Do you puzzle it together by copy/pasting info from previous letters? Or do you have one shared, jointly managed source of truth? If one common source: is it free text, or structured? If structured: do you use Snomed CT concepts? If so: do you search in all relevant hierarchies or in a managed clinical vocabulary? do you manage this in a problem list subset? do you manage your terminology inside our outside your Electronic Medical Record?
(I know, it's a lot of questions, but I'm really curious where we are with this in practice)
2 Comments
Anna Rossander
We do not have one shared common source of truth. There is a free-text based one but it is not used. In real life people repeat previous histories in current notes. It is possible to search for all ICD-codes that a person har been assigned in all of Sweden, but it is a external system and not all EHRs are connected to it, so it is not complete.
In my region we are implenting Cerners Millennium and after that we will have one common list in our region. We are looking at SCT but we are not there yet.
Jeffrey Chen
1, we use an in-house developed system to record personal and their family health history. It's stored in a structured database table which contains a few basic data elements: date/age of diagnosis, kinship, and diagnosis.
2, we use ICD-10 as the diagnosis code instead of SNOMED CT and looking to use a reference set to replace the ICD-10 code list.
3, we are not planning to use hierarchies as it is really hard for our biostatistician to do data analysis. SAS and R are their best friends.
4, yes, we do manage our own problem list as we are specialised in melanoma treatment and only record what the clinicians' interest in.
5, we are currently managing the reference set inside eMR and planning to introduce a terminology server like system to manage the terminology binding in multiple code systems.