May be the backbone of your ehr system May be part of a cross mapping table from legacy data May have components integrated into a knowledge engine
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- Hester Scott
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2 May be the backbone of your ehr system May be part of a cross mapping table from legacy data May have components integrated into a knowledge engine (weighted concepts, CDS) May be integrated with other code sets May be totally off-line (value sets, quality measures) May be part of drop-down menus or search terms.. Varies with type of implementation
3 Differences in opinion..some want SNOMED CT preferred terms for interface others want to use terms they prefer in their practice (customized by locale, use of templates, etc. ) May vary by country (lot of nuances with language/translation)
4 Hospital System XXX123 myocardial infarct X SNOMED CT enables the integration of clinical data from disparate systems Doctor s Office ABC444 cardiac infarction X myocardial infarction (disorder) SNOMED CT Outpatient Dept X heart attack Shows interoperability and enabling of data integration across disparate systems
5 Interface Interface of clinical application
6 Interface ID14859 ID00456 ID02455 ID00457 ID00044 ID00364 ID00462 ID14993 ID00169 ID00415 CHEST DISCOMFORT HISTORY OR SYMPTOM DYSPNEA HISTORY OR SYMPTOM DYSPNEA ON EXERTION HISTORY OR SYMPTOM DYSPNEA PAROXYSMAL NOCTURNAL HISTORY OR SYMPTOM DIAPHORESIS HISTORY OR SYMPTOM NAUSEA HISTORY OR SYMPTOM ORTHOPNEA HISTORY OR SYMPTOM EXTREMITY EDEMA HISTORY OR SYMPTOM CHEST PALPITATIONS HISTORY OR SYMPTOM PRESYNCOPE HISTORY OR SYMPTOM ID01594 ID01007 FEAR OF IMPENDING DEATH OR DOOM HISTORY OR SYMPTOM EXERCISE TOLERENCE RELATIVE HISTORY OR SYMPTOM Proprietary terminology representing the interface terms
7 Interface terminology Front end SNOMED to represent the clinical terms needed by an ehr product Want one to one mapping interface terms and SNOMED CT (pre-coordinated terms; use of local extensions) End-users want only oneclick Implementers/vendors must design products to display SNOMED CT terms (drop downs/search) SNOMED CT tied to endusers practice Other standards depend on SNOMED CT concepts Reference terminology Back end -SNOMED CT is the reference standard for interoperability (Other code sets are also important) SNOMED CT modeled in back end from interface term (terms can be postcoordinated Vendors customize interface/use templates Implementers/vendors allow for customization- use of local terms/use of templates SNOMED CT is seamless to end-user SNOMED CT is only one of several standards within an ehr
8 The quality of data collected is directly proportional to the care with which options are presented to the user so the functionality of the ehr product is as important as the terminology (Usability factors)
9 Terminology model now needs to relate to the architecture or design of a clinical system Information model There is more than one way to manipulate data.must balance between Terminology model and Information model
10 Allergies BP Temp Resp Pulse Hx and Physical Patient Name...xxx Penicillin 180/95 - Observable entity Disorder FH PMH Lung cancer Chronic lung disease Situation with explicit context Exam Breath sounds on R Clinical finding Dx Pneumonia Disorder Plans Bronchoscopy, sputum culture Rx: Amoxicillin 500mg TID X 10d Procedures
11 Represent a question or a feature which can be given an answer or result Things that can be measured or observed Example structured docs
12 Blood pressure (observable entity) Heart rate (observable entity) Respiratory rate (observable entity) Patient name (observable entity)
13 The result of a clinical observation, assessment or judgment Includes both normal and abnormal clinical states The sub-hierarchy of Disease includes everything that could be called a disorder
14 finding of increased blood pressure (finding) fever (finding) tachypnea (finding) Example: BP = 180/95 Elevated blood pressure A clinical finding interprets an observation
15 Examples PR interval feature (observable entity) Prolonged PR interval (finding) Body temperature (observable entity) Hypothermia (finding) / Fever (finding) Knee reflex (observable entity) Knee reflex brisk (finding) Observable entity + Value = Clinical finding
16 Allergies BP Temp Resp Pulse Hx and Physical Patient Name...xxx Penicillin 180/95-24 Observable entity 74 Disorder FH PMH Lung cancer Chronic lung disease Situation with explicit context Exam Breath sounds on R Clinical finding Dx Pneumonia Disorder Plans Bronchoscopy, sputum culture Rx: Amoxicillin 500mg TID X 10d Procedures
