Transcript Introduction to SNOMED CT

Introduction to SNOMED CT
Why SNOMED CT? Features, Examples of Use &
Benefits
Monday 16th November, 10.30 – 11.30
Presented by
Jo Oakes ([email protected])
1
WHY SNOMED CT?
Electronic Patient Records
Quality Healthcare requires effective
communications
Effective communications need a
common language and a common
structure for humans AND for computers
SNOMED CT allows clinical data to be
recorded in a human recognisable and a
computer recognisable way
Why SNOMED CT?
• SNOMED CT has been selected and
approved as the terminology to be adopted
by the NHS in England. It is the most
comprehensive international terminology
currently available and can be used across
all care settings and all clinical domains.
Interoperable
With an agreed
structure data
can be passed
from one
system to
another
Discharge Summary
(may contain SNOMED CT)
Patient
visits GP
SNOMED
CT
Clinician
treats
Patient
To achieve this
we need to use
structured
records and a
structured
terminology
Using Choose & Book
to make the referral
SNOMED CT
• The chosen terminology for the NHS
England
GP’s
Laboratories
Community
SNOMED
CT
A&E
Acute
Mental
Health
Use of
Synonyms
helps cater
for different
expressions
with the same
meaning
‘Coding’ in the NHS
• Clinical phrases that are recorded in a
patient
record (EPR)
and
capture
Terminologies are
designed
to
be
used
by
clinically relevant data related to
Terminologies
clinicians in their recording
of data
in aProvides
patienta
individuals and
their care.
standard
vocabulary of
terms.
record. Classifications
are intended
forclinical
population
statistics and analysis. Maps between SNOMED
CT and the classifications
are provided as part of
• categorise episodes of care into
the national products
to support
classification
populations
or groups
of patients
according
Classifications
coding.to specific business rules
and support epidemiology, payment,
population monitoring
Any Questions
Please put yourself on mute when not talking. Many Thanks
SNOMED CT
SNOMED CT – What is it?
• SNOMED CT is a clinical terminology
Systematized Nomenclature of Medicine (Clinical Terms)
SNOMED CT – What is it?
• SNOMED CT is a clinical terminology
Systematized Nomenclature of Medicine (Clinical
Terms)
• Collection of names and words
SNOMED CT – What is it?
• SNOMED CT is a clinical terminology
Systematized Nomenclature of Medicine (Clinical
Terms)
• Collection of names and words
• Relevant to the field of medicine
SNOMED CT – What is it?
• SNOMED CT is a clinical terminology
Systematized Nomenclature of Medicine (Clinical
Terms)
• Collection of names and words
• Relevant to the field of medicine
• Organised in a structured and logically consistent
manner
SNOMED CT – What is it?
• SNOMED CT is a clinical terminology
Systematized Nomenclature of Medicine (Clinical Terms)
• Collection of names and words
• Relevant to the field of medicine
• Organised in a structured and logically consistent
manner
More ‘like’ a thesaurus than just a coding scheme
SNOMED CT Content
Clinical
Findings
Causes of
Disease
Procedures
•
•
•
•
Disease and deformity – scar
Symptoms – difficulty breathing
Social – finding of walking aid use
Examination findings – tachycardia
• Forces – pressure change
• Events – road traffic accident
• Organisms – herpes simplex virus
•
•
•
•
Laboratory
Therapy
Clinical Investigation
Surgical procedure
SNOMED CT Content
Anatomy
Observations
Products
• Normal – knee joint
• Abnormal – ganglion cyst
• Lesions – bony callus
• Vital signs – blood pressure
• Body product observable – colour of urine
• Values - present
• Drugs – paracetamol
• Substances – latex
• Devices – bedpan
Sitting Blood
pressure
Blood
pressure
Lung
von Recklinghausen's bone
disease
Clinical ‘ideas’ are Concepts in the
terminology
toe
inflammation
mild
finger
moderate
ischaemic
infection
severe
acute
bacterial
cough
exertional
viral
angina
phlegm
A Concept
Codes and descriptions
Relationships
Is a
Attributes
Qualifiers
& values
A Concept in SNOMED CT
Preferred Term: Heart Disease
Synonym: Cardiopathy
Synonym: Disorder of Heart
Synonym: Morbus Cordis
Synonym: Cardiac Disorder
Synonym: Cardiac Diseases
Synonym: Heart Diseases
Heart disease (disorder)
56265001
Relationships
Is a cardiac
finding
Is a disorder of
mediastinum
Is a disorder of
cardiovascular
system
Finding site
heart
structure
Severity
Episodicity
Courses
Disease
Infectious disease
Disorder by body site
Infection by site
Disorder of trunk
Bacterial infectious disease
Disorder of thorax
Respiratory tract infection
Bacterial infection by site
Disorder of lung
Lower respiratory tract infection
Lung consolidation
Pneumonia
Bacterial respiratory infection
Infectious disease of lung
Infective pneumonia
Bacterial lower respiratory infection
Bacterial pneumonia
Subsets
What is a SUBSET?
• SNOMED CT is extensive – it is supporting a
common vocabulary for all healthcare specialisms,
and all healthcare professionals, as well as
keeping up to date with current practice
• A subset is ‘smaller set of SNOMED CT ‘ that
meets a particular requirement
• A SNOMED CT subset can be a group of
concepts, descriptions or relationships chosen for
relevance under certain conditions or in certain
contexts
Subsets
Why SUBSETS?
