Introduction: SNOMED CT is a comprehensive clinical terminology with significant potential to improve care, yet implementation at the jurisdictional scale remains uneven. Research question: "What are the root causes of poor uptake, and what practical steps will change the trajectory?
Methods: Hands-on engagement with pan-Canadian EMR data (1.2 million de-identified patient records), Snap2SNOMED-assisted mapping and curation, and a targeted review of peer-reviewed and gray literature. We analyzed findings using a people, process, technology, and economics lens.
Results: Five structural limitations appear to impede jurisdiction-wide adoption: (1) workflow misalignment that puts coding work on clinicians during time-pressed encounters, (2) insufficient localization, including Canadian synonyms, bilingual content, and curated value sets, frustrating for clinicians (3) inadequate error surfacing for developers, including weak exposure of inactivation reasons, historical associations, and version changes through developer-facing services, which allows errors and divergence to go undetected, (4) a maturity model that ignores complexity in early stages, accumulating technical debt, and (5) lack of structural incentives that align costs with benefits for vendors and clinics.
Discussion: Although the Canadian context makes these barriers concrete, similar issues appear internationally. We propose four system-level actions that aim to reduce costs for vendors and increase value for clinicians: (1) a centralized, authoritative terminology service hosted by a trusted national actor to lower vendor costs, enable synonym localization, and enforce history rules, (2) workflow-embedded standardization that moves coding effort into background services, (3) monetary and non-monetary incentives and innovation challenges that garner publicity for vendors to stimulate adoption and 4) a simple capability framework to replace the staged maturity, prioritizing debt-cutting basics first. Together, these measures offer a practical path to make SNOMED CT usable, consistent, cost-effective, and sustainable at scale.
