The NHS phased transition to SNOMED CT began earlier this month, marking the beginning of a new coding regime, which will facilitate the seamless exchange of coded documents. A standardised vocabulary of clinical terminology intended to be used in Electronic Patient Records (EPR), SNOMED CT contains in excess of 300,000 medical terms that can then be easily recognised across different hospitals, practices, and even countries.
According to the official SNOMED website it is, “the most comprehensive, multilingual healthcare terminology in the world [and] is already used in more than fifty countries… SNOMED CT can be used to represent clinically relevant information consistently, reliably and comprehensively as an integral part of producing electronic health information.”
In practical terms, the rollout of SNOMED – or Systematised Nomenclature of Medicine – Clinical Terms – will help NHS practices and hospitals to capture patient records with greater depth and accuracy. The replacement of three existing medical vocabularies with a single coding system will also reduce any possible confusions that may occur and thus improve patient care, particularly when transferring patients.
SNOMED CT also presents an opportunity to analyse big data in healthcare, with the standardisation of coding making it easier to identify trends and draw conclusions at both local and national levels.
However, what are the challenges that lie ahead during the implementation?
SNOMED CT – Opportunities and issues
As clinical coding becomes standardised across the NHS, there is a clear opportunity for medical professionals at all levels to reduce errors and create richer electronic patient records. But in order to do so, it is vital to use complimentary medical coding products that will make it possible to get the best out of the new system for coding in healthcare.
A Guardian article about the work of a clinical coder reveals a potential seam for problems, even with new coding: “This time, poor handwriting and conflicting accounts by clinicians make it difficult to determine whether my patient has a malfunctioning tracheostomy or if it’s her artificial voice box playing up.”
While errors of this sort can be reduced by the digitisation of patient records, how those records are created in digital form is important. For example, if practice GPs dictate these notes to be typed up by secretaries, errors can still occur, with terms being misheard or otherwise recorded erroneously. Medical professionals typing up patient notes themselves meanwhile can also produce errors, as well as taking additional time that could be spent treating patients.
Digital dictation – The key to accurate clinical coding
Medical transcription software such as Dragon Medical provides a solution to the problem of inaccurate coding, as well as saving time and resources. Direct voice-to-text dictation with accuracy levels of 99%+ ensures that what is said is what is recorded. As Dragon Medical solutions can be setup to record direct to the EPR, substantial amounts of time can be saved, whether in non-medical staff hours spent typing or time spent by GPs typing the patient notes themselves.
Dragon Medical solutions can work in tandem with SNOMED CT to revolutionise clinical coding and the EPR. While SNOMED provides the common language with which to describe and categorise patients sessions, Dragon Medical solutions provide the direct intuitive interface and accuracy to enable medical professionals to create rich and detailed narratives.
In short, use of medical transcription software can help improve the integrity and depth of clinical coding and patient notes, by providing clinicians with the means to transform their own voice into accurate digital notes.