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NHS introduces common vocabulary for electronic records

NHS introduces common vocabulary for electronic records

A scheme is underway to introduce a single vocabulary of SNOMED Clinical Terms for patient records to help drive primary care efficiencies and improve patient care.

According to the National Information Board (NIB), the new terminology will enable diagnoses, symptoms, drugs and medical devices to be captured on records in a “clear, unambiguous and consistent way”.

It is critical, NHS Digital says, that all health and care providers use the same electronic dictionary for electronic records as the healthcare system strives to become ‘paperless’.

The initiative will potentially save thousands of hours of effort and millions of pounds, says NHS Digital.

The terminology will replace ‘Read Codes’, which are due to be phased out by April 2018.

By the end of next month, partners will be actively collaborating to ensure that all primary care systems adopt SNOMED CT, according to the NIB report ‘Personalised Health and Care 202: A Framework for Action’.

notice under the Health and Social Care Act has been added declaring that the input vocabulary 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, etc. must change to using 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.”

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.

“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.”