Representing Cardiovascular Concepts in an Electronic Health Record Using SNOMED CT®

The University of Kansas School Of Nursing implemented an electronic health record (EHR) as a teaching/learning strategy to provide students the opportunity to learn about EHRs, standardized terminology, clinical information, and critical thinking. Patient assessments, the first EHR function developed, required using a standardized concept-based terminology. This type of terminology provides a common language that enables a consistent way of capturing, sharing, and aggregating health data across specialties and sites of care. It supports searching patient information, triggering decision support, measuring outcomes, and exchanging information. SNOMED CT® (SCT) was selected as the terminology of choice since it contains over 366,000 health care concepts with unique meanings and formal logic-based definitions organized into hierarchies. SCT provides 993,000 unique descriptions and 1.46 million semantic relationships. Theses descriptions and relationships enable reliability and consistency of data retrieval.