SNOMED Training Workshop SNOMED CT in primary care Denise Downs, Ian Spiers, Helen Beecroft

Welcome to SNOMED Training Workshop Agenda 9.30 Registration 10.00 Welcome and Introductions 10.30 Training others on SNOMED CT 11.30 Tea/Coffee 11.50 Training Presentations 12.30 Data Quality 13.00 Lunch 13.45 Data Quality Continued 14.15 Existing Searches (Tea/Coffee at 3.00) 15.15 Supplier updates 16.00 End of workshop Who we are ? Fire/Toliets/Lunch Respect statements and no question is a silly question What we want from the day, jot down anything want to share or discuss – lots of Q&A sessions Best if people from same organisation sit on different tables Ice breaker

Housekeeping Toilets Fire Refreshments Introductions to NHSD team

Don’t need to know anything about SNOMED CT Nothing will change Things will greatly improve I need to understand SNOMED CT Hear what appear to be contradictory thoughts – but the intention is that need to change the underlying terminology, and can then develop incrementally improved functionality. As systems in daily use, desire to do that in a smooth transition for users.

Year 2000 again ??? Plan for the worst Hope for the best!

Objectives Give you time to get more confident and ask questions Understand SNOMED and what is the key information for training practice staff Understand Data Quality and differences between Read and SNOMED Understand SNOMED Searches Update on suppliers Key Objectives for Day

Pre-workshop Requirements Webinars/Recorded Presentations ‘Introduction to SNOMED CT for general practice’ ‘Exploring Content in SNOMED CT’ Laptop or Smart device for Internet Browsers Example templates and reports Prior to the workshop we would ask that you have listened to the ‘Introduction to SNOMED CT for general practice’ and ‘Exploring Content in SNOMED CT’. The introduction is available a s a live webinar, a recorded version or bit-sized version of the full recording. Details of both sessions are on our Education and Training web pages.   Can we also remind you of the requirement to bring either a laptop or a Smart Device that is capable of connecting to the internet; there will be some workshop time that requires you to browse the SNOMED CT on-line browser and Look-ups.

Ice Breaker

Ice Breaker In pairs, find five things you have in common with the other person (5 mins) This does not include anatomy  In your pairs, what is one thing you want to come away from today with ?

Understanding SNOMED CT and training practice staff

Understanding SNOMED CT and training practice staff In pairs: Workbook Sections 1-3 (40 mins) In groups of 4: Design Training for a practice (20 mins) Create bullet points of what are the key things to cover Devise a 10 min presentation Tea/Coffee Break 3 of the presentations will be chosen to present 10.30 Understanding SNOMED CT and training practice staff 11.30 Tea/Coffee 11.50 Training Presentations 12.30 Prepare materials to give the introduction to practice managers with bullet points of what are the key things to cover. We’ll pick 3 from a hat

Data Quality

Inactive codes SNOMED CT can deal with inaccuracies in a way Read couldn’t: Concepts can be made inactive Descriptions can be made inactive Inactive concepts/descriptions should not be visible for data entry Inactive concepts can be used in searches

In the browser Some Read codes are mapped to inactive SNOMED CT Descriptions Need to choose

Inactive concepts

Look-up for Read to SNOMED Browsers Top 2 browsers created from NHS Digital maps Demo look-ups including what inactive content means

Some current maps are to inactive codes

Inactive code - ambiguous Some Read codes are mapped to inactive SNOMED CT Bill/fee sent inactive in SNOMED CT It is ambiguous, do have Bill sent and Fee sent Need to choose

Ambiguous codes Serum bilirubin borderline is inactive in SNOMED CT It is ambiguous, do have Borderline low and Borderline high Need to choose

Not interoperable Terms with Clinic A / Clinic B have codes mapped to inactive SNOMED CT concepts These will map but to inactive codes; they are not interoperable, never went through GP2GP Different Practices will have different clinics Use specific clinic type administrative terms in future e.g. seen in asthma clinic, referral to asthma clinic

NOS, NEC, unclassified … Classification Terms 3519007 |Disorder of synovium (disorder)| 68172002 |Disorder of tendon (disorder)| 10597006 |Disorder of bursa (disorder)| 68962001 |Muscle pain (finding)| 26889001 |Myositis (disorder)|

