Using snomed CT to develop an electronic health record system for surgery department : a case study of the university teaching hospital Zambia

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Leza, Danny
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The University of Zambia
The University Teaching Hospital is an integral national referral Hospital made up of eight departments. Systems interoperability is key for successful flow of patient information from one department to another and from section to section within a department. In this study, the Systemized Nomenclature of Medicine-Clinical Terms (SNOMED CT) is proposed to develop an Electronic Health Record System for the Surgery Department at UTH. SNOMED CT is widely recognized as the leading global clinical terminology standard which is used to develop interoperable Electronic Health Records (E.H.R). Lack of a SNOMED CT E.H.R System in surgery departments causes inefficient scheduling of surgical procedures, insufficient and inaccu-rate pertinent patient historical information, misconceptions and error arising from ambiguities in terminol-ogy usage. The result is unhealthy clinician working environment leading to high death rates among patients. The Study aim at examining the patient record system being used at UTH and its drawbacks. Further the study sort to model and develop a prototype as a solution to the challenges. Baseline survey in which inter-views, questionnaires and record inspection were used to give a full picture of the situation on the ground. Convenient sampling was used with a sample size of 40. The data from the questionnaires were analyzed using a statistical package called SPSS. The results from the Quantitative data analysis, Interviews and Rec-ord inspection were used to come with the requirements for the design of the SNOMED CT E.H.R Model. The SNOMED CT Model was designed using Traditional Systems Development Life Cycle with prototyp-ing. Further Universal Modelling Language and User Case Diagrams were used to model the Objects and User Interactions. The SNOMED CT prototype was developed using Java and MySQL for the Database. Baseline Survey Reviewed that out of 40 respondents 72.5% had computers in their section 27.5% did not have, 60% were using Paper Records and Microsoft Excel, 37.5% were using Paper Based Records, 2.5% were using electronic record system. Further, more than 50% of the medical practitioner ranging from nurses to surgeon were dissatisfied with the manual paper based system. In addition, Records Inspected showed that paper based system had redundancy. Records of patients are destroyed every after ten to fifteen years in order to create space for new ones. The Model as a solution was designed incorporating Snomed CT as a Sematic Standard to aid interoperability. A prototype was developed in which a link to Snomed CT International Browser was embedded and an offline version of Snomed was added using a system called Clinic Clue Xplore. Prototype is able to capture patient details, scheduled patients for surgery, capture pre-surgery details and enter post-surgery details. All diagnosis and prescription have a Snomed CT concept ID and its descrip-tion. It is recommended that further development be done to interconnect the prototype to other systems in the department. Key Words: Electronic Health Records, Snomed CT, Interoperability, Paper Based Records, Stand-ardization.
Snomed CT. , Electronic Health Records. , Medical records systems--Computerized. , Medical records--Data processing.