The impact of SNOMED CT on clinical coding quality and productivity

Abstract

Background/Aims Studies have shown that using the clinical terminology SNOMED CT can improve clinical documentation, data quality and workforce productivity. This study aimed to evaluate the impact of a SNOMED CT-based digital tool on the quality, completeness and efficiency of clinical coding. Methods A SNOMED CT-enabled clinical coding tool (SNOMED CT - Clinical Coding Assistant) was created. The tool used nursing assessments to identify relevant conditions that should be coded. SNOMED CT concepts and the nationally published SNOMED CT to ICD-10 cross-maps were compared to clinical coding data generated by the typical clinical coding and audit processes. The tool's impact on coding quality, completeness and productivity was assessed using various statistical measures. A total of 1681 coded hospital spells, representing 1589 patients, were included, across a 2-month period. Results Use of the SNOMED CT - Clinical Coding Assistant led to ICD-10 codes being added or changed in nearly half (n=773, 46.0%) of the hospital spells. The tool identified that over a third of the spells (n=588, 35.0%) had missing ICD-10 codes. The tool significantly reduced the time taken to find and validate the presence of numerous conditions for subsequent coding (P<0.001). Conclusions Use of SNOMED CT-based tools can improve clinical coding accuracy, completeness and productivity. SNOMED CT has an important role to play in clinical coding transformation and effective system implementation is critical.