3 November 2016: A programme of work is underway to introduce a single vocabulary for patient records to help drive primary care efficiencies and improve patient care.
SNOMED Clinical Terms (SNOMED CT) enables items such as diagnoses, symptoms, drugs and medical devices to be captured on records in a clear unambiguous and consistent way. The terminology replaces 'Read Codes', which are due to be phased out by April 2018.
As the NHS strives to embrace a 'paperless' ethos, it is critical that all providers of health and care use the same electronic dictionary for capturing this key information at the point of care.
A notice under the Health and Social Care Act has now been published outlining the implementation dates for general practices and other providers to adopt SNOMED CT.
NHS Digital is working closely with suppliers to make the transition as seamless as possible.
The use of a single consistent vocabulary supports clinical decision making and provides improved functionality for sharing vital information between care settings. SNOMED CT will remove the need for manual Read Codes input when structured electronic documents are received, which mitigates against data entry errors and drives business efficiency.
Integrating SNOMED CT in general practices will save thousands of hours of effort and potentially millions of pounds worth of clinical time each year simply by being able to directly bring items such as A&E episode information into patient records in the GP system.
Other long-term benefits include:
- improved interoperability - SNOMED CT enables data to be exchanged between IT systems in different clinical and care settings. This interoperability means that health and care data will be in a form that care sectors can share and different systems can process when appropriate - supporting the seamless care of patients even when delivered by multiple providers
- comprehensive coverage - SNOMED CT offers a greater depth of detail and content for all clinical specialities and professions
- a global voice - SNOMED CT is a multilingual solution used in over 50 countries, meaning the UK can benefit from a wider range of healthcare solutions
- modern technology - SNOMED CT has evolved based on the experience of previous terminologies while embracing the technology of today
- enhanced data analysis - SNOMED CT facilitates a range of analysis techniques to support more extensive clinical audit and research work
SNOMED CT is the only current information standard for clinical terminology and must be adopted by all GPs and systems used by general practice service providers before 1 April 2018.
Secondary Care, Acute Care, Mental Health, Community systems and other systems used in the direct management of care of an individual must then use SNOMED CT before 1 April 2020.
Beverley Bryant, Director of Digital Transformation at NHS Digital, which is leading the implementation, said:
"A common clinical language across care settings underpins a more effective and safer healthcare system, and being able to facilitate this is essential to the future plans of the NHS.
"The accurate transmission of information from GP surgeries to specialists, from nurses to doctors, and from care workers to doctors is central to good medical practice."
Arvind Madan, clinical lead for primary care at NHS England, added:
"SNOMED CT allows the electronic transmission of information between any part of the health system. The terms are easy for clinicians to use and can be just as easily understood by patients and their families.
"This transitional work will ensure a standard way of transmitting information about patients and I hope that all clinicians will accelerate the use of this terminology for the benefit of the patients we care for."
Dr Charles Gutteridge, National Clinical Director for Informatics at the Department of Health and Medical Director, Barts and the London NHS Trust added:
"Barts Health has used a SNOMED-based system for many years, and routinely within my clinics I ensure that the data on the system about a patient's health and care is complete and captured using SNOMED.
"It is highly beneficial to have access to key data about the patient quickly and in a way that is easy to find in the system. This is only made possible by key data being entered in SNOMED CT.
"We now have an integrated health record with a number of our local GP practices, and as more systems move to SNOMED CT it will enable us to transfer data safely and efficiently. This is for the benefit of both our patients and clinical staff."
Further information on SNOMED CT in primary care is available on the NHS Digital website.