Fire and Ice - SNOMED for CORE strength - John Fountain

SNOMED CTClinically Oriented Record Entry

Dr John S Fountain

SNOMED CT(Systematized Nomenclature of Medicine – Clinical Terms)

SNOMED Clinical Terms (SNOMED CT) is the most comprehensive, multilingual clinical healthcare terminology (ontology) in the world.

SNOMED CT can be used to represent clinical information in a coded form, with the level of expressivity appropriate for clinical documentation, and also with extensive support for meaning based retrieval, analysis and reporting.

SNOMED Clinical Terms (SNOMED CT) is the most comprehensive, multilingual clinical healthcare terminology (ontology) in the world.

It contains in excess of 400,000 clinical concepts (clinical thoughts) each identified by human readable descriptions (over 1.2 million). These concepts can be:• Translated into a range of languages• Mapped to existing classification systems

Difficulties with Data Exchange

This provides effective access to information required for decision support and consistent reporting and analysis.

Patients benefit from the use of SNOMED CT because it improves the recording of EHR information and facilitates better communication, leading to improvements in the quality of care.

The Health Information Standards Organisation (HISO) has endorsed the use of SNOMED CT as the clinical terminology to be used across the health and disability sector in New Zealand.

Great, what now?

There is a clear need for effective bedside clinical decision support

The challenge is not in developing an effective Clinical Decision Support tool, which by definition:

• Is integrated into clinical workflow rather than a separate log-in or screen;

• Provides recommendations for care, not just assessments; and• Provides CDS at the point of care.1

It is in designing a clinical user interface to allow effective data collection to support decision-making.

1. Adapted from:Kawamoto K et al. Improving clinical practice using clinical support systems: a systematic review of trials to identify features critical to success. British Medical Journal 2005; 330 (7494): 765

Clinically Oriented Record Entry - CORE

The critical first step is the efficient and effective collection of data. Without this, SNOMED CT implementations:

• Will not deliver on promises, or• Will squander healthcare dollars, or• Will impede clinical care and patient outcomes, or• All of the above

Clinically Oriented Record Entry - CORE

Search / Input Functionality

A reference set (or ‘refset’) is a mechanism used to refer to a set of SNOMED CT components and to add customised information to these components. Refsets can be used for many purposes, including representing subset of concepts, descriptions or relationships, language and dialect preferences, maps to and from other code systems, ordered lists, navigation hierarchies and aggregated hierarchies.

Reference Sets

Ambulance

• Ambulance electronic patient report form (ePRF)• Emergency observations and interventions refset

Reference Sets

Ambulance

• Ambulance electronic patient report form (ePRF)• Emergency observations and interventions refset

Emergency Departments

• Emergency Department at a Glance (EDaaG )• Emergency care refset

Refsets are good for such devices as:

• Pick lists• Drop downs• Short (or relatively short) searchable lists

They are a good mechanism to emulate systems currently available for data collection, but which may not adequately or appropriately code data.

Reference Sets

But, refsets may negate the full potential of SNOMED CT by exposing users to only a small subset of the full ontology:

• Terms not within the refset may not be (easily) available• The granularity of data input is reduced • Such systems may persist for long periods without being

updated• Desired clinical concepts may not be available in SNOMED CT

Reference Sets

A set of terminology components and derivatives that add to and are dependent on the SNOMED CT International Edition, and are created, structured, maintained and distributed in accordance with SNOMED CT specifications and guidelines.

Extension / National Extension

SNOMED CT International

Extension

New Zealand Medicines Terminology

• Body structure• Clinical finding• Environment or geographical

location• Event• Linkage concept• Observable entity• Organism• Pharmaceutical / biologic product• Physical force• Physical object• Procedure• Qualifier value• Record artifact• Situation with explicit context• Social context• Special concept• Specimen• Staging and scales• Substance

SNOMED CT HIERARCHIESConcepts are organized into top-level

hierarchies

Hierarchy Search

Searching within a specific hierarchy rather than the entire ontology

Hierarchy Search

Term Hierarchy Number Descriptors

“Tibia” All

Hierarchy Search

“Tibia” All 1,304 Tibia Tibia Part

Tibia VaraTibia VeinTibia X-rayDistal TibiaTibial NerveEntire TibiaTibial BraceTibial VesselTibial Insert

