Using SNOMED CT in the Southern Cluster

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Using SNOMED CTin the Southern Cluster

• Dr Roger Tackley
• 24th April 2007
• UK Member SNOMED International Standards Board
• Chairman Southern Cluster Terminology Group
• Anaesthetist, Torbay Hospital

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Topics

• What is SNOMED CT and why is it part of the NHS
  direction of travel?
• What is the future of SNOMED and CAP?
• Where does SNOMED CT fit into Cerner release 0?
• How will you get clinicians to use it?
• How will it help clinical coding and PBR?
• What is its relevance to Public Health?

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What is SNOMED CT?

• Systematised Nomenclature of MEDicine
• Clinical Terms
• A comprehensive controlled clinical terminology
• Its a terminology, not a classification
• It is the largest clinical terminology worldwide
  and on track to become an international standard.
• It is mandated for all NHS CfH electronic record
  systems
• Licensing Free to NHS organisations
• (Standards Development Organisation)

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Development of terminologies
SNOMED CT
2000
SNOMEDRT
READ 3 (CTV3)
1990
READ 2
SNOMED 3
Read 4 byte
1980
SNOMED 2
1970
SNOP
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And now.The International Health Terminology
Standards Development Organisations IHTSDO
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Who are the Potential Charter Members?

• Australia
• Canada
• Denmark
• Lithuania
• New Zealand
• Netherlands
• Sweden
• United Kingdom
• United States

• Plus ongoing discussions with three other
  countries who are as yet undecided

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Three Principle Drivers

• Purpose
• Support clinical care of patients internationally
• Primary and secondary purposes
• Integrity
• Ensure clinical, organisational and technical
  integrity
• Funding
• Stable and secure governance structure
• Financial sustainability

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Why are 9 countries doing this?

• Improved Governance
• Validated Product
• Shared Ownership
• Localisation Support
• Global Collaboration
• Compatible with Other Standards

• Enhanced Contribution
• Sustainable Model
• Code of Conduct
• Simple Licensing
• Vendor Engagement
• Clear and transparent management processes

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How is it Governed and Managed?

• Legal Entity is to be a Danish Society
• Not for Profit type organisation, but has an
  unusual name Commercial Society
• The legal entity holds liability not the Members
  of it
• Described in its Articles of Association which
  will be published and open
• Registered in Denmark

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SNOMED SDO Structure
GENERAL ASSEMBLY
Harmonisation Boards
Affiliate Forum
Management Board
Quality Assurance Committee
Research Innovation Committee
Technical Committee
Content Committee
Research Teams
Working Groups
Working Groups
Working Groups
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IHTSDO Enterprise Model
National Release Centre
SNOMED SDO
National Release Centre
National Release Centre
Local/National Health Entities
National Release Centre
Shared technology environment enables
collaboration
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Thoughts from Martin Severs

• Terminology implementation is difficult and
  expensive
• The implementation of a terminology exposes data
  practices
• Data practices are not well developed
• It is easier to blame the terminology than face
  the data practice shortcomings
• Patient real time access to their record, the
  cost of data collection and decision support are
  the most likely stimuli for better terminology
  production and data practice

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Source of Concepts in SNOMED CT
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What does SNOMED CT contain?

• 300,000 concepts
• 1,250,000 terms
• 750,000 English
• 350,000 Spanish
• 250,000 (rising) German
• 1,500,000 relationships
• Mappings to OPCS and ICD

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Components of SNOMED CT

• Concepts
• The basic units of SNOMED CT
• Descriptions
• These relate terms that name the concepts to the
  concepts themselves. Each concept has at least
  two Descriptions.
• Hierarchies
• Concepts are organized into twenty SNOMED CT
  hierarchies (in UK extension). Each hierarchy has
  sub-hierarchies within it.
• Relationships
• Relationships are the connections between
  concepts in SNOMED CT.
• mappings
• Many-to-many mappings to terms in ICD and OPCS
• Inclusion of Dictionary of Medicines and Devices

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Concepts

• Represent distinct clinical meanings
• Identified by a unique numeric identifier
  (Concept ID)
• never changes and a
• unique human readable name
• (Fully Specified Name)
• Associated with each concept
• a set of descriptive terms, e.g. synonyms
• a set of relationships (the logical definition)
• Differing levels of granularity

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Description types

• Preferred Term (usually one)
• The most common word or phrase used by clinicians
  to name a concept
• Fully Specified Name (one and only one)
• Provides an unambiguous way to name a concept
• Synonyms (any number)
• The rest of the names that may be used for a
  concept

