Transcript I Arrowsmith PACS SIG 25 Jun 03

The Principles of Electronic
Transfer of Radiology
Reports to GPs
Ian Arrowsmith
NHS Information Authority
(Why) do we need electronic
clinical messaging ?
The NHS Plan
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An “NHS designed around the patient”.
Stresses the need to support well co-ordinated
“seamless” services across “whole systems”.
The right information available at the right place, at the
right time for the right care provider (and in a useful
form)
What is a clinical message ?
What is a message ?
Main Entry: 1mes·sage
Pronunciation: 'me-sij
Function: noun
Etymology: Middle English, from Old French, from
Medieval Latin missaticum, from Latin missus, past
participle of mittere
Date: 14th century
1 : a communication in writing, in speech, or by
signals
2 : a messenger's errand or function
3 : an underlying theme or idea
Merriam-Webster
What is a clinical message ?
What is communication?
Main Entry: com·mu·ni·ca·tion
Pronunciation: k&-"myü-n&-'kA-sh&n
Function: noun
Date: 14th century
1 : an act or instance of
transmitting.....information.....a verbal or
written message....a process by which information
is exchanged between individuals through a common
system of symbols, signs, or behavior...
Merriam-Webster
What is a clinical message ?
‘Clinical information’ as defined by CEN:
Information about a patient, relevant to the health or
treatment of that patient, that is recorded by or on behalf
of a healthcare professional.
CEN - Commite Europeen de Normalisation; a Brussels based
organisation of 18 national standards bodies in Europe. The Health
Informatics Technical Committee of the European Standardization
Committee is known as CEN TC251
What is a clinical message ?
A communication in writing, in speech,
or by signals which contains information
about a patient, relevant to the health or
treatment of that patient, that is
recorded by or on behalf of a healthcare
professional.
A simple clinical message
Clinical messaging in the
21st Century
NHS Definition
Clinical Messaging can be defined
as
“The secure electronic
transmission of structured data
that contains patient information,
between healthcare parties."
Basic Clinical Message Types
Request/Order
 Report/Result
 Query/Update
 Acknowledgement

Clinical message examples
Pathology requests and reports to GPs
 Radiology requests and reports to GPs
 Discharge summaries to GPs
 Out of Hours messages to GPs
 NHS Direct messages to GPs
 GP to GP record transfer
 GP to Outpatient referrals
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What do we want to achieve ?
Faster delivery of report
 ‘Safer’ delivery of report
 More timely treatment of patient
 Possible provision of links to images
 Information incorporated directly in GP
patient record

Current Practice
Pony Express
 Snail Mail
 Fax
 Unstructured text report emailed
 Structured text ‘message’ delivered
 Notification that a report is available for
browsing sent to GP by email
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Disadvantages of current practice
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Data may be unstructured -incorporation into
GP record not automated
Data may be structured in different ways
Inconsistency in composition of data
transferred - coding schemes
Variable levels of Security/Confidentiality
Properties of a National
Message Specification
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The Message should be Structured
The Message structure should be
Standardised
The Message content should be
Standardised
The Message should be transferred
securely
Structured Message
Family history

Diagnosis

Message
System A
System B
Technical aspects
Messaging standards
 Security/Confidentiality
 Infrastructure
 Coding
 Browsing

Security/Confidentiality
Content Integrity
 Clinical domain-domain encryption
 Origin authentication by application
 Secure confirmed receipt by application
(non-repudiation)
 Access control

Message Development Issues
Developing standards
 Emerging technologies
 Government Edicts
 NHS Strategy
 Stakeholder buy-in
 Patient access to reports
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Benefits
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Delivery times for diagnostic imaging reports to
GPs are improved
Availability and speed of access of diagnostic
imaging reports by GPs is improved
Confidentiality is enhanced due to direct clinicianclinician communication
Reliability of delivery of reports is increased
Clinical terminology and its
application to Radiology
Ian Arrowsmith
NHS Information Authority
Clinical Terminology
• What is a clinical terminology?
• Why do we need one?
• What do we use it for?
• What are the properties of a terminology
• SNOMED CT
What is a clinical terminology ?
A collection of health related terms to allow
healthcare providers to accurately record all
aspects of patient-related activity consistently
NHS Information Authority definition
What does it cover ?
These terms describe the care and
treatment of patients covering areas such
as diseases, operations, treatments, drugs
and administrative items
What is a clinical terminology
used for ?
The terminology enables computer
systems to accurately capture, and then
retrieve on demand, patient information,
in a natural clinical language
Practical uses
• Clinical summaries
• Integrated computerised decision support
• Prescribing
• Referral/Discharge letters
• Clinical Messaging
• Aggregated data analysis
Fundamental properties of a
Terminology
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Codes, Concepts, Terms
Synonyms
Hierarchies
Compositionality
Semantic Definition
Dynamism
Codes, concepts and terms
• “Concept” includes:
• Term:
• Code:
• Symbol:
Stomach
7N301
Preferred terms and synonyms
• Each concept has one unique
preferred term without ambiguity,
and may have any number of
synonyms
• Synonyms may be shared with other
concepts
Ambiguity
• Absent thumb PF263 (Read V2)
• Could be congenital or acquired
Ambiguity
P…. Congenital anomalies
PF… Other congenital limb anomalies
PF2.. Reduction deformity of upper limb
PF26. Agenesis of radial ray
PF263 Absent thumb
Ambiguity in radiology
• Barium enema
•
•
•
•
Single contrast ?
Double contrast ?
Unprepared ?
Via colostomy ?
Synonymy
Spinal cord compression
Cord compression
Xa0Nk
Umbilical cord compression X40Cc
Cord compression
Synonymy in radiology
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atlantoaxial X-ray (procedure)
atlantoaxial X-ray
C1 C2 X-ray
craniocervical junction X-ray
plain X-ray atlas/axis
odontoid peg X-ray
Hierarchies
•Arrange randomly
•Arrange by spelling
A
D
O
Apple Dog Orange
•Arrange by meaning
Fruit
Animal
Apple
Dog
Orange
Zebra
Z
Zebra
Hierarchies
Compositionality - eg Laterality
• Departmental system
• Left thumb X-ray code 001a
• Terminology
• Thumb X-ray
• Laterality
• Left
code 241074003
code 272741003
code
7771000
Or Enumeration ?
Primary open fixation of fracture of left femur
using locked reamed intramedullary nail
32 possible combinations
Semantic definition
Emergency amputation of leg
Priority: Emergency
Method: Amputation
Site:
Leg
Dynamism
• Things change over time – terminology
needs to reflect this
• Molegraphy
• Clivogram
• Air encephologram
• Update mechanism
SNOMED® Clinical Terms
Collaboration between the NHS
and the
College of American Pathologists
History of Read Codes
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1985
1988
1990
1992
1994
1995
1999
4 Byte set introduced
Recommended standard GP computing
Crown Copyright + Version 2 introduced
Terms Projects
Clinical Terms (Version 3) released
First hospital use Version 3
Collaboration with SNOMED
History of SNOMED
• 35 year history
• SNOP
1965
• SNOMED International
1993
• SNOMED® RT
2000
SNOMED CT - a superset
SNOMED RT
CT V3
International Relations
• Healthcare sub-language
Oesophagus/esophagus
Anaemia/anemia
• General
Cortico-pontine fibres/fibers
Grey/gray matter
Thank you for listening..
• Further information available from
• www.snomed.org
• www.nhsia.nhs.uk