Relieving the electronic health records headache

Inaccurate or missing data in patient records has resulted in people being hospitalised unnecessarily and wastage of an estimated 25 per cent of clinicians’ time spent collecting patient data.

As part of the Federal Government’s e-health initiatives, the National E-Health Transition Authority (NEHTA) is implementing an internationally agreed standard for the dictionary of clinical terms used in electronic health records software, called SNOMED CT.

CSIRO E-Health Theme Leader, Dr David Hansen, said that while SNOMED CT has been customised for Australia, health practitioners are still encountering problems with the system.

“Existing electronic systems do not necessarily use the same terms as the SNOMED CT dictionary. Our software, known as Snapper, helps to translate terms in the existing system to terms which are in SNOMED CT.”

To make SNOMED CT easier to use, NEHTA is incorporating CSIRO software in its infrastructure.

Dr Hansen said an example of how computer systems would use SNOMED CT is if someone arriving in an emergency department with a leg injury who, after being x-rayed, is told they have a fracture of the tibia. In this case the initial presenting problem, “leg injury”” is recorded with the more specific diagnosis “facture of the tibia”.

CSIRO’s Snapper software enables the information captured in say, emergency department computer systems, to be understood by the computer systems used for hospital in-patients, and again by GP’s computer systems once the patient has been discharged.

“Our software helps computer systems to ‘talk’ the same language, as well as to check for known complications related to that diagnosis.”

Another software tool, Snorocket, has already been adopted by the international standards organisation that maintains SNOMED CT for use in expanding the terminology.

Both were developed by the Australian e-Health Research Centre – a joint venture between CSIRO and the Queensland Government.