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Empowering clinical data collection at the point of care
  1. Andy Spencer1,
  2. Karen Horridge2,
  3. Denise Downs3
  1. 1UK Terminology Centre, Health & Social Care Information Centre, Leeds, UK
  2. 2Department of Paediatrics, Sunderland Royal Hospital, Sunderland, UK
  3. 3UK Terminology Centre, Health & Social Care Information Centre, Leeds, UK
  1. Correspondence to Dr Andy Spencer, UK Terminology Centre, Health & Social Care Information Centre, 1 Trevelyan Square, Boar Lane, Leeds LS1 6AE, UK; stephen.spencer{at}nhs.net

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Introduction

Collecting clinical data has huge benefits, and many bespoke systems have been well supported by clinicians with outputs leading to improved care.1 The National Health Service (NHS) has one of the most comprehensive data collection systems for inpatients in the world (Hospital Episode Statistics). Although the data are used extensively for commissioning and NHS management, few clinicians find the data either accessible or useful.2 This is unfortunate because potentially quality indicators3 could be developed that would significantly enhance quality of care and patient safety. Clinicians have not generally engaged with these data because it is normally extracted after the episode of care from unstructured notes and recorded using the International Classification of Diseases V.10 (ICD-10).4 The end result is deemed too inaccurate for clinician-led research, audit or quality improvement. In truth the data quality is normally good but not sufficiently granular for this type of clinical analysis. A further problem is the lack of clinical information recorded in outpatients, especially for specialties like community paediatrics that are now almost entirely outpatient based.5

Comprehensive high-quality clinical data require the involvement of clinicians on a daily basis at the doctor–patient interface. As clinicians are pressured for time, they will only be able to achieve this goal if provided with an appropriate tool. Furthermore, for national comparison, it is essential that a spade is always a spade and a shovel a shovel; in other words, there has to be clear agreed and published definitions.

SNOMED – clinical terms

The NHS is signed up to a terminology that is appropriate for clinicians to use, especially when delivered using electronic systems.6 The Systemized Nomenclature of Medicine – Clinical Terms (SNOMED CT) was created by amalgamating the American Pathology terms of SNOMED-Reference Terms and Read Clinical Terms V.3.7 Read terms were developed by …

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