互通性電子病歷之辭彙標準－臨床醫學術語系統(SNOMED CT)之現狀與發展

Exchange and sharing of clinical information through Interoperable Electronic Health Record (iEHR) can improve the healthcare organization's efficiency and enhance patient care quality. Following the footsteps of the US and many advanced European countries, Taiwan invested recently a big bundle in health information technology development. Systematic Nomenclature of Medicine-Clinical Term (SNOMED CT) has become one of the most valued clinical term standards of electronic health record and widely adopted by these countries interested. Aside from using literature review, by which we looked into the evolution and content of 7 existing versions of SNOMED CT, we also tried to find out the current situation of hospital development here in Taiwan through a case study, and to understand the preliminary needs of clinical physicians and information professionals in the establishment of operative matter system through interviews. SNOMED CT happens to be a powerful reference terminology system for clinical medicine, which contains more than 344,000 concepts, 913,000 descriptions, and 1,360,000 relationships. Clinical data are exchanged and interoperated by three, concept, description, and relationship, tab les. SNOMED CT clearly defines medical concepts, synonyms and semantic relationship, gives emphasis to the reciprocal manipulation of two meanings, and uses the like of relational database way to establish multi relations between concepts both in varied strata and channels, so that a patient's clinical data can be indexed, stored, retrieved, and aggregated by different participating clinicians at different locations of the caring, yet the reliability and coherence of it can be assured and the content variability be kept at minimum. 1n case of applying its information code system and reference terminology to clinical data, not only can healthcare workers use them to log patient's condition and do cancer registry, but also information personnel can develop electronic health record system with them, medical caring institutions can apply them as a versatile tool to support their decision making, cost analysis, and clinical research. Currently, more than 30 countries including the United States, Canada, and the UK have already adopted the system. In prospect, we believe that SNOMED CT terminology standard will be an important competition tool to run a healthcare institution, and an inevitable trend for hospital information construction. However, the formulation of this standard requires active collaboration of the government, the institution, and individual professionals in clinical medicine and information industry to establish a nationwide clinical terminology standard that meets internationally set criteria, and the goals include rendering healthcare institutions and the industry a standard to observe and facilitating information sharing and exchange, and thus vastly improving the quality of medical care.