SNOMED CT for Nursing Anne Casey FRCN Editor Paediatric Nursing Adviser in Informatics Standards, Royal College of Nursing UK Clinical Lead, NHS (England) Information Standards Board Member, SNOMED Content Committee
Overview SNOMED CT Josef Ingenerf SNOMED CT and nursing terminologies Implementation issues Working with SNOMED CT nursing contribution to development Questions & Discussion
1. Terminologies concept representation systems Many terminologies to represent the complexity of healthcare Formal and less formal terminological systems (terminologies) Specific features of different terminologies make them more of less useful for particular purposes and technological environments.
Concept representation systems How we think about them Things in the real world How we communicate about them Pyrexia
2. Different terminologies have features suited to their different purposes clinical definitions e.g. pyrexia in an immunocompromised patient = 37.5 C knowledge relationships e.g. contraindications for use of aspirin classification concepts e.g. other procedure coding scheme e.g. A1, A1.1, A1.11 B1, B1.1 grouping / organisation of terms for particular purposes e.g. a list of investigations to be done for pyrexial patient
Nursing terminologies development assumptions A limited system of key concepts could be defined, taught and researched Defining these concepts could support costing of nursing care (US model) There was a desire to develop a knowledgebase and professionalise nursing Primary purpose was (and is now?) to promote diagnostic thinking, decision making and outcome assessment.
American Nurses Association - recognised entities Nursing Minimum Data Set (NMDS) Nursing Management Minimum Data Set (NMMDS) North American Nursing Diagnosis Association, Inc. (NANDA) Nursing Interventions Classification System (NIC) Clinical Care Classification (CCC) Omaha System Nursing Outcomes Classification System (NOC) PeriOperative Nursing Dataset (PNDS) International Classification for Nursing Practice (ICNP ) ABC codes SNOMED CT Logical Observation Identifier Names & Codes (LOINC )
SNOMED Clinical Terms. a clinical terminology for use in electronic systems in healthcare supporting entry, communication and retrieval of clinical data, links to decision support, maps to other terminologies, translations etc Maintained and distributed by the International Healthcare Terminology Standards Development Organisation (IHTSDO)
Features to support purpose Interface properties synonyms, precoordinated expressions, detail Reference properties concepts defined according to relationships with other concepts in the terminology (supports retrieval, aggregation, mapping) Comprehensive, multi-disciplinary
Multi disciplinary terminology issues Terms in SNOMED CT are profession neutral e.g. NOT physiotherapy terms, nursing assessment terms etc Profession context is provided by record structure and/or user ID Professional groups take the lead for areas of content but must work collaboratively e.g. nurses: care regimes ophthalmologists: eye findings dieticians: dietary assessment cardiologists: cardiac procedures
Two purposes. Conceptualising nursing Representing nursing practice in systems
SNOMED CT doesn t do what some other terminologies do.. Nursing terminologies such as NANDA Support the description of nursing for practice, education and research; may include knowledge that supports clinical reasoning (e.g. defining characteristics of NANDA diagnoses) Usually not structured to optimise use in electronic systems.
