title: SNOMED CT implementation: implications of choosing clinical findings or observable entities.
abstract: Internationally, it is a priority to develop and implement semantically interoperable health information systems.[1] One required technology is the use of standardised clinical terminologies. The terminology, SNOMED CT, has shown superior coverage compared to other terminologies in multiple clinical fields. The aim of this paper is to analyse SNOMED CT implementation in an Electronic Health Record (EHR). More specifically, differences and consequences of applying clinical findings (CFs) as an alternative to observable entities (OEs) is analysed. Results show that CFs represents the content of the templates with better coverage, with more parent concepts and with a higher degree of fully defined terms than the OEs. We discuss the possibility to further evaluate the observable entity hierarchy to overcome a potential overlapping use of the two hierarchies.
authors: Department of Health Science and Technology, Medical Informatics, Aalborg University, Denmark. arra@hst.aau.dk
authors: Anne Randorff
authors: AR
authors: Rasmussen
authors: Kirstine
authors: K
authors: Rosenbeck
mesh_terms: D000465:Algorithms; D057286:Electronic Health Records; D005568:Forms and Records Control / Q000145:classification*; D006801:Humans; D008490:Medical Informatics / Q000379:methods*; D015233:Models, Statistical; D009730:Nursing Assessment; D012660:Semantics; D012984:Software; D039061:Systematized Nomenclature of Medicine; D009626:Terminology as Topic; D014584:User-Computer Interface; D018875:Vocabulary, Controlled