SNOMED CT implementation: implications of choosing clinical findings or observable entities.

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.

Balancing centralised and decentralised EHR approaches to manage standardisation.

Balancing regional and national electronic health record (EHR) approaches requires cooperation between clinical and technical experts at different organisational levels. Bridging is necessary to achieve interoperability between regional EHR systems, without neglecting the clinical usefulness. This study has investigated the approaches chosen in modelling the clinical content of EHRs in two out of five regions in Denmark. Based on the knowledge obtained in these studies a 'clinical content format' was developed to facilitate the work of the regions, where the clinical content of EHR systems is modelled. The objective of the clinical content format is to enable share and reuse across organisations, furthermore an objective is to gradually introduce standards. The results of the first iteration of a 'clinical content format' are presented and future adjustments are discussed based on the results.