Maps to higher level terms E2B.. Depressive disorder NEC 35489007 Depressive disorder Eu32. [X]Depressive episode X00SO Depressive episode Eu32y [X]Other depressive episodes   [X]Depression: [oth episode][atypic][single epis masked NOS] Eu32z [X]Depression NOS [X] Depression NOS [X]Depressive disorder NOS [X]Depressive episode, unspecified [X](Depressn: [episode unsp][NOS (& react)][depress dis NOS] Eu33z [X]Monopolar depression NOS Depressive illness Depression Depressed XaB9J Depression NOS XE1Za XE1Zb

Maps to different hierarchies Template Design 1 Under care of team District nurse Social context Practice nurse Dietitian Hospice Environment / location Under care of care of the elderly physician Clinical finding Under care of palliative care physician Under care of continence nurse Under care of podiatrist This will mean you have to write cherry picked searches in SNOMED CT, ideally all should be Under of care terms so can interoperate (we’ll come back to this)

Section 4 Workbook (30 mins) In groups look at Data Quality Guidance Will this effect your sample templates/reports? Review those you have brought with you. What can you do ahead of time? Lunch (13.00-13.45) Q&A 12.30 Data Quality 13.00 Lunch 13.45 Data Quality Continued 14.15 Demo look-ups including what inactive content means Part 4 of workbook

Data Quality : Questions and Answers Any questions/observations? 13.00 Lunch 13.45 Data Quality Continued 14.15 Demo look-ups including what inactive content means Part 4 of workbook

Collaborative space - Delen Area specifically for trainers to share information If you don’t have access email: snomedprimarycare@nhs.net

Searches

Designing Searches Presentation Convert one of your searches (Use look up tables and Browser) Questions and Answers (1 hour) (tea and coffee at 15:00 ) 14.15 Searches (Tea/Coffee at 3.00) 15.15

Concepts and descriptions Synonyms are truly synonymous Searches are done on the concept id FSN is often the term provided in search definitions Fully specified name Preferred term Acceptable synonyms Preferred term is usually the description seen in the system Concepts can have many descriptions as clinicians have many different ways of expressing the same things Searches will be written at concept level

Language of SNOMED CT specifications Operators in SNOMED CT - Expression Constraint Language (ECL) conceptid just this concept <conceptid the descendants of this concept <<conceptid this concept and all its descendants ^refsetId members of refset Then any of the above preceded by MINUS exclude concepts (s) OR include concepts(s) or concept(s) AND include concept(s) AND concepts(s)

Expressing a search We can express a search in two ways: Use ECL and the hierarchy structure : Concept and all of its descendants <<233838001 | Acute posterior myocardial infarction (disorder) | Cherry pick the codes (cluster list): List each concept seperately 233838001 | Acute posterior myocardial infarction (disorder) | 70998009 | Acute myocardial infarction of posterobasal wall (disorder) | 15713201000119105 | Acute ST segment elevation myocardial infarction of posterobasal wall (disorder) | Although these produce the same result, that may only be true for a particular release. We’ll see that using the hierarchy is a better way to write the searches when we can. Simple example, most searches are expected to be much larger First specifies the exact codes we’re interested in Second method uses the |is a| relationship to define the search |is a| relationships are as shown on the right (note |is a| relationships to other concepts are not shown << realtes to the concept and all its children, more on this later

Walkthrough – Example 1 Hip replacement

Search for hip replacement Total Revision Partial

Where in the hierarchy do we search:

Walkthrough – Example 2 Contraception – comparison with Read If we searched on children of Contraception 61…

Would get patients on contraception …

Would get patients Not on contraception

Would get patients Not actually person of record term Unknown whether on contraception or not

Have a go yourselves Either do some you brought with you (either looking for data items for a template or a search) OR Try the following: All patients who have had a stroke All obese patients

Moving to SNOMED CT – things to be aware of Searches will continue to work once moved to SNOMED CT UNTIL someone starts recording data that does not have a Read code equiv. Two ways to approach migrating a search from Read v2/CTV3 to SNOMED CT Take the previous search definition and write a new SNOMED CT search from scratch This may include SNOMED CT concepts that do not have a Read v2/CTV3 equivalent Take the previous search codes and map these to SNOMED CT This will need extending and reviewing in future as SNOMED CT concepts without a Read v2/CTV3 equivalent are used SNOMED CT evