Abstract

In order to achieve the full potential of information technology in healthcare, information systems must have the ability to share and exchange data, which requires the support of standardised medical terminology, such as Systematised Nomenclature of Medicine--Clinical Terms (SNOMED-CT). The Royal Prince Alfred Intensive Care Service and the School of Information Technologies, University of Sydney have been collaborating for over two years, developing pioneering software initiatives for clinical information systems (CIS). More recently, the collaboration resulted in the development of two prototype systems. The Ward Round Information System (WRIS) has been designed to convert clinicians' clinical notes into the formal medical encoding ontology SNOMED-CT, thus enabling more consistent descriptions of patient conditions and allowing large-scale retrieval and analysis from the narrative part of the patient record. In addition, a Clinical Data Analytics Language (CDAL) system has also been developed and is designed to answer questions of the data stored in the CIS. It will assist clinicians in the management of vast amounts of complex information generated during an ICU admission and ultimately improve the quality and efficiency of care. CDAL provides clinicians with the ability to frame any question about their data in their database and get the answer almost immediately. Both systems went live in October 2007, and this report summarises the background, purpose, and progress thus far.

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