Data entry needs to be easy in terms both of the time and effort required to record the information needed, but also easy in the way it fits in with working practices.
User interfaces should make it easy to enter data that includes SNOMED CT where this is required to enable effective retrieval and reuse. Hence, data capture is only worthwhile if the data captured can be usefully reused, and therefore data capture needs to be designed to meet requirements for subsequent retrieval.
SNOMED CT encoded data should be rendered in ways that are easily read and understood as part of the clinical record. Approaches to data entry therefore need to be tailored to the way different groups of clinicians work and think. On the one hand, the application of SNOMED CT must be done by a common approach across the various user interfaces to support consistency. On the other hand, the system should not be designed as one size fits all, as this will decrease the applicability of the system. SNOMED CT supports flexible and user-oriented data entry mechanisms, allowing for detailed and very specific data entry as well as bridging different levels of granularities applicable for retrieval of common patterns.
Applying SNOMED CT in EHR has implications for how data can be utilized for effective clinical documentation, enhanced retrieval and decision support functionalities. To support effective display and subsequent retrieval of SNOMED CT coded data, questions about an individual patient or a selected population must have answers that are:
- Accurate – no false negatives
- Precise – no false positives
- Timely – available when needed
- Efficient – without disproportionate cost, time and effort
- Consistent – independent of how the data was entered
To meet the above requirements, collected data must be stored in a consistent form that enables reliable retrieval.
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