title: Using SNOMED CT codes for coding information in electronic health records for stroke patients.
abstract: For a project on development of an Electronic Health Record (EHR) for stroke patients, medical information was organised in care information models (templates). All (medical) concepts in these templates need a unique code to make electronic information exchange between different EHR systems possible. When no unique code could be found in an existing coding system, a code was made up. In the study presented in this article we describe our search for unique codes in SNOMED CT to replace the self made codes. This to enhance interoperability by using standardized codes. We wanted to know for how many of the (self made) codes we could find a SNOMED CT code. Next to that we were interested in a possible difference between templates with individual concepts and concepts being part of (scientific) scales. Results of this study were that we could find a SNOMED CT code for 58% of the concepts. When we look at the concepts with a self made code, 54.9% of these codes could be replaced with a SNOMED CT code. A difference could be detected between templates with individual concepts and templates that represent a scientific scale or measurement instrument. For 68% of the individual concepts a SNOMED CT could be found. However, for the scientific scales only 26% of the concepts could get a SNOMED CT code. Although the percentage of SNOMED CT codes found is lower than expected, we still think SNOMED CT could be a useful coding system for the concepts necessary for the continuity of care for stroke patients, and the inclusion in Electronic Health Records. Partly this is due to the fact that SNOMED CT has the option to request unique codes for new concepts, and is currently working on scale representation.
authors.affiliation: Acquest, Koudekerk aan den Rijn, the Netherlands. acquest@acquest.nl
authors.forename: Judith
authors.initials: J
authors.lastname: van der Kooij
authors.forename: William T F
authors.initials: WT
authors.lastname: Goossen
authors.forename: Anneke T M
authors.initials: AT
authors.lastname: Goossen-Baremans
authors.forename: Marinka
authors.initials: M
authors.lastname: de Jong-Fintelman
authors.forename: Lisanne
authors.initials: L
authors.lastname: van Beek
mesh_terms: D005568:Forms and Records Control / Q000145:classification*; D006801:Humans; D016347:Medical Records Systems, Computerized; D009426:Netherlands; D020521:Stroke / Q000628:therapy*; D039061:Systematized Nomenclature of Medicine