Search is an important part of the clinical information life-cycle. Effective search must make it quick and easy for users to accurately select the relevant content for data entry. The selected Concept or Description may need to be stored in ways that represent information consistently and allow it to be processed effectively.
An EHR system must also have a user interface that makes search easy in terms of the time and effort required to find suitable Concepts to enter into the clinical record. Improving the usability of search can help increase the utility of SNOMED CT for data entry, and hence, the overall adoption of clinical systems. Increasing the utility and the added value of clinical systems depends on improving the tradeoff between time taken to code, and the quality of the coded content produced. This is true whichever terminology is chosen to be implemented 'front of house'.
Leveraging SNOMED CT advanced design and implementing it properly is specifically intended to give better leverage in this tradeoff than we could ever have on other coding systems. However, if badly implemented, SNOMED CT will make an already bad situation worse. On the other hand, a multitude of different but generally poor designs is equally dangerous. There is a minimum level of functionality that should be universal, and implementers need to be more prescriptive when designing the search functionality.
Approaches to search embedded in clinical systems need to be tailored to the way different groups of clinicians work and think. While this guide identifies useful techniques to support searching, the ways in which these are applied may need to vary to match the working practices of a clinical specialty or the priorities of a particular health provider organization.
For effective data entry, the interface needs to be designed to meet the requirements for subsequent display and retrieval. Data entered and stored in the clinical record, needs to be displayed in ways that can be easily read and understood. The data should also be retrievable to enable reporting analysis, decision support and appropriate communication to other systems and other users.