Implementing Standard Terminologies to Share Data: SNOMED Case Studies

Cyndie Lundberg, Clinical Informatics Educator, College of American Pathologists, SNOMED Terminology Solutions and Robert H. Dolin, MD, FACP, FACMI, Kaiser Permanente, Department of Internal Medicine, Physician Lead, KP HealthConnect Convergent Medical Terminology Team. The use of standard terminology provides interoperable patient data and the ability to share data across acute care departments and other facilities. The extracted data can provide research and analysis to improve outcomes, manage costs by eliminating redundant testing, and reduce errors through alerts and reminders. In the case study organizations, SNOMED CT represents clinically relevant information consistently, reliably and comprehensively as an integral part of electronic health records. They demonstrate that: 1) Electronic health record systems that do not have a strategy to implement structured terminology lack the ability to extract interoperable data, 2) The inability to extract interoperable data does not support analysis that results in shorter length of stays, cost containment, and improved patient care outcomes, 3) Transfer of care from home care to acute care results in data loss, and 4) Lacking resources to develop and maintain encoded clinical terms undermines project viability.