Relationship between SNOMED CT and Nursing terminologies If an organisation wishes to use a particular terminology, the individual concepts can be represented using SNOMED CT (content additions may be required) The other features of the terminology are not held within SNOMED CT i.e. definitions, structure / relationships etc A map between SNOMED CT and the terminology / classification may be useful
Nursing Terminology in SNOMED CT Nursing diagnoses are within the Findings hierarchy Nursing interventions are within the Procedure hierarchy Nursing outcomes are within the Observable entity hierarchy Assessment findings are within the Findings hierarchy Integration / maps: NANDA diagnostic labels, NIC intervention terms, NOC indicator terms, CCC, Omaha System, PNDS Copyright 2004 College of American Pathologists
Nursing Diagnosis in SNOMED CT Finding related to ability to perform breathing functions IsA Defining attribute Interprets Respiratory pattern Ineffective Breathing Pattern Defining attribute NANDA 00032 PNDS X7 CCC L26.2 Defining attribute Finding site Respiratory system structure Has interpretation Inefficient Copyright 2004 College of American Pathologists Synonym Breathing pattern impairment Respiratory pattern impairment Ineffective breathing Impaired breathing
SNOMED CT and ICNP As ICNP catalogues develop and are implemented in clinical record systems, the concepts in the catalogues will be represented using codes. In places where SNOMED CT is the standard coded terminology it will be possible to represent the concepts in the ICNP catalogues using SNOMED CT. 2007 : Project to explore / improve coverage of both terminologies (Prof Park, Korea)
SNOMED CT a terminological resource The benefit of recording information in a standard terminology such as SNOMED CT is linked to the benefits of the electronic care record and the benefits of recording clinical information in a structured form SNOMED CT - the language of the NHS Care Records Service. www.connectingforhealth.nhs.uk/publications
Evolution of. Systems SNOMED CT Users In the context of ACTUAL requirements for coded data (also evolving)
Migration of clinical systems Level 2 systems have internal support for SNOMED CT using both pre and post co-ordinated content.. most fully exploit the benefits of using SCT. For the most part these systems do not exist and will require the development of new user interfaces, database information and system interfaces. [Implementing SNOMED CT within national electronic record solutions CHIRAD Health Informatics, www.chirad.org.uk]
Migration of clinician users from unstructured, non standard, narrative records from vague, ambiguous, local terminology and locally adapted clinical tools...from paper records to structured, standard records and messages...to standard, defined, evidence based terminologies and tools to ICT that supports clinical workflow, decision making, recording and communication (and has standard terminology for interoperability)
SNOMED CT Training & Knowledge Model Training Responsibility Experts Terminology Developers Changing / adding Content to SNOMED CfH Tech Office Designers/Builders System Designers Subset Developers Best Practice Groups Cluster Analysts Technical Architects Domain Clinical Experts Power Users Designers influencing changes to SNOMED Information Analysts Clinical Coders/Auditors Information Managers Health Record Managers Clinical Research Groups Managers of Clinical Databases Using information drawn from SNOMED for analysis Trust Trainers End Users of IT applications IT Managers Doctors Clinical Admin Pharmacists Nurses Allied Health Professionals End Users indirectly using SNOMED through clinical applications
SNOMED nursing working group Examples of contribution Subject of Information (ISO model) How to represent NOC concepts Education, teaching and counselling Assessment scales in SNOMED CT Coverage reviews and other quality checks Nursing orders guidance Mapping guidance SNOMED CT nursing subset feasibility study
Coding, mapping.. NOT A CLINICAL TASK A clinical terminologist task with expert clinical input Pain = 22253000
Mapping guidance example The concept is what you need not necessarily the obvious term e.g. dressing The concept may be expressed in SNOMED CT using words that are different to the ones you are searching for you may need to think laterally and paraphrase to find what you want
Paraphrasing example You want... Unwilling to eat Poor food intake Potential for abuse Help with toileting Unable to transfer SNOMED has Refusing food Inadequate food diet At risk of abuse Self care assistance toileting Dependent: chair/bed transfer If a widely used synonym is missing: request it
Structure of assessment tools Name: Braden scale Topic: Pressure ulcer risk assessment Observable: Mobility Value: Fully Waterlow Score Mobility Pressure ulcer prevention assessment Fully Restricted etc. + Composite score values & term: 21 / high risk
Term matching - Implications A need for consensus building to improve interreviewer reliability: Differences in term only matches Differences in concept only matches Cases where no attempted match was made by one or both reviewers Cases where one reviewer found a term match but the other went further to concept matching or to suggest a new concept
SNOMED CT Nursing Subset feasibility project Conducted on behalf of the Royal College of Nursing by Nicholas Hardiker RN PhD Senior Research Fellow, University of Salford, UK Associate Professor (Adjunct), University of Colorado-Denver, USA Visiting Associate Professor, University of Wisconsin-Madison, USA
Conclusion A nursing-relevant subset would refer to several thousands (and possibly several tens of thousands) of concepts. It is difficult to see the advantage of such a subset in operational terms, other than perhaps in marginally reducing search time when browsing and in identifying preferred terms for entities
Participation Nursing working group meeting Copenhagen 26-27 October 2007 www.ihtsdo.org Review previous activity (nursing list closed information about communications soon) www.snomed.org Contact Chair Dr Judy Warren jwarren2@kumc.edu
Resources International Healthcare Terminology Standards Development Organisation www.ihtsdo.org NHS information and resources www.connectingforhealth.nhs.uk Implementing SNOMED CT within national electronic record solutions CHIRAD Health Informatics www.chirad.org.uk