Introduction to SNOMED CT

Jo Oakes Training Consultant

NHS Data Standards & Products

Agenda

History of Coding What is SNOMED CT? What are the benefits of SNOMED CT?

History of Coding

A Background to Coding

17th Century John Gaunts Weekly Bills of Mortality

London Bills of Mortality

every Thursday from 1603 until the 1830s

Aggregated Statistics 1665

Manchester Mercury
January 1st 1754
List of diseases & casualties this year 19276 burials 15444 christenings Deaths by centile
Aged 1456 Consumption 3915 Convulsion 5977 Dropsy 794 Fevers 2292 Smallpox 774 Teeth 961 Bit by mad dogs 3 Broken Limbs 5 Bruised 5 Burnt 9

Drowned 86
Excessive Drinking 15

Executed 18 Found Dead 34 Frighted 2 Kill'd by falls and other accidents 55 Kill'd themselves 36 Murdered 3 Overlaid 40 Poisoned 1 Scalded 5 Smothered 1 Stabbed 1 Starved 7 Suffocated 5

Quotation
I am fain to sum up with an urgent appeal for adopting some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison If wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have means of ascertaining at present.

Florence Nightingale

Notes on Hospitals, London: Longman, Green, Roberts, Longman and Green, 1863.

Florence Nightingale 1856

Outcome groups
Relieved Not Relieved

Died

Dr William Farr 1855

Developed the International Listing of Causes of Death

Adopted by World Health Organisation (WHO) in 1948

History of the Clinical Terms

1985 1990 1990 1992 1994 1999 2007 4 byte set introduced Version 2 introduced Purchase by Department of Health Terms Projects Version 3 introduced SNOMED Collaboration IHTSDO created

What is SNOMED CT?

First things first

Systematized Nomenclature of Medicine SNOMED CT- Clinical Terms Developed by NHS and the College of American Pathologists (CAP) Merges the content of the NHSs Clinical Terms Version 3 (The Read Codes) with CAPs SNOMED Reference Terminology (SNOMED RT) For the front end users (clinicians) SNOMED is not about the codes, but the terms it is unlikely clinicians will see the codes

SNOMED CT overview
Comprehensive clinical terminology that is used to: Code Retrieve, and Analyze clinical data Comprises of: Concepts Terms Relationships All necessary to precisely represent clinical information across the scope of health care.

Basic Elements of SNOMED CT

Concepts The basic units of SNOMED CT Descriptions These relate terms that name the concepts to the concepts themselves. Each concept has at least two Descriptions. Hierarchies Concepts are organized into twenty SNOMED CT hierarchies (in UK extension). Each hierarchy has subhierarchies within it. Relationships Relationships are the connections between concepts in SNOMED CT.

Concepts
Represent distinct clinical meanings Identified by a unique numeric identifier (Concept ID) that never changes and a unique human readable name (Fully Specified Name) Associated with each concept is a set of relationships (the logical definition) and a set of names or terms Differing levels of granularity There are currently around 400,000 terms in SNOMED CT

Descriptions
Concept descriptions relate the terms or names of a SNOMED CT concept to the concept itself. Term in this context means a phrase used to name a concept. A single description associates a single term with a single Concept ID. Each of these descriptions has a unique Description ID, but all of these descriptions are associated with a single concept (and a single Concept ID). Descriptions are an important interface property because they give end users the flexibility to use terms that they are familiar with. The Concept ID ties terms with the same meaning together to aid consistent interpretation and retrieval.

Description types
Preferred Term The most common word or phrase used by clinicians to name a concept The Fully Specified Name Provides an unambiguous way to name a concept Synonyms The rest of the names that may be used for a concept

Example of components
Some of the descriptions associated with ConceptID 22298006: Fully Specified Name: Myocardial infarction (disorder)
DescriptionID 751689013

Preferred term: Myocardial infarction

DescriptionID 37436014

Synonym: Cardiac infarction

DescriptionID 37442013

Synonym: Heart attack

DescriptionID 37443015

Synonym: Infarction of heart

DescriptionID 37441018

Words and semantics

Its not what you say, its what you mean The meanings of words and phrases change In context Between places Between disciplines and specialties Between different times SNOMED CT encodes meaning, not just words

The problem with words and meaning

What is a pyogenic granuloma? Pyogenic = pus forming Granuloma = a collection of inflammatory cells of a particular type But Pyogenic granuloma = a benign tumor of small blood vessels of the skin It is neither pyogenic nor a granuloma.

Combinations are frequently very different from the sum of their parts

The problem with words and meaning

Does the leg mean the same as the lower limb?

Thats what the average person assumes Health professionals also often use the word leg in this way
But medical dictionaries take a different view

Stedmans: the segment of the inferior limb between the knee and the ankle Dorlands: that section of the lower limb between the knee and ankle
Ordinary dictionaries recognise both meanings

Some formal definitions conflict with ordinary usage

Practical Tip
Dressing (oneself) Dressing (observable entity) parent personal care activity Dressing, device (physical object) Dressing patient (procedure)
Dressing of wound (procedure)

Dressing (e.g. a bandage) Dressing (assisting the person to dress) Dressing (of wound)

SNOMED is not the language police

SNOMED CT seeks to

Establish how language is used by clinicians To represent meaning as faithfully as possible.

