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. Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. As a provider of continuing education, the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: 1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; 2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and 3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. AHIMA 2007 Audio Seminar Series i 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. AHIMA 2007 Audio Seminar Series ii 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 AHIMA 2007 Audio Seminar Series 1 ® 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