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Working Toward a Shared Diagnosis Vocabulary in the U.K.

University College London Hospitals NHS Foundation Trust in the United Kingdom helped clinicians document more quickly, promoted interoperability, and improved the accuracy of research and statutory reporting by embedding a standard diagnosis vocabulary, SNOMED CT®, directly in the electronic patient record.

In the United Kingdom (U.K.), a governmental organization called NHS England is responsible for establishing a wide range of national regulatory standards related to healthcare. These standards tend to focus on operational data, such as referral-to-treatment metrics and vaccination coverage. Patient-level clinical data doesn’t yet have the same level of standardization at the secondary care level, which includes a wide range of hospital services. For example, if a patient’s diagnosis is documented at one organization using the International Classification of Diseases (ICD-10) code of Q15.9 “Congenital malformation of eye, unspecified”, a different organization using Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) diagnoses needs to map or translate that code to a value such as “Glaucoma associated with chamber angle anomaly” to be meaningful in its patient care and compliance reporting efforts. University College London Hospitals NHS Foundation Trust (UCLH) expanded on NHS England’s broad SNOMED CT® recommendations as the NHS clinical data standards by integrating SNOMED CT® in the electronic patient record (EPR) for clinicians to document patient diagnoses at the point of care.

How They Did It:

  • Improved clinicians’ diagnosis documentation workflows through adopting a shared diagnosis code set
  • Facilitated interoperability with general practitioners and health information exchanges
  • Eliminated technical overhead related to managing multiple terminologies
  • Streamlined statutory submissions to the NHS to improve compliance with national standards

Read the full article on EpicShare