Hierarchy Search

“Tibia” All 1,304Body Structure 373 Tibia

Tibial VeinDistal TibiaTibial NerveEntire TibiaTibial VesselTibial ArteryShaft of TibiaTibial PlateauTibial Plafond

Hierarchy Search

“Tibia” All 1,304Body Structure 373Procedure 390 Tibial X-ray

Biopsy of TibiaTibial AngiogramTibial OsteotomyDivision of TibiaIncision of TibiaGrafting of Tibia

Hierarchy Search

“Tibia” All 1,304Body Structure 373Procedure 390Disorder 403 Tibia Vara

Injury of TibiaUnossified TibiaSarcoma of TibiaFracture of TibiaTibial NeuropathyAgenesis of TibiaNeoplasm of Tibia

Hierarchical lists can be ranked by likelihood of occurrence‘Common things happen commonly’

Therefore when looking at disorders the list is more practical when reordered:

Hierarchy Search

Tibia VaraInjury of TibiaUnossified TibiaSarcoma of TibiaFracture of TibiaTibial NeuropathyAgenesis of TibiaNeoplasm of Tibia

Injury of TibiaFracture of TibiaTibial NeuropathyNeoplasm of TibiaSarcoma of TibiaTibia VaraUnossified TibiaAgenesis of Tibia

Becomes

SNOMED CT expressions are a structured combination of one or more concept identifiers used to represent a clinical idea in a logical manner that is computer processable.

There are:

• Precoordinated expressions

• Postcoordinated expressions

Expressions

There are:

• Are single concept identifiers that represent the meaning of individual concepts which are predefined in SNOMED CT

Expressions

Acute otitis media

Disorder of the ear

Acute inflammatory disease

Otitis media

Sudden onset AND/OR short duration

Acute inflammation

Middle ear structure

Is a(attribute)

Finding site(attribute)

Clinical course(attribute)

Associated morphology(attribute)

3110003

Precoordination

There are:

Expressions

There are:

• Expressions that contain two or more concept identifiers adding more detail to the meaning of a single concept.

Expressions

Fracture of lower limb

Bone structure of tibia

Fracture

Injury of tibia

Is a(attribute)

Fracture of tibia

Precoordination

31978002

Fracture of tibia

Postcoordination

Bone structure of tibiaFinding site(attribute)

Postcoordination

FractureAssociated morphology(attribute)

Postcoordination

FractureAssociated morphology(attribute)

Fracture of tibia

Postcoordination

Fracture of lower limb

Fracture

Injury of tibia

Is a(attribute)

Fracture of tibia 31978002

Postcoordination

Working diagnosis

Investigation

Medication

Working diagnosis

Muscles

Skeletal

Investigation

Medication

Working diagnosis Skeletal

Investigation

Medication

Left tibiaInvestigation

Medication

Fracture

Neuropathy

Osteomyelitis

Medication

Fracture

Medication

Working diagnosis Fracture left tibia

Investigation

Medication

Working diagnosis Fracture left tibia X-ray

CT scan

Investigation

Medication

Investigation

Medication

Investigation

Medication

Antiemetic

Fluids

Working diagnosis

Investigation

Medication

X-ray Morphine

Tramadol

Oxycodone

Codeine

Paracetamol

PainFracture left tibia

Working diagnosis

Investigation

Medication

X-ray Dose

Morphine

Fracture left tibia

Working diagnosis

Investigation

Medication

X-ray Dose

Morphine

Fracture left tibia

Working diagnosis

Investigation

Medication

X-ray Dose

Morphine

Morphine 10mg

Fracture left tibia

Working diagnosis

Investigation

Medication

X-ray Dose

Morphine

Morphine 10mg

Fracture left tibia

Working diagnosis

Investigation

Medication

X-ray Dose

Morphine

Morphine 10mg IV

Fracture left tibia

Working diagnosis

Investigation

Medication

X-ray Dose

Morphine

Morphine 10mg IV

Hourly

2Hourly

Fracture left tibia

Working diagnosis

Investigation

Medication

Morphine 10mg IV STAT

Antiemetic

Fluids

Fracture left tibia

Implementation Exemplar

Develop a circumscribed, achievable example of SNOMED CT implementation which:

• Collects meaningful data/information• Supports clinical decision making• Can be efficiently and effectively used in the clinical

environment• Is scalable• Can be proven to improve clinical practice / patient outcome

SNOMED CTClinically Oriented Record Entry

Dr John S Fountain

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