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- Use SNOMED CT for searching, display, storage, communication, knowledge linkage, querying and analytics in the following clinical domains (or specific data elements)
- Problems, Diagnosis and Clinical Findings
- Reason for Admission
- Procedures (e.g. Planned Procedures, Performed Procedures)
- Allergies
- Support searching for SNOMED CT concepts using any term that is preferred or acceptable in the national language reference set.
- The vendor shall include one of the following options for each SNOMED CT coded data element (depending on user preferences and local requirements for standardization of interface terms):
- Upon selection of a concept, use the term entered by the user to display the selected concept; OR
- Upon selection of a concept, use the preferred term from the national language reference set) to display the selected concept; OR
- Upon selection of a concept, use the preferred term from the regional or institution specific language reference set to display the selected concept.
- The vendor shall allow searching and selection of only those concepts from the SNOMED CT subset that has been specifically bound to that data element.
- The vendor shall display the most frequently selected concepts at the top of the list, for elements bound to a subset containing more than 20 concepts.
- As the user types each character into a SNOMED CT coded data element, limit the selection of concepts to those with a preferred or acceptable term that matches the characters types (using a ‘word prefix any order’ algorithm), and use auto-complete when only one option is available for selection.
- When displaying the list of possible matches, display the concept with the shortest matching term first.
- For each free text data element that records clinical information (e.g. Past history, Clinical notes) use SNOMED CT-enabled techniques (e.g. Natural Language Processing) to suggest possible SNOMED CT encoding (including appropriate contextual information), for selection and confirmation by the user.
- Support the capture of SNOMED CT post-coordinated expressions using predefined expression templates and automatically-generated interface terms – for laterality, allergies and family history.
- Use SNOMED CT concept identifiers stored in the EHR to suggest patient-specific clinical knowledge to the clinician, and to test clinical decision support rules.
- Use SNOMED CT codes stored in the EHR, together with SNOMED CT and other map-enabled coding systems (e.g. SNOMED to ICD-10) to suggest appropriate codes for the clinician to select (if required).
- The system shall be sufficiently performant to return the first (X) results in a given time period (e.g. less than 1s).
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