Evidence map›Paper›PMID 34817387›Full record

ArticleJMIR medical informatics2021

Introduction of Systematized Nomenclature of Medicine-Clinical Terms Coding Into an Electronic Health Record and Evaluation of its Impact: Qualitative and Quantitative Study.

Tanya Pankhurst, Felicity Evison, Jolene Atia, Suzy Gallier, Jamie Coleman, Simon Ball, Deborah McKee, Steven Ryan, Ruth Black

Open access · goldAbstract read
In one paragraph

Article in JMIR medical informatics, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.

0numbers the graph read from it
0cells of the map it votes in
2citing papers in PubMed
1.6field-weighted citation impact, top 12% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

2 citing papers in PubMed, 8 citations in OpenAlex.

  1. Observational
  2. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

9 authors at 2 institutions in 1 country.

Tanya PankhurstNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0002-8341-668X
Felicity EvisonNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0002-9378-7548
Jolene AtiaNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0001-7569-2599
Suzy GallierNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0003-1026-4125
Jamie ColemanNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0002-7512-5153
Simon BallNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0001-7410-5268
Deborah McKeeNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0001-6822-8464
Steven RyanNHS Foundation Trust, University Hospitals Birmingham, Birmingham, United Kingdom.ORCID https://orcid.org/0000-0001-8679-7353
Ruth BlackInstitute for Global Health Innovation (IGHI), Imperial College London, London, United Kingdom.ORCID https://orcid.org/0000-0002-2440-7169
University Hospitals Birmingham NHS Foundation Trust · GBImperial College London · GB

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundThis study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations.

objectiveThe aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable remodeling of medical pathways.

methodsThe study used qualitative and quantitative data to understand the successes and gaps in the project, clinician attitudes toward the new tool, and the future use of the tool.

resultsThe new coding system (tool) was well received and immediately widely used in all specialties. This resulted in increased, accurate, and clinically relevant data collection. Clinicians appreciated the increased depth and detail of the new coding, welcomed the potential for both data sharing and research, and provided extensive feedback for further development.

conclusionsSuccessful implementation of the new system aligned the University Hospitals Birmingham NHS Foundation Trust with national strategy and can be used as a blueprint for similar projects in other health care settings.

Indexed as

clinical decision supportclinical usabilityClinician led designclinician reported experiencecoding standardsdata sharingdiagnoseselectronic health recordselectronic health record standardshealth data exchangehealth data researchInternational Classification of Diseases version 10 (ICD-10)National Health Service Blueprintpatient diagnosespopulation healthproblem listresearchSystematized Nomenclature Of Medicine–Clinical Terms (SNOMED-CT)use of electronic health datauser-led design

Identifiers

PMID34817387
PMCPMC8663536
OpenAlexW3216171962

What OpenQuestion holds

Textmetadata
LicenceCC BY
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Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.