact-, similar- and non-match. RESULTS: Exact match was found for 9 out of 19 items from the registry and EHR, relating to clinical history, observations and findings at the examination and tumor control. Similar match concerned clinical findings of more common side effects to therapy whether present or absent. Both EHR and the registry had information with no compared match. CONCLUSION: Clinical documentation during a follow-up in head and neck cancer contains a core set of items recorded in both EHR and registry, representing clinical history, observations and more common side effects and tumor evaluation. These core items could be the point of departure for integration or re-design of EHR-systems.

Applying the SNOMED CT Concept Model to Represent Value Sets for Head and Neck Cancer Documentation.

This paper presents an analysis of the extent to which SNOMED CT is suitable for representing data within the domain of head and neck cancer. In this analysis we assess whether the concept model of SNOMED CT comply with the documentation needed within this clinical domain. Attributes from the follow-up template of the clinical quality registry for Danish Head and Neck Cancer, and their respective value sets were mapped to SNOMED CT using existing mapping guidelines. Results show that post-coordination is important to represent specific types of value sets, such as absence of findings and severities. The concept model of SNOMED CT was found suitable for representing the value sets of this material. We argue for the development of further mapping guidelines for consistent post-coordination and for initiatives that demonstrate use of this important terminological feature in actual SNOMED CT implementations.

Re-use of SNOMED CT subset in development of the Danish national standard for home care nursing problems.

SNOMED CT was chosen as reference terminology for standardisation of homecare nursing documentation to make reporting comparable across the 98 Danish municipalities. The method outlined in this paper for developing a Danish national homecare nursing SNOMED CT subsets is a pragmatic approach to build new SNOMED CT subsets drawing on existing and available SNOMED CT subsets. Combining this approach with awareness of hierarchical coherency in SNOMED CT subsets makes effective retrieval of data possible.

E-health stakeholders experiences with clinical modelling and standardizations.

Stakeholders in e-health such as governance officials, health IT-implementers and vendors have to co-operate to achieve the goal of a future-proof interoperable e-health infrastructure. Co-operation requires knowledge on the responsibility and competences of stakeholder groups. To increase awareness on clinical modeling and standardization we conducted a workshop for Danish and a few Norwegian e-health stakeholders' and made them discuss their views on different aspects of clinical modeling using a theoretical model as a point of departure. Based on the model, we traced stakeholders' experiences. Our results showed there was a tendency that stakeholders were more familiar with e-health requirements than with design methods, clinical information models and clinical terminology as they are described in the scientific literature. The workshop made it possible for stakeholders to discuss their roles and expectations to each other.

SNOMED CT adoption in Denmark--why is it so hard?

What prevents the National Health Care Terminology based on SNOMED CT from being implemented in the EHR systems and ongoing EHR implementations in Denmark? SNOMED CT was translated into Danish language from 2006-2009 and by 2013 it is not yet implemented in a clinical information system. Fourteen key persons broadly representing all major stakeholders in the process of system configuration accepted an invitation to discuss questions about what kind of challenges they experience in handling terminology in clinical information systems today and what they expect from a future implementation of a SNOMED CT based national terminology. Three types of challenges of terminology implementations resulted from two parallel focus group interviews: 1. Methods to manage terminology-implementation like preventing inconsistency and redundant representations of identical information. 2. The existing terminology and classifications used are sufficient to accommodate the required governance and 3. SNOMED CT is expected to be immature for system-implementation. These results suggest further research in methods to facilitate implementation of a complex terminology and studies that evaluate SNOMED CT in clinical use; but the results also support national and regional decision makers regarding what kind of challenges they must manage.