SNOMED CT declares what it thinks a phrase means

To reflect current usage To minimise ambiguity Not to shape or control the way a phrase is used
If you want someone to demand that clinicians change what they call pyogenic granuloma

That may be someone elses job Its not something SNOMED CT is trying to do

Top-level hierarchies (October 2007)

1. Clinical finding 3. Observable entity 5. Organism 7. Pharmaceutical/biologic product 9. Physical object 2. Procedure 4. Body structure 6. Substance 8. Specimen 10. Physical force

11. Events
13. Social context

12. Environment or geographical Location

14. Situation with explicit context

15. Staging and scales

17. Special concept 19. Record artifact

16. Qualifier value

18. Linkage concept 20. SNOMED-CT UK Administrative Concepts

Hierarchies Clinical Finding: Contains the sub-hierarchies of Finding and Disease Important for documenting clinical disorders and examination findings Procedure: Concepts that represent the purposeful activities performed in the provision of health care Observable entity Concepts represent a question or procedure which, when combined with a result, constitute a finding Body structure Concepts include both normal and abnormal anatomical structures Abnormal structures are represented in a subhierarchy as morphologic abnormalities

Examples Finding: Swelling of arm Disease: Pneumonia

Biopsy of lung Diagnostic endoscopy Foetal manipulation Gender Tumour size Ability to balance Entire Liver ( body structure) Neoplasm (morphologic abnormality)

Hierarchies
Organism Coverage includes animals, fungi, bacteria and plants necessary for public health reporting and used in evidence-based infectious disease protocols Substance Covers a wide range of biological and chemical substances Includes foods, nutrients, allergens and materials Used to record the active chemical constituents of all drug products Pharmaceutical/Biological Product This hierarchy is separate from the Substance hierarchy in order to clearly distinguish drug products (products) from the chemical constituents (substances) of drug products

Examples
Hepatitis C virus Streptococcus pyogenes Acer rubrum (Red maple) Felis silvestris (Cat) Dust Oestrogen Haemoglobin antibody Methane Codeine phosphate Sex hormone product (product) Mineralocorticoid preparation (product) beta-Blocking agent (product)

Hierarchies

Examples

Specimen Contains concepts representing entities that are obtained for examination or analysis, usually from a patient They are defined in terms of the normal or abnormal body structure from which they are obtained, the procedure used to collect the specimen, the source from which it was collected, and the substance of which it is comprised
Physical object Concepts include natural and man-made objects Focus on concepts required for medical injuries

Nail specimen Pus specimen Clean catch urine Specimen from patient Calculus specimen

Prosthesis Artificial organs Vena cava filter Colostomy bag

Physical force Fire Includes motion, friction, electricity, sound, radiation, Gravity thermal forces and air pressure Pressure change Other categories are directed at categorizing mechanisms of injury

Hierarchies
Events Concepts represent occurrences that result in injury Exclude all procedures and interventions Environment or geographical location Includes all types of environments as well as named locations such as countries, states, and regions Social context Contains social conditions and circumstances significant to healthcare Includes family and economic status, ethnic and religious heritage, and life style and occupations

Examples
Flash flood Motor vehicle accident

Islands of North America NHS day treatment facility Cancer hospital

Economic status (social concept) Asian (ethnic group) Clerical supervisor (occupation) Donor (person) Thief (life style) Judaism (religion/philosophy)

Hierarchies

Examples

Situation with Explicit Context To represent medical information completely, it is sometimes necessary to attach additional information to a given concept If this information changes the concept's meaning, it is known as context This category represents concepts that carry context embedded within in them
Staging and scales Contains concepts naming assessment scales and tumour staging systems

No family history of stroke Nasal discharge present Aspiration pneumonia resulting from a procedure

Glasgow coma scale (assessment scale) Alcohol use inventory (assessment scale) Dukes staging system (tumour staging)

Hierarchies

Examples

Qualifier Value Contains values for SNOMED CT attributes Values that are not contained elsewhere in SNOMED CT are needed for attributes and these are contained here
Special Concept This has three sub hierarchies containing concepts which have been set aside from the logical hierarchy of semantic subtypes

Bilateral Open Reduced Removal action Right

Inactive concept the supertype ancestor of all Inactive Concepts Navigation concept the supertype of all Navigation Concepts Namespace concept the supertype of all Namespace Concepts

Hierarchies

Examples

Linkage Concept Attributes and other concepts used to link concepts with other concepts
Record Artefact Reports and forms associated with the delivery of healthcare