• It is often desirable to constrain the SNOMED
CT concepts available to a subset, say to help
faster data entry – so for example, all possible
performed procedures in a radiology department
or a theatre department
Subsets
HOW APPLICATIONS USE SUBSETS
• Supports easier navigation
• Can be used to limit to specific SNOMED
CT codes
• Can act like a ‘favourites’ for the end user
• Can be used nationally or locally –
synchronised national releases
• Access to subsets may be role based
Current Subsets Examples
Allergens
Diagnosis
Laterality
Radiology
procedures
Browser Demo
• Examples of concepts in a browser
Any Questions
Please put yourself on mute when not talking. Many Thanks
EXAMPLES OF USE
Success with SNOMED CT
Things are normally in the
singular, e.g. eye not eyes
When searching don’t always use
full words, e.g. diab would return
both diabetic and diabetes
Don’t enter words like “and”, “to”
and “the”
Success with SNOMED CT
Use techniques similar to how you
currently search the internet and
medical publications
Search for significant words and don’t
worry about the order, e.g. implant
lumbar cath would return implantation
of lumbar epidural catheter
Try common abbreviations, e.g. PID
for prolapsed intervertebral disc
What’s Recorded?
Examples of patient information
that are currently recorded using
SNOMED CT include:
•
•
•
•
•
Diagnoses – e.g. Crohn’s Disease
Procedures – e.g. colonoscopy with biopsy
Allergies – e.g. metronidazole
Symptoms – e.g. abdominal pain
Drugs – e.g. prednisolone
What the Clinician Sees
Crohn’s Disease
34000006
Decision to Admit
If it is decided to admit a patient in
A&E, a structured form is completed
with details of the speciality referred
to and treatment required. When
these are recorded in SNOMED CT
they can be sent electronically to the
GP so they are kept informed of key
information about their patients.
Allergies/ADRs
The recording of Allergies and
Adverse Reactions can be critical
for the effective care of a patient.
Ensuring these are clearly
recorded for use by other clinicians
is an ideal use of SNOMED CT.
Discharge Summary
Once the intervention has
been completed a discharge
summary is returned to the GP
and may contain SNOMED CT
terms that could be taken
straight into the GP system
SNOMED CT in Action
• The following sections contain screen
shots from applications that use SNOMED
CT
• We are grateful for their kind permission to
use these as without them it is sometimes
difficult to envisage what SNOMED CT
looks like in use
MOORFIELDS EYE HOSPITAL
– OPEN EYES SOFTWARE
SNOMED CT in Action
Click on the drop down
list to see a list of
common diagnoses
which are all SNOMED
CT terms
SNOMED CT in Action
Diagnosis can be
selected from a list of
common diagnoses
which are all SNOMED
CT terms
SNOMED CT in Action
Alternatively type in
what you are looking for
and a list of SNOMED
CT terms containing the
text will appear
SNOMED CT in Action
The same can be done
for procedures, select
from a list of commonly
used procedures which
are all SNOMED CT
terms
SNOMED CT in Action
You can also type in the
procedure you are
looking for and the list
that appears will all be
SNOMED CT terms
NHS E-REFERRAL SERVICE
Making an Appointment
• GPs can use e-Referral to make
appointments for their patients who can
then make their decision based on choices
such as ease of travel or nearest location
SNOMED CT in Action
The Clinical Term is selected
from a list of SNOMED CT
terms
SNOMED CT in Action
Type in the term to
be searched for
SNOMED CT in Action
A list of terms appears
SNOMED CT in Action
The selected term is shown
below with its parents and
children
SNOMED CT in Action
Select the required term
SNOMED CT in Action
The selected term then
appears in the Clinical
Term box
CSC LORENZO
Type in what you are
looking for and then
click on the search
button
Select the
required
term
Select certainty
from the drop down
list
Find the term
you require
Select severity
from the drop
down list
Select severity
from the drop
down list
The body site then
needs to be
selected
Type in the body site
and click to search for
it
Select body site
from the list
displayed
Select laterality
from the drop down
list
Select laterality
from the drop down
list
Click on add to add
the body site
Click on Finish to
complete save
Start to type the
procedure you are
looking for
Click on the search
button to display
the procedures
Click to use the
advanced search
Children of the term are
displayed allowing you to
select a more detailed term
Select the term to
display even more
detailed terms
Further terms are
displayed
Select the required
term
Click on Finish to
add it to the record
The other fields can be
completed in the same
way as for diagnosis
Click on Finish to
complete save
SNOMED CT in Applications
• SNOMED CT has been implemented in
many applications and as has been shown
in the previous slides should not make
things complicated
• Clinicians should just see terms they are
familiar with using and not even realise
they are SNOMED CT terms
BENEFITS OF SNOMED CT
Across Professions
Across different specialisms: orthopaedics,
cardiology, renal, microbiology, histopathology ...
Across primary, secondary, community, social
care, mental health
Synonyms – same concept said in different ways
to support cross discipline working
Communication – “Connect all”
Seamless transfer - coded information to
be electronically communicated - without
mapping
Translated into different languages:
Spanish, French, Swedish, Danish ...
Work starting in Lithuanian, Polish
International
Suppliers in different countries using the same terminology
Potential for improved functionality of systems as supporting
just one terminology
Collaborative effort: more cost effective
Links with other international standards – eg. World Health
Organisation
How can I look at SNOMED CT?
• There are various free to use browsers
available on the market. Details of those
that support the UK Edition of SNOMED
CT can be found in the UKTC:
• http://www.hscic.gov.uk
Learn more about SNOMED CT
Visit: Training and Resources on UKTC website
eLearning
future webinars
SNOMED CT NHS network
Documentation
Case studies
Any Questions
Please put yourself on mute when not talking. Many Thanks