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Clinical audit seeks to improve patient care and outcomes through systematic review of care against defined standards and the implementation of change. It informs care providers and patients where their healthcare services are doing well and where there could be improvements. The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made.

Clinical audits can be performed in primary care facilities, individual clinics, hospitals, enterprises or jurisdictions. Audit can have major beneficial impacts in ensuring the consistent delivery of quality healthcare. The questions asked in audit are often chosen pragmatically according to local data collection practices. For example

  • What proportion of patients invited to attend cervical screening did so?
  • How many patents with ischemic heart disease are receiving appropriate drug treatments?
  • Are all patients with diabetes mellitus reviewed within a stated time interval?

Current audit schemes use a combination of reporting against the classifications or questions specifically collected for audit purposes. SNOMED CT will facilitate an increase in such audits being able to collect some of the data by extracting data from the patient record thus reducing the additional burden of collection; it will also enable more a more accurate picture from say tertiary centers where some of their procedures may fall into the NOS or NEC classification and provide an unrepresentative comparison with other centers when the procedures are complex and innovative/new.

SNOMED CT is well suited to service the ad hoc requirements that emerge in clinical audit questions, using the techniques described in section 6 SNOMED CT Analytic Techniques. Using the SNOMED CT codes recorded during care delivery can reduce the additional burden of data collection specifically for audit purposes. SNOMED CT may also facilitate more accurate audit results than classifications, by distinguishing between distinct concepts (e.g. clinical findings or procedures) which may fall into the 'Not Otherwise Specified' or 'Not Elsewhere Classified' categories in these classifications.

A number of vendor products, such as Cerner's PowerInsight® Data Warehouse (case study 12.2.7 Cerner), are able to support clinical audit using SNOMED CT enabled analytics tools.



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