The struggle to standardize clinical terminology in the UK

In the US, structured clinical terminology is integrated into most electronic health records. However, across the pond there is no standard clinical terminology that is widely being used for documentation. This means clinicians must often go directly to code sets such as ICD-10 or SNOMED®* to document clinical encounters. IMO’s Senior Vice President of Global Clinical Services, Steven Rube, MD, takes a look at the reasons for this difference in the capture of patient data from a clinical informatics perspective.

Contrary to popular belief, clinicians are not anti-technology. Quite the opposite. In fact, the medical profession has been at the forefront of many of the most outstanding technological advancements of the last century. So, why is there this misconception that “doctors hate computers”? The answer is complicated, but I believe it lies in understanding two major tenets that govern a clinician’s actions:

  1. Delivering the highest quality of care possible
  2. Delivering this care in the most efficient manner possible

Central to accomplishing these two tenets is accurate clinical documentation, which is made possible by using standardized, structured clinical terminology. The oldest of these terminology standards, the International Classification of Diseases (ICD), was originally designed to categorize the reason for a patient’s death and, later, for their disease. These groups were often broadly defined, and the titles were written in a very actuarial, or non-clinical, language. ICD was followed by the Systematized Nomenclature of Medicine, or SNOMED. This system was designed to collect and store a comprehensive index of data that was easily retrievable. Notice – the word document is not used to describe the functions of SNOMED terminology.

Medical coding terms and the UK

As the UK continues its digital transformation, SNOMED CT UK will play a more prominent role in the clinical setting.

The current guidance from the NHS is that in England, SNOMED CT must be implemented across primary care and will be deployed to GP practices in a phased approach – a process that began in April 2018. Systems used by GP service providers must:

  1. Adopt SNOMED CT
  2. Use SNOMED CT in place of Read Codes

Additionally, secondary care, acute care, mental health, community systems, dentistry, and other systems used in direct patient care must implement SNOMED CT as their clinical terminology before December 31, 2020.

As painful as the mandate may seem, decades of electronic patient record (EPR) usage in the US have shown the benefits of using standardized terminology to improve documentation accuracy. For example, when patient information is accurately and appropriately documented, the EPR has been proven to decrease medical errors due to illegibility, missed information, drug-allergy, and drug-drug interactions. Additionally, EPRs allow multiple clinicians to simultaneously access a patient record to coordinate and communicate treatment plans, thereby revolutionizing the way clinicians manage patients and deliver care.

Given the obvious clinical benefits of EPRs and accurate clinical terminology for documentation, why does a recent audit from the NHS highlight that 87% of acute trusts self-assess their digital capability – the use of digital technology to support the delivery of care, such as access for clinicians to electronic patient records – as mid or low? And, equally as stunning, why do nearly 62% of trusts self-report that they are non-compliant with SNOMED CT UK standards?1

To be certain, the reasons are both personal and functional but, as a former practicing clinician, the complexity of and lack of familiarity with the SNOMED CT system should be investigated and considered as a root cause of limited adoption. In fact, in a recent HIMSS study, 51% of respondents agreed that documenting patient conditions with SNOMED CT is time consuming. Another 35% stated that SNOMED CT UK terminology is too complex. And, the most alarming insight, 20% of respondents stated that SNOMED CT has very or somewhat negatively impacted clinician satisfaction.2 The topline view of these insights casts a negative shadow on SNOMED CT, which is unfair. Without a doubt, it is a great tool; however, we clinicians and administrators should consider it closely and question if it is the best tool for clinical documentation.

There is no doubt of the significant role that reference terminologies like SNOMED CT play with regard to analytics and reporting in the UK. Clinical interface terminologies such as those provided by IMO can assist clinicians in getting to the best and most complete SNOMED codes via accurate clinical documentation.

To learn how IMO can help your organisation, click here.

1 National Audit Office, Department of Health & Social Care, NHS England. Digital Transformation in the NHS. 15 May 2020. Accessed via

2 HIMSS. September 2020. SNOMED CT UK Terminology: Adoptions and Perceptions. Chicago.

* SNOMED and SNOMED CT are registered trademarks of SNOMED International

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