Useful Applications for SNOMED CT®
Audio Seminar/Webinar March 8, 2007
Practical Tools for Seminar Learning
© Copyright 2007 American Health Information Management Association. All rights reserved.
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Faculty
James Richard Campbell, MD is Professor of Internal Medicine at the University of Nebraska Medical Center. He received a Bachelor of Science Degree in Physics from the University of Rochester, and his Medical Degree from the University of Nebraska College of Medicine. Dr. Campbell further completed an internship, residency and fellowship in Internal Medicine at the University of Nebraska and is boarded in Internal Medicine. Dr. Campbell has postgraduate training in computer science and has developed and implemented clinical information systems for over 25 years. He is Chief Medical Information Officer for the Nebraska Medical Center. He has authored and co-authored numerous articles, book chapters and abstracts. He lectures frequently on a national and international level. He currently participates in standards organizations including HL7 and is a member of the SNOMED Editorial Board.
Debra Konicek RN, MSN, BC, is the Director, Clinical Standards Initiatives for SNOMED International. In her role, she coordinates all aspects of SNOMED's standards efforts to ensure that SNOMED CT content correlates with current national and global standards initiatives. She develops relationships with key stakeholders and decision makers to ensure that SNOMED CT content effectively supports customer requirements and quality patient care. Previously as the Terminology Manager for Nursing, she was responsible for the integration of nursing terminology as well as liaisons with nursing informatics and terminology experts.
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Table of Contents
Disclaimer ...... i Faculty ...... ii Seminar Outline ...... 1 Terminology History and Emergence of SNOMED CT ...... 1 Importance of Composition ...... 3 Definitions ...... 3 SNOMED Facts...... 5 January 2007 Release...... 5 Content and Relative Size...... 6 Step-by-Step...... 7 Subsets and Maps ...... 7 Problem List Case Study ...... 8 Post-coordination ...... 8 How does problem list work ...... 9 Problem Capture ...... 10 Problem Record...... 11 Clinical Findings are Specific...... 12 “Right carotid stenosis”...... 12 Maintaining Precise Clinical Data...... 13 Extension Concept Creation… ...... 13 Multi-use Clinical Data...... 14 Nebraska Lexicon ...... 15 SNOMED CT and Guidelines ...... 15 Guidelines Studied...... 16 Results ...... 16 Guideline Vocabulary Analysis...... 17 Hierarchical Relationships...... 17 Guidelines and Real Databases ...... 18 Guidelines and Nebraska Records ...... 18 Conclusions Clinical Scenario...... 19 How does problem list work?...... 20 Problem Capture ...... 20 Primary Use Case for SNOMED CT Used in Nursing Practice ...... 22 Integration of Nursing Terminologies ...... 22 What SNOMED CT Hierarchies are Used in Nursing Domain...... 23 SNOMED CT Data Query ...... 23 Getting back to our patient...... 24 Guidelines Studied...... 24 Plan of Care Based on Problem List...... 25 Hierarchical Relationships...... 25 Specific Diet Education: Diabetes...... 26 What can a SNOMED CT provider do for nurses?...... 26 Conclusions ...... 27 Resources ...... 28 Appendix ...... 31
AHIMA 2007 Audio Seminar Series ® Useful Applications for SNOMED CT Notes/Comments/Questions
Outline
Why SNOMED CT? • History • Design features and implementation SNOMED CT facts SNOMED CT for problem list: how to… Clinical scenario and benefits SNOMED CT and multi-disciplinary care 1
Terminology History and Emergence of SNOMED CT
Exploratory studies demonstrate that administrative classifications function poorly for recording clinical events 1995: Medical concept model: Galen and Pen&Pad • “Compositional employment of Galen promising but ambiguity and under-specification become issues” 1997: CPRI study of clinical vocabularies • “No system comprehensive or ideal; SNOMED 3.1 and Read v3 most complete; SNOMED composition unclear” 1997: NLM Large Scale Vocabulary Test • “Only SNOMED 3.1 and Read v3 had more than 50% of concepts” 2
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Terminology History and Emergence of SNOMED CT
“No pre-coordinated set of concepts and terms can completely serve clinical recording needs over time”
Elkin PL, Brown SH, Husser CS, Bauer BA, Wahner-Roedler D, Rosenbloom ST, Speroff T. Evaluation of the content coverage of SNOMED CT: ability of SNOMED clinical terms to represent clinical problem lists. Mayo Clin Proc. 2006 Jun;81(6):741-8.
