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Electronic Patient Records

SNOMED-CT and Project E-vitaTM Medical Records

Introduction

Project E-vitaTM utilises the power of SNOMED-CT for encoding information in its Electronic medical / patient records. All data in Project E-vitaTM is stored using SNOMED-CT structures making data interchange with other systems using technologies like HL7 easier to accomplish. In addition to using picklists, the system also leverages high speed search algorithms enabling the user to search the clinical terminology in the background while the physician refines their search in the foreground. Saving you time while coding.

Over and above free text consultation data, each and every clinical / medical encounter recorded against a patients record can have optional clinical coding attached from either SNOMED-CT, Diagnostic terms from ICD-10 / ICD-9 and also from procedure terminologies like OPCS-4 or CPT for instance.

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What is SNOMED-CT?

SNOMED Clinical Terms (SNOMED CT) is a dynamic, scientifically validated clinical health care terminology and infrastructure that makes health care knowledge more usable and accessible. The SNOMED CT Core terminology provides a common language that enables a consistent way of capturing, sharing and aggregating health data across specialties, sites of care and International boundaries.

The SNOMED CT Core terminology contains over 364,400 health care concepts with unique meanings organized into hierarchies. The fully populated table with unique descriptions for each concept contains more than 984,000 descriptions. Over 1.5 million semantic relationships exist to enable reliability and consistency of data retrieval. Project E-vitaTM can be loaded with any language version of SNOMED-CT. German, French, Portuguese and Spanish variants are all under development or already available from the IHTSDO.

SNOMED-CT is a result of extensive collaboration between two worldwide leaders in clinical terminology: SNOMED® International, a division of the College of American Pathologists (CAP), and the United Kingdom’s National Health Service (NHS). Drawing on many years of combined research, development and health care leadership, SNOMED CT merges the content and structure of the CAP’s SNOMED Reference Terminology® (SNOMED RT®) Version 1.0 with the NHS’ Clinical Terms Version 3 (Read Codes). It builds on the experience of SNOMED users in over 40 countries. From May 2007 the Intellectual Property Rights for SNOMED-CT were transferred to the IHTSDO, an international “Not for profit” governing body based in Denmark.