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Example of components

• The descriptions for Concept 22298006
• Fully Specified Name Myocardial infarction
  (disorder)
• DescriptionID 751689013
• Preferred Term Myocardial infarction
• DescriptionID 37436014
• Synonym Cardiac infarction
• DescriptionID 37442013
• Synonym Heart attack
• DescriptionID 37443015
• Synonym Infarction of heart
• DescriptionID 37441018
• SEE CLUE BROWSER

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Clue Browser Demo

• Especially to show
• Range of hierarchies
• Synonyms
• Semantic definitions
• Cross maps
• To get CLUE browser SNOMED CT Free
• Preferably ask your local NHS trust who should
  already have these, or should get one for you
• -or-
• Contact NHS CfH data standards helpdesk direct
• 01392 206248
• datastandards_at_cfh.nhs.uk

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A clinical statement illustrationHuman-readable
patient story

• "On the 12th of June 2004 Mr Pat Mann attended
  for a consultation at Anytown Clinic and was seen
  by Dr Jenny Praxis. He complained of difficulty
  breathing. The doctor listened to his chest and
  heard wheezing. His Peak Expiratory Flow Rate was
  measured as 250 L/min and his blood pressure was
  120/75mmHg which the doctor noted was normal. A
  diagnosis of asthma was made and he was
  prescribed a Salbutamol Inhaler 2 puffs 4 hourly
  as required. A request for lung function tests
  was sent to St Elsewhere's Hospital".

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A clinical statement illustrationInformation in
the patient story

• "On the 12th of June 2004 Mr Pat Mann attended
  for a consultation at Anytown Clinic and was
  seen by Dr Jenny Praxis. He complained of
  difficulty breathing. The doctor listened to his
  chest and heard wheezing. His Peak Expiratory
  Flow Rate was measured as 250 L/min and his blood
  pressure was 120/75mmHg which the doctor noted
  was normal. A diagnosis of asthma was made and
  he was prescribed a Salbutamol Inhaler 2 puffs 4
  hourly as required. A request for lung function
  tests was sent to St Elsewhere's Hospital".

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A clinical statement illustration The Clinical
Record in a processable structure

• Mr Pat Mann
• 12-June-2004
• 01) Consultation at Anytown Health Centre with Dr
  Jenny Praxis
• 02) Complained of difficulty breathing
• 03) Wheezing present on auscultation of chest
• 04) Peak Expiratory Flow Rate measurement 250
  L/min
• 05) Blood pressure measurement normal
• 06) Systolic blood pressure measurement 120 mmHg
• 07) Diastolic blood pressure measurement 75 mmHg
• 08) Diagnosis of asthma
• 09) Prescription
• 10) Supply request - one Salbutamol inhaler
• 11) Recommend administer - Salbutamol 2 puffs 4
  hourly as required
• 12) Referral for lung function tests sent to St
  Elsewhere's Trust

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Where do clinicians enter patient records using
SNOMED CT in Cerner R0?
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Entering a request
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Entering details of procedure request
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Problems and diagnosis tab
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Adding a diagnosis
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SNOMED CT term options- when searching for a
diagnosis
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Procedures tab
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Entering a procedure note incorrect coding
scheme chosen!
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Upstream coding
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Coding screen
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Coding screen
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How do we get clinicians to use SNOMED CT in
Cerner?
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SNOMED CT Delivers Information

• Most clinicians should neither know nor care
• How many digits are in a concept identifier
• How many concepts are in SNOMED CT
• How descriptions and relationships are tied to
  concepts
• David Markwell, Chair of SNOMED Concept Model
  Working Group

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What Clinicians care about is

• Clinical records they use meet their needs
• Record system components that work together
  reliably
• Being able to easily express the information they
  wish to enter in a patient record
• Being able to retrieve information to support
  delivery of care or for secondary uses with a
  minimum of extra effort
• David Markwell, Chair of SNOMED Concept Model
  Working Group

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Trusts business and clinical needs
Clinical Records Clinical Terminology Clinical
communication Decision support Clinical
Audit Clinical Coding Payment Operational
Management
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Secondary Uses Service

• The central repository of health data for
  secondary uses
• Most data to be collected or derived from
  clinical systems as a by-product of direct care
• SUS has all NHS related activity and other
  non-patient record based data.
• Provides the tools and services for an effective
  and secure working environment for analysis and
  reporting

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Possible Applications for SUS

• Payment by Results
• Access and Choice
• Commissioning, referral patterns, total waits
• Healthcare Commission
• Standards and performance monitoring
• Public health
• Screening ,surveillance, epidemiology
• Patient safety
• Longitudinal studies, adverse drug reactions
• Research and Development
• Effectiveness, outcomes

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Expected Dataflows for the Secondary Uses Service
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CODES gt Terminologies, Classifications, Casemix
HRG
Managed by HSC IC
Healthcare
Casemix - Groupings
Resource
Groups
c. 500
Mappings up to
ICD Classification of Diseases
-
10
OPCS 4 Classification of Procedures

