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.

The Costs and Benefits of SNOMED CT Implementation: An Economic Assessment Model.

As part of its investigations, the EU-funded ASSESS CT project developed an Economic Assessment Model for assessing SNOMED CT's and other terminologies' socio-economic impact in a systematic approach. Methodology and key elements of the model are presented: cost and benefit indicators for assessing deployment, and a cost-benefit analysis tool to collect, estimate, and evaluate data.

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.

Semantic Krippendorff's α for measuring inter-rater agreement in SNOMED CT coding studies.

Semantic interoperability requires consistency in use of terminologies such as SNOMED CT. Inter-rater agreement measurement can be used to quantify this consistency among terminology users. Increasingly, studies of SNOMED CT include inter-rater agreement measures. However, published studies do not consider distance between concepts when calculating the inter-rater agreement measures. In this paper we propose a semantic inter-rater agreement measure for use with SNOMED CT encoded data. A semantic Krippendorff's α measure is implemented using a path-length based difference function. The measure is tested using three different datasets. Results show that the proposed semantic measure is sensitive to seriousness of coding differences whereas a nominal measure is not. The proposed measure reflects the intuition that distance matters when comparing uses of SNOMED CT.

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.

Content analysis of physical examination templates in electronic health records using SNOMED CT.

OBJECTIVES: Most electronic health record (EHR) systems are built on proprietary information models and terminology, which makes achieving semantic interoperability a challenge. Solving interoperability problems requires well-defined standards. In contrast, the need to support clinical work practice requires a local customization of EHR systems. Consequently, contrasting goals may be evident in EHR template design because customization means that local EHR organizations can define their own templates, whereas standardization implies consensus at some level. To explore the complexity of balancing these two goals, this study analyzes the differences and similarities between templates in use today. METHODS: A similarity analysis was developed on the basis of SNOMED CT. The analysis was performed on four physical examination templates from Denmark and Sweden. The semantic relationships in SNOMED CT were used to quantify similarities and differences. Moreover, the analysis used these identified similarities to investigate the common content of a physical examination template. RESULTS: The analysis showed that there were both similarities and differences in physical examination templates, and the size of the templates varied from 18 to 49 fields. In the SNOMED CT analysis, exact matches and terminology similarities were represented in all template pairs. The number of exact matches ranged from 7 to 24. Moreover, the number of unrelated fields differed a lot from 1/18 to 22/35. Cross-country comparisons tended to have more unrelated content than within-country comparisons. On the basis of identified similarities, it was possible to define the common content of a physical examination. Nevertheless, a complete view on the physical examination required the inclusion of both exact matches and terminology similarities. CONCLUSIONS: This study revealed that a core set of items representing the physical examination templates can be generated when the analysis takes into account not only exact matches but also terminology similarities. This core set of items could be a starting point for standardization and semantic interoperability. However, both unmatched terms and terminology matched terms pose a challenge for standardization. Future work will include using local templates as a point of departure in standardization to see if local requirements can be maintained in a standardized framework.

Developing an acute-physical-examination template for a Tegional EHR system aimed at improving inexperienced physician's documentation.

It is well-established that to increase acceptance of electronic clinical documentation tools, such as electronic health record (EHR) systems, it is important to have a strong relationship between those who document the clinical encounters and those who reaps the benefit of digitalized and more structured documentation. [1] Therefore, templates for EHR systems benefit from being closely related to clinical practice with a strong focus on primarily solving clinical problems. Clinical use as a driver for structured documentation has been the focus of the acute-physical-examination template (APET) development in the North Denmark Region. The template was developed through a participatory design where precision and clarity of documentation was prioritized as well as fast registration. The resulting template has approximately 700 easy accessible input possibilities and will be evaluated in clinical practice in the first quarter of 2013.