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Terminology History and Emergence of SNOMED CT
2003: UCLA study of SNOMED CT for problem list functionality • “88.4% of concepts present; 98.5% of concepts covered with SNOMED CT” 2006: Mayo clinic evaluation of SNOMED CT for problem list • used as compositional terminology, 92.3% of terms exactly represented
Wasserman H, Wang J. An applied evaluation of SNOMED CT as a clinical vocabulary for the computerized diagnosis and problem list. AMIA Annu Symp Proc. 2003;:699-703.
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Importance of Composition
The need for concept composition: • Arises to manage “combinatorial explosion” of codes required for clinical records • Implies that post-coordination will be required in clinical use of vocabulary
Extends the value of the vocabulary: • Defining relationships become essential features which enhance data organization for retrieval, display management and decision support software
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Definitions
Composition: a concept is created by the coding system through the assembly of component elements of meaning which then form a complete and unique definition Pre-coordination: SNOMED International creates the complete definition and coding for a concept with associated terms and publishes these in standard releases Post-coordination: the vendor software supports the interactive definition of a new concept not found in the pre-coordinated release, and maintains (and shares) that code within a
community of users 6
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Importance of Composition
The need for concept composition: • Arises to manage “combinatorial explosion” of codes required for clinical records • Implies that post-coordination will be required in clinical use of vocabulary Extends the value of the vocabulary: • Defining relationships become essential features which enhance data organization for retrieval, display management and decision support software
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Composition: example of post-coordination
“Pneumococcal pneumonia of right lower lobe” • Is_a Î “Pneumococcal lobar pneumonia” 266350000 • Finding site Î “Right lower lobe structure” 2660005
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® Useful Applications for SNOMED CT Notes/Comments/Questions
SNOMED Facts
Name: Systematized Nomenclature of Human and Veterinary Medicine Organization: College of American Pathologists Code versions: • SNOP • SNOMED III (International) • SNOMED-RT • SNOMED-CT Information: http://www.snomed.org/ 9
SNOMED CT ® January 2007 Release Features
SNOMED Core Content • Concepts • More than 308,000 active concepts • Descriptions • 777,000 active English language descriptions • Relationships • 924,000 defining relationships 10
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® Useful Applications for SNOMED CT Notes/Comments/Questions
SNOMED CT ® January 2007 Release Formal logic-based definitions are organized into the following top-level hierarchies
Clinical finding Physical object Procedure Physical force Observable entity Events Body structure Environments/geographical Organism locations Substance Social context Pharmaceutical/biologic Situation with explicit product content Specimen Staging and scales Qualifier value Linkage concept Record artifact Special concept (Inactive concept) 11
SNOMED Content and Relative Size of other Terminologies
250,000 Other: Social Context Physical object Other Context-Dependent Observable Entity Staging and Scales Qualifier Value EnvironmentsPhysical and Object Pharmaceutical/Biological Product geographical locations Attribute Substance SpecimenStaging and Scales 200,000 Physical Force Events Organism Environments and geographical locations Body Structure 150,000
ICD-O Attribute Finding Specimen
NURSING Physical Force 100,000 Procedure Events CPT
50,000 Disease ICD-9-CM
0
S N O M E D C T ® 12
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® Useful Applications for SNOMED CT Notes/Comments/Questions
SNOMED CT: Step-by-Step How to implement a problem list
Inventory concepts and terms for use case Encode clinical meaning with SNOMED CT Add maps from concepts as necessary for workflow and data sharing Create the user interface from subset of terms relevant to use case Check to see if someone has done it for you… The SNOMED community offers a collection of subsets for user interface implementation and maps to support translation from SNOMED CT to other coding systems
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SNOMED CT Subsets and Maps
Subsets: Maps: Problem list ICD-9-CM Allergens ICD-10 Cancer check lists ICD-O3 US Drugs OPCS-4 Languages: NANDA- International US English NIC, NOC, Omaha, UK English HHCC, PNDS Spanish LOINC German
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Problem List Case Study: University of Nebraska 700 bed hospital; 24,000 admissions/year; 1200 medical staff, both academic and private practice; 250 house staff 500,000 outpatient visits; two dozen outpatient sites across broad geographic area Computerized patient records since 1982 GE Centricity Enterprise for inpatient
and outpatient care… 15
Problem List Post-coordination: GE Healthcare (Centricity)
1997: Installation coded problem list • SNOMED 3.1 clinical coding, now SNOMED CT 2006B • ICD-9-CM map for administrative translation and coding • Problem maintenance information layer User interface: • Navigational (now rapid keyword search) • “Just-in-time” post-coordination from user terms Warren JJ, Collins J, Sorrentino C, Campbell JR. Just-in-time coding of the problem list in a clinical environment. Proc AMIA Symp. 1998;:280-4. Database: • Extension identifiers stored in user record; SNOMED CT and NMC extension maintained in GE Concept Dictionary files
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Problem List Post-coordination: GE Healthcare (Centricity)
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Clinical Scenario: How does problem list work?