17 Used to represent findings and procedures that make explicit: Whether a finding is present or absent or probable, or a procedure was done or not done, or planned, etc. Who the finding or procedure is about When the finding or procedure occurred
18 family history of neoplasm of lung (situation) no cough (situation) Absent clinical findings lung volume test not done (situation) history of - chronic lung disease (situation)
19 Allergies BP Temp Resp Pulse Hx and Physical Patient Name...xxx Penicillin 180/95-24 Observable entity 74 Disorder FH PMH Lung cancer Chronic lung disease Situation with explicit context Exam Breath sounds on R Clinical finding Dx Pneumonia Disorder Plans Bronchoscopy, sputum culture Rx: Amoxicillin 500mg TID X 10d Procedures
20 Disorder same as disease *Always abnormal Disease is a sub hierarchy of clinical findings clinical finding (finding) disease (disorder) Different FSNs All Diseases are Clinical Findings
21 pneumonia (disorder) asthma (disorder) chronic obstructive lung disease (disorder) decreased breath sounds (finding) large airway sounds (finding) dyspnea on exertion (finding)
22 Allergies BP Temp Resp Pulse Hx and Physical Patient Name...xxx Penicillin 180/95-24 Observable entity 74 Disorder FH PMH Lung cancer Chronic lung disease Situation with explicit context Exam Breath sounds on R Clinical finding Dx Pneumonia Disorder Plans Bronchoscopy, sputum culture Rx: Amoxicillin 500mg TID X 10d Procedures
23 Body structure includes normal and abnormal structures Anatomical concepts used to specify the site of a Procedure or of a Clinical finding are found in this hierarchy
24 Lobe of liver (body structure) Mitral valve structure (body structure) Cecum structure (body structure) Bone structure of sternum (body structure) Lung structure (body structure)
25 Sub-hierarchy of Body structure Used for Clinical finding concepts as value of Associated morphology Used for Procedure concepts as the value of Procedure morphology
26 Polyp (morphologic abnormality) Plaque (morphologic abnormality) Adenosarcoma (morphologic abnormality) Embolus (morphologic abnormality) Inflammation (morphologic abnormality) Consolidation (morphologic abnormality)
27 Allergies BP Temp Resp Pulse Hx and Physical Patient Name...xxx Penicillin 180/95-24 Observable entity 74 Disorder FH PMH Lung cancer Chronic lung disease Situation with explicit context Exam Breath sounds on R Clinical finding Dx Pneumonia Disorder Plans Bronchoscopy, sputum culture Rx: Amoxicillin 500mg TID X 10d ACTION ITEMS Procedures
28 Diagnostic Chest X-Ray, Bronchoscopy, Sputum culture Therapeutic.prescribe medication Amoxicillin 500 TID X 10 days Patient Education Referral to stop-smoking clinic
29 Prescription of drug (procedure) Ambulating patient (procedure) Standard chest X-ray (procedure) Lobectomy of lung (procedure)
30 Represent ACTIONS Includes administrative, invasive, diagnostic, imaging and education procedures
31 Breath sounds on R What you see Interface term
32 What you get Stored terms
33 TRIGGERS ALERT Order for Amoxicillin
34 Allergies BP Temp Resp Pulse Hx and Physical Patient Name...xxx Penicillin 180/ TRIGGERS ALERT FH PMH Lung cancer Chronic lung disease Exam Breach sounds on R Dx Pneumonia Plans Bronchoscopy, sputum culture Rx: Amoxicillin 500mg TID X 10d
35 PATIENT HISTORY ALERT TRIGGERED MEDICATION ORDER
36 Diagnoses Findings Procedures Allergies Pneumonia Allergy to Penicillin
37 CDS Integration with other code sets For public health/reporting Abdominal pain Hemorrhagic diarrhea Hemolytic anemia Serum creatinine raised (SNOMED CT) Patient signs and symptoms Stool culture + e.coli 0157 (Lab Code) Lab Result Hemolytic uremic syndrome (disorder) (SNOMED CT) Diagnosis For administrative /billing /statistics Notifiable Disease Hemolytic-uremic Syndrome (ICD9CM) Billing
38 Can analyze data by different hierarchies Find all patients with diseases having lung consolidation Or all procedures done on gastric mucosa
39 Recommendations for Successful Implementation Begin with products (ehrs) that clinicians use Make interfaces easy and not require SNOMED knowledge by end-users Clinician focus is on patient care. not searching for codes not during pt visit Put standards on the back end Help from Informaticists and domain experts Implement only what you understand.includes meaning and context Do No Harm!
40 Geraldine Wade MD, MS Contact: Clinical Informatics Consulting Member of the Content Committee for the IHTSDO ( ) The Americas
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