Laterality, Method, Severity, Is manifestation of, Has reason

Jury exemption form, Postmortem report

SNOMED CT UK Administrative Concept Seat belt exemption admin, Concepts that are unique to the Item of service administration administrative processes in healthcare in the UK

Relationships
The connections between concepts Every SNOMED CT concept has at least one relationship to another concept Relationships characterize concepts and give them their meaning The list of relationships for a particular concept makes up the logical definition of that concept 2 types: IS-A (sub-type/super-type) Attribute

Relationships cont
Is a relationship also known as supertype-subtype or parent child relationships
A relationship is assigned only when that relationship is always known to be true

IS-A relationships
SNOMED CTs hierarchies consist entirely of IS-A relationships IS-A relationships in the Inflammatory disorder hierarchy: Lumbar discitis IS-A Discitis Discitis IS-A Arthritis Arthritis IS-A Inflammatory disorder Inflammatory disorder IS-A Disease Some concepts have more than one IS-A relationship. These concepts have parent concepts in more than one hierarchy: Lumbar discitis IS-A Discitis Lumbar discitis IS-A Disorder of back

Procedure IS_A Procedure on lymph node IS_A Biopsy of lymph node

IS_A
Surgical biopsy of lymph node IS_A Excisional biopsy of lymph node

SNOMED CT Concept

Disease

Disease of respiratory system Infectious disease Disease of lung

Pneumonia

Infective pneumonia

Bacterial infectious disease

Bacterial pneumonia

Attribute Relationships
Characterize and specify concepts An example of an attribute is FINDING-SITE, which is used to further specify Disease concepts

e.g. part of the logical definition of the concept Pneumonia in SNOMED CT is: Concept = Pneumonia Attribute = FINDING-SITE Value of attribute = Lung structure

Attribute Relationships
finding lower limb pain in limb

pain in lower limb

lower limb structure

pain in calf

structure of calf of leg

Why is SNOMED CT relevant?

Cross Boundary
Universal Language

The Spine

SNOMED CT Delivers Information

Most clinicians should neither know nor care

- How many digits are in a concept identifier - How many concepts are in SNOMED CT - How descriptions and relationships are tied to concepts
David Markwell, Chair of SNOMED Concept Model Working Group

What clinicians care about is

Clinical records they use meet their needs Record system components that work together reliably Being able to easily express the information they wish to enter in a patient record Being able to retrieve information to support delivery of care or for secondary uses with a minimum of extra effort
David Markwell, Chair of SNOMED Concept Model Working Group

What are the benefits of SNOMED CT?

SNOMED CT: The Benefits

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

Benefits of an Electronic Record

Reduced storage costs Can be accessed from many places Can be transferred quickly It is legible

Benefits of a Structured Record

Can display logical progression of clinical data Can retrieve clinical data based on situation or author Allows clinical data items to be transmitted longitudinally through a patients record

Benefits of using a Clinical Terminology

Controlled vocabulary Point of care uses: The ability to search records for clinical information Identification of patients who match a given set of criteria Provision of decision support

Benefits of using a Clinical Terminology

Aggregation uses: Public health monitoring Outcomes analysis Performance analysis

Benefits of using SNOMED CT

Provides a consistent terminology across all care domains SNOMED CT allows precise recording of clinical information SNOMED CT has an inherent structure SNOMED CT is a developing international standard

What does it mean for clinicians?

It will be legible! May encourage more detailed documentation Decrease duplication of recording patient information Less ambiguous/better clarity of clinical information More communicable Consistency leads to better sharing of information Improved granularity for research purposes

The Future for Clinical Coders

What does this mean for Clinical Coders?

The current system of ICD-10 and OPCS-4 classification is not going to disappear overnight The cross-mapping of SNOMED CT to ICD-10 or OPCS-4 can only ever be a semi automatic process Coders will continue to be responsible for the clinical classification coding and trust payment Coders will be supported by new tools that help with some of the simpler translations of SNOMED CT to ICD-10 and OPCS-4

What does this mean for Clinical Coders? (2)

NHS CFH Informatics and the NHS Classifications Services are assessing the training and support coders require under the Education, Training and Development unit with CFH Support for clinical uses of SNOMED CT and maintenance of SNOMED CT subsets is potentially an enormous opportunity for people who understand the issues surrounding coded medical information and are skilled at performing complex data analysis If the process of populating HRGs from SNOMED CT can be proved, there will be additional benefits in rationalising the many coding schemes currently used in medicine.

Is SNOMED CT Perfect?
The man who makes no mistakes does not usually make anything. E J Phelps (1822 - 1900) so SNOMED CT is not perfect

The goal is fitness for purpose not perfection

Contact details and further information

NHS Data Standards & Products http://www.connectingforhealth.nhs.uk/standards/ - SNOMED CT http://www.connectingforhealth.nhs.uk/snomed

- UK Terminology Centre (UKTC) http://www.ihtsdo.org.uk

- Helpdesk DS&P Helpdesk : Tel : 0044 (0)1392 206 248 Email: datastandards@nhs.net