Recording COVID-19 consultations: review of symptoms, risk factors, and proposed SNOMED CT terms

Bhautesh Dinesh Jani; Jill P Pell; Dylan McGagh; Harshana Liyanage; Dave Kelly; Simon de Lusignan; Christopher J Weatherburn; Ronnie Burns; Frank M Sullivan; Frances S Mair

doi:10.3399/bjgpopen20X101125

Recording COVID-19 consultations: review of symptoms, risk factors, and proposed SNOMED CT terms

BJGP Open. 2020 Oct 27;4(4):bjgpopen20X101125. doi: 10.3399/bjgpopen20X101125. Print 2020 Oct.

Authors

Affiliations

¹ Clinical Senior Lecturer in General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK bhautesh.jani@glasgow.ac.uk.
² Henry Mechan Professor of Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
³ Medical Sciences Divison, University of Oxford, Oxford, UK.
⁴ Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
⁵ Albasoft Limited, Centre for Health Science, Inverness, UK.
⁶ Professor of Primary Care and Clinical Informatics, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
⁷ Scottish Clinical Information Management in Practice, National Services Scotland, Edinburgh, UK.
⁸ McKenzie Burns Practice, Parkhead Health Centre, Glasgow, UK.
⁹ Professor of Primary Care Medicine, Medical School, University of St Andrews, St Andrews, UK.
¹⁰ Norie Miller Professor of General Practice, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.

Abstract

Background: There is an urgent need for epidemiological research in primary care to develop risk assessment processes for patients presenting with COVID-19, but lack of a standardised approach to data collection is a significant barrier to implementation.

Aim: To collate a list of relevant symptoms, assessment items, demographics, and lifestyle and health conditions associated with COVID-19, and match these data items with corresponding SNOMED CT clinical terms to support the development and implementation of consultation templates.

Design & setting: Published and preprint literature for systematic reviews, meta-analyses, and clinical guidelines describing the symptoms, assessment items, demographics, and/or lifestyle and health conditions associated with COVID-19 and its complications were reviewed. Corresponding clinical concepts from SNOMED CT, a widely used structured clinical vocabulary for electronic primary care health records, were identified.

Method: Guidelines and published and unpublished reviews (N = 61) were utilised to collate a list of relevant data items for COVID-19 consultations. The NHS Digital SNOMED CT Browser was used to identify concept and descriptive identifiers. Key implementation challenges were conceptualised through a Normalisation Process Theory (NPT) lens.

Results: In total, 32 symptoms, eight demographic and lifestyle features, 25 health conditions, and 20 assessment items relevant to COVID-19 were identified, with proposed corresponding SNOMED CT concepts. These data items can be adapted into a consultation template for COVID-19. Key implementation challenges include: 1) engaging with key stakeholders to achieve 'buy in'; and 2) ensuring any template is usable within practice settings.

Conclusion: Consultation templates for COVID-19 are needed to standardise data collection, facilitate research and learning, and potentially improve quality of care for COVID-19.

Keywords: COVID-19; General practice; Medical Records Systems, Computerised; Primary health care; Systematised Nomenclature of Medicine.