Classifications
c. 15,000
c. 7,000
Mappings up to
SNOMED CT
Terms and Concepts
Clinical Terms
c. 400,000 concepts
dmd Dictionary of Medicines and Devices
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Example of incomplete coding

• Patient with acute inferior MI and 2 AV block
  had temporary IV pacemaker implanted.
• Example 1 Incomplete coding
• I21.1 (ICD 10) Acute transmural myocardial
  infarction of inferior wall
• I44.1 (ICD 10) Atrioventricular block, second
  degree
• HRG E12 Costs 1185
• Correct Coding
• I21.1 (ICD 10) Acute transmural myocardial
  infarction of inferior wall
• I44.1 (ICD 10) Atrioventricular block, second
  degree
• K60.1 (OPCS) Implantation of intravenous cardiac
  pacemaker
• Y70.5 (OPCS) Temporary operations
• HRG E07 Costs 2998

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Example of coding from SNOMED CT terms

• Patient with acute inferior MI and 2 AV block
  had temporary IV pacemaker implanted.
• Clinician records SNOMED CT terms
• acute myocardial infarction of inferior wall
• second degree atrioventricular block
• implantation of temporary intravenous cardiac
  pacemaker
• Correct Coding
• I21.1 (ICD 10) Acute transmural myocardial
  infarction of inferior wall
• I44.1 (ICD 10) Atrioventricular block, second
  degree
• K60.1 (OPCS) Implantation of intravenous cardiac
  pacemaker
• Y70.5 (OPCS) Temporary operations
• HRG E07 Costs 2998

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Incomplete coding - 2

• Patient with 1 burns of shoulder and upper limb
  and 3 burns of trunk (extent of body surface
  25) received meshed split autograft to skin of
  anterior trunk
• Example 2 Incomplete coding
• T21.3 (ICD10) Burn of third degree of trunk
• T22.1 (ICD10) Burn of first degree of shoulder
  and upper limb except wrist and hand
• S36.2 (OPCS) Full thickness autograft of skin nec
• HRG J26 Costs 2489
• Correct Coding
• T21.3 (ICD10) Burn of third degree of trunk
• T22.1 (ICD10) Burn of first degree of shoulder
  and upper limb except wrist and hand
• T31.2 (ICD10) Burns involving 20-29 body surface
• S35.2 (OPCS) Meshed split autograft of skin nec
• Z49.3 (OPCS) Skin of anterior trunk
• HRG J20 Costs 6987

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Use in Public Health?

• PHSkb A knowledgebase to support notifiable
  disease surveillance
• Timothy J Doyle1, Haobo Ma1, Samuel L
  Groseclose1 and Richard S Hopkins1,2
• BMC Medical Informatics and Decision Making 2005,
  527 doi10.1186
• Conclusions The PHSkb provides an extensible,
  interoperable system architecture component to
  support notifiable disease surveillance. Further
  development and testing of this resource is
  needed.

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Examples of disease
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Notifiable disease coverage
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SNOMED CT Encoded Cancer Protocols

• SNOMED Clinical Terms (SNOMED CT) is being used
  to encode the Cancer Protocols published by the
  College of American Pathologists (CAP). As of
  January 1, 2004, one of the standards set for
  approved cancer programs by the American College
  of Surgeons Commission on Cancer will be that at
  least 90 of surgical pathology reports contain
  all essential data elements identified in the CAP
  Cancer Protocols.
• Monique M. van Berkum, MD
• College of American Pathologists, Northfield, IL
• AMIA 2003 Symposium Proceedings - Page 1039

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Public Health Summary

• Get a SNOMED CT browser!
• Review all PH data sets for coverage by SNOMED CT
• Work with CFH to develop national SNOMED CT
  subsets

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SNOMED CT - The Benefits

• Everyone in the NHS will be using the same
  language to talk about patients conditions and
  treatments this should reassure patients and
  enable clinical communication
• A single dynamic, and comprehensive system of
  terms, centrally maintained and updated for use
  in all NHS organisations
• Greater consistency in communication of patients'
  electronic clinical records
• Long term portability of records between systems
• NB current process for GP-to-GP transfers!
• Opportunity for simplified data entry and
  retrieval of structured records
• Supports the deployment of decision support
• Reliable analysis and research based on a common
  understanding of health terms and concepts stored
  in a coded form (rather than as free text)
• Good links (cross maps) to recognised health
  classifications (ICD10) and surgical
  classifications (from OPCS) to make coding easier
  and assist research into disease and treatment

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Contacts

• roger.tackley_at_nhs.net
• http//www.connectingforhealth.nhs.uk/technical/st
  andards/snomed/