Useful Applications for SNOMED CT

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

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

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. 3 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. 4 AHIMA 2007 Audio Seminar Series 2

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 5 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 AHIMA 2007 Audio Seminar Series 3

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 AHIMA 2007 Audio Seminar Series 5

SNOMED CT January 2007 Release Formal logic-based definitions are organized into the following top-level hierarchies Clinical finding Procedure Observable entity Body structure Organism Substance Pharmaceutical/biologic product Specimen Qualifier value Record artifact Physical object Physical force Events Environments/geographical locations Social context Situation with explicit content Staging and scales Linkage concept Special concept (Inactive concept) 11 SNOMED Content and Relative Size of other Terminologies 250,000 200,000 150,000 100,000 NURSING ICD-O CPT Social Context Context-Dependent Observable Entity Qualifier Value Pharmaceutical/Biological Product Substance Organism Body Structure Finding Procedure Other Physical Object Staging and Scales Other: Physical object Staging and Scales Environments and geographical locations Attribute Specimen Physical Force Events Environments and geographical locations Attribute Specimen Physical Force Events 50,000 ICD-9-CM Disease 0 S N O M E D C T 12 AHIMA 2007 Audio Seminar Series 6

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 13 SNOMED CT Subsets and Maps Subsets: Problem list Allergens Cancer check lists US Drugs Languages: US English UK English Spanish German Maps: ICD-9-CM ICD-10 ICD-O3 OPCS-4 NANDA- International NIC, NOC, Omaha, HHCC, PNDS LOINC 14 AHIMA 2007 Audio Seminar Series 7

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 16 AHIMA 2007 Audio Seminar Series 8

Problem List Post-coordination: GE Healthcare (Centricity) 17 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 18 AHIMA 2007 Audio Seminar Series 9

Problem Capture 19 Problem Capture 20 AHIMA 2007 Audio Seminar Series 10

Problem Capture 21 Problem Record 22 AHIMA 2007 Audio Seminar Series 11

Clinical Findings are Specific Dr C orders testing of carotid circulation to assess bruit detected on examination 23 Right carotid stenosis 24 AHIMA 2007 Audio Seminar Series 12

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 26 AHIMA 2007 Audio Seminar Series 13

Case Study: Maintaining Precise Clinical Data 27 Case Study: Multi-use Clinical Data Order entry Service recognition 28 AHIMA 2007 Audio Seminar Series 14

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 postcoordination, UMLS, ICD-9-CM Vocabulary coding reviewed and graded: Exact, Broad, Narrow, Missing Assess for systematic strengths, deficiencies and suggestions of editorial priorities 30 AHIMA 2007 Audio Seminar Series 15

Guidelines Studied Immunizations Standards of care for patients with diabetes Pressure ulcer risk assessment and prevention Major depression in adults for mental health providers Institute For Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute For Clinical Systems Improvement(ICSI);2002 Jun. 49p. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002 Jan;25(Suppl 1):S33-S49. Royal College of Nursing. Pressure ulcer risk assessment and prevention. London: Royal College of Nursing; 2001 Apr. 36 p. Institute For Clinical Systems Improvement (ICSI). Major depression in adults for mental health care providers. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2002 May. 43 p. 31 Results: SNOMED CT coding completeness by guideline Exact match Broader Narrower Missing Immunizations N=127 98% 0 0 2% Diabetes N=90 92% 3% 3% 2% Depression N=93 85% 1% 6% 8% Pressure sores N=71 70% 15% 0 15% 32 AHIMA 2007 Audio Seminar Series 16

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. 33 SNOMED CT Hierarchical Relationships Guideline goal: If patient has diabetes mellitus, Then administer a flu shot 34 AHIMA 2007 Audio Seminar Series 17

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) 35 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 problem list 36 AHIMA 2007 Audio Seminar Series 18

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? 37 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 38 AHIMA 2007 Audio Seminar Series 19

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 Nurse K records diagnoses on problem list 39 Problem Capture 40 AHIMA 2007 Audio Seminar Series 20

Problem Capture 41 Problem Capture 42 AHIMA 2007 Audio Seminar Series 21

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 43 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 AHIMA 2007 Audio Seminar Series 22

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) 45 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 46 AHIMA 2007 Audio Seminar Series 23

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 Standards of care for patients with diabetes Pressure ulcer risk assessment and prevention Major depression in adults for mental health providers Institute For Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute For Clinical Systems Improvement(ICSI);2002 Jun. 49p. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002 Jan;25(Suppl 1):S33-S49. Royal College of Nursing. Pressure ulcer risk assessment and prevention. London: Royal College of Nursing; 2001 Apr. 36 p. Institute For Clinical Systems Improvement (ICSI). Major depression in adults for mental health care providers. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2002 May. 43 p. 48 AHIMA 2007 Audio Seminar Series 24

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 50 AHIMA 2007 Audio Seminar Series 25

Specific Diet Education: Diabetes 51 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 52 AHIMA 2007 Audio Seminar Series 26

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 53 Questions??? AHIMA 2007 Audio Seminar Series 27

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 Audio Seminar Discussion Following today s live seminar Available to AHIMA members at www.ahima.org Click on Communities of Practice (CoP) icon on top right AHIMA Member ID number and password required for members only Join the Clinical Terminology Community from your Personal Page then under Community Discussions, choose the Useful Applications for SNOMED CT Audio Seminar thread You will be able to: Discuss seminar topics Network with other AHIMA members Enhance your learning experience AHIMA 2007 Audio Seminar Series 28

AHIMA Audio Seminars Visit our Web site http://campus.ahima.org for information on the 2007 seminar schedule. While online, you can also register for seminars or order CDs and pre-recorded Webcasts of past seminars. Upcoming Audio Seminars Information Integrity in EHRs March 13, 2007 Coding Kidney Disease and Treatment March 15, 2007 New Date: Understanding and Using ICD-10-PCS April 10, 2007 AHIMA 2007 Audio Seminar Series 29

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