Building SNOMED CT Reference Sets for Use as Interface Terminologies
David P Hansen, Marcel Giermanski, Monika Dujmovic, Josh Passenger, Michael J Lawley
The SNOMED CT Clinical Terminology has been made available to the Australian health community as the clinical terminology to be used to standardise the collection of clinical data. Reference Sets are a mechanism to identify a specific subset of SNOMED CT concepts relevant to a particular medical domain. They also provide alternate organisation or navigation hierarchies. As such, they attempt to bridge the gap between the general purpose reference terminology and an interface terminology. In this paper we describe the process of building a Reference Set that can be used to describe colonic pathologies and how that Reference Set can be used as an interface terminology in a specific software system. Ideally the Reference Set will be generally useful for other applications, such as to support synoptic reporting. This would also help to meet the aim of recording clinical information in a standard vocabulary. The process described uses the Reference Set Editor in the Snapper Platform from the Australian e-Health Research Centre (AEHRC), which already supports the building of SNOMED CT extensions through a reverse mapping module. Pathology terms from a standard text on performing endoscopies formed the basis of a terminology for describing colonic pathologies. The CSIRO Colonoscopy Simulator at the AEHRC provides an ideal case study for the issues of using Reference Set in specialised health software. For Australian Health IT providers to successfully implement the vision of recording all clinical information using a single terminology, tool support for the creation of Reference Sets will need to be flexible enough to handle many issues.
Clinical Terminology; Health Data Mining; Electronic Health Records