Dr. C does initial outpatient exam on 69 y/o male who presents with a blood sugar of 245 mg/dl, blood pressure of 170/100 Examination remarkable for bruit in right neck, heart murmur, loss of sensation in both feet with open sore on great toe Laboratory confirms diabetes and stage II kidney disease Dr C records diagnoses on problem list…
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Problem Capture
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Problem Capture
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Problem Capture
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Problem Record
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Clinical Findings are Specific
Dr C orders testing of carotid circulation to assess bruit detected on examination 23
“Right carotid stenosis”
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Case Study: Maintaining Precise Clinical Data
Just-in-time post-coordination supports dynamic clinical coding dictionaries with clinical precision: • Clinicians employ the specific concepts they need • AHIMA certified coding staff manages new clinical concepts as they are recorded • SNOMED post-coordination is done as necessary and mapping is employed within Centricity behind the scenes 25
Extension Concept Creation…
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Case Study: Maintaining Precise Clinical Data
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Case Study: Multi-use Clinical Data
Order entry Service recognition
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Nebraska Lexicon©: GE Healthcare Problem List
Initially implemented with 11,200 descriptions Multi-disciplinary problem list supports all departments in primary and referral-based care Now 14,600 descriptions employing 11,000 concepts Distributed and maintained on behalf of 21 healthcare enterprises in US Coding updates with each release of SNOMED CT and ICD-9-CM Physician and one full time certified coding staff maintain user interface and manage updates; GE distributes resource to other customers 29
SNOMED CT and Guidelines
Systematically select and process publications from www.guideline.gov Employ standardized procedures for guideline analysis and coding Analyze vocabulary needs studying SNOMED CT with and without post- coordination, UMLS, ICD-9-CM Vocabulary coding reviewed and graded: Exact, Broad, Narrow, Missing Assess for systematic strengths, deficiencies
and suggestions of editorial priorities 30
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Guidelines Studied
Immunizations Institute For Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute For Clinical Systems Improvement(ICSI);2002 Jun. 49p. Standards of care for American Diabetes Association. Standards of patients with diabetes medical care for patients with diabetes mellitus. Diabetes Care 2002 Jan;25(Suppl 1):S33-S49. Pressure ulcer risk Royal College of Nursing. Pressure ulcer risk assessment and assessment and prevention. London: Royal prevention College of Nursing; 2001 Apr. 36 p.
Major depression in Institute For Clinical Systems Improvement adults for mental health (ICSI). Major depression in adults for mental providers health care providers. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2002 May. 43 p.
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Results: SNOMED CT coding completeness by guideline
Exact Broader Narrower Missing match
Immunizations 98% 0 0 2% N=127
Diabetes 92% 3% 3% 2% N=90
Depression 85% 1% 6% 8% N=93
Pressure sores 70% 15% 0 15% N=71
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Guideline Vocabulary Analysis
ICD captured only 22% of clinical concepts; only SNOMED CT approached 100% Analysis of concept requirements is one critical element of the utility of a reference terminology However, our experience clearly dictates that decision logic function depends upon other terminology features….
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SNOMED CT Hierarchical Relationships
Guideline goal: “If patient has diabetes mellitus, Then administer a flu shot”
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® Useful Applications for SNOMED CT Notes/Comments/Questions
SNOMED CT Relationships: Guidelines and Real Databases SNOMED “Is_a” relationships support decision logic identification of all instances of concepts for logical completeness In the guidelines studied: • Average 8.9 SNOMED children per concept (0-161) • Average 224 SNOMED descendant concepts (0-17227)
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SNOMED CT Relationships: Guidelines and Nebraska Records We analyzed problem list data for 1.4 million records (252,000 patients) in the Nebraska Centricity® database We counted whether the descendant concepts from our guideline analysis occurred anywhere in actual clinical records Average use of related concepts per guideline concept invoked in Nebraska coded records was 22 (0-1606) E.g.: Query asks for “diabetes” but “Complicated type I diabetes” is in 36 problem list
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Conclusions
For support of clinical problem list, SNOMED CT: • Is more clinically exact • Can be implemented within a user interface • Can be implemented to effectively support multiple data recipients and use cases • Provides better decision support features
What about other clinical record users?
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Return to our clinical scenario…
Based upon clinical findings of neuropathy and foot ulcer, Dr C refers patient to wound care nurse specialist for shared management…
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Clinical Scenario: How does problem list work?
Nurse K does initial new patient assessment on 69 y/o male who has been identified by his physician to need diabetic management specifically in terms of current neuropathy and great toe lesion Assessment interview reveals that patient is at risk for further skin breakdown due to his diabetes, associated neuropathy, and existing lesion on great toe. Further history taking also identifies that this patient has minimal knowledge regarding his diabetes 39 Nurse K records diagnoses on problem list…
Problem Capture
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Problem Capture
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Problem Capture
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Primary Use Case for SNOMED CT Used in Nursing Practice
SNOMED CT Recommended as core nursing terminology choice by the NCVHS and required by the Federal Consolidated Healthcare Informatics Initiative
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Integration of Nursing Terminologies
SNOMED CT Nursing is providing an integrated resource where the various nursing terminologies are available for electronic interoperability applications. Examples: The American Nursing Association (ANA) recognized nursing terminologies A variety of patient safety and nursing quality resources 44
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® Useful Applications for SNOMED CT Notes/Comments/Questions
What SNOMED CT Hierarchies are Used in the Nursing Domain?
Nursing diagnoses: clinical findings (problem list, assessments, plan of care, subsets, nursing notes, flow sheets) Signs and symptoms: clinical findings (assessments, plan of care) Interventions and actions: procedures (order sets, plan of care, education plan, nursing notes) Outcomes: observables (plan of care, nursing notes)
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SNOMED CT Data Query
SNOMED CT provides the ability to query the data based upon the defined organizational inclusion criteria.
The data extracted will collect all concepts based on the SNOMED CT relational defining relationships.
This is what makes SNOMED CT unique from other standardized nursing terminologies
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Clinical Scenario: Getting back to our patient…. Nurse K does initial new patient assessment on 69 y/o male who has been identified by his physician to need diabetic management specifically in terms of current neuropathy and great toe lesion
Assessment interview reveals that patient is at risk for further skin breakdown due to his diabetes, associated neuropathy, and existing lesion on great toe.
Further history taking also identifies that this patient has minimal knowledge regarding his diabetes
Nurse K records diagnoses on problem list… 47
Guidelines Studied
Immunizations Institute For Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute For Clinical Systems Improvement(ICSI);2002 Jun. 49p. Standards of care for American Diabetes Association. Standards of patients with diabetes medical care for patients with diabetes mellitus. Diabetes Care 2002 Jan;25(Suppl 1):S33-S49. Pressure ulcer risk Royal College of Nursing. Pressure ulcer risk assessment and assessment and prevention. London: Royal prevention College of Nursing; 2001 Apr. 36 p.
Major depression in Institute For Clinical Systems Improvement adults for mental (ICSI). Major depression in adults for mental health providers health care providers. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2002 May. 43 p.
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Plan of Care Based on Problem List
Guideline goal: “If patient has knowledge deficit:diabetes Provide specific disease related education” 49
SNOMED CT Hierarchical Relationships
Diet Education query will find all child concepts and related concepts based on the “definition” of Diet education
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Specific Diet Education: Diabetes
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What can a SNOMED CT provider do for nurses?
Collect comprehensive data in a convenient and consistent manner
Manage data in electronic format
Enable data analysis
Compare data within and across settings • Data truly comparable
Evaluate clinical practice and its effectiveness
Validate the contributions of nursing and allied health
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® Useful Applications for SNOMED CT Notes/Comments/Questions
Conclusions
For support of clinical problem list, SNOMED CT: • Is more clinically exact • Can be implemented within a user interface • Can be implemented to effectively support multiple data recipients and use cases • Provides better decision support features • Can effectively support a multidisciplinary team approach to diagnosis and decision making……
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Questions ???
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Resources
Website: SNOMED CT http://www.snomed.org/
Online learning: Clinical Vocabularies: A Technology for the CPR http://campus.ahima.org/campus/course_info/CSS/CSS_info.htm
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® Useful Applications for SNOMED CT Notes/Comments/Questions
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® Useful Applications for SNOMED CT Notes/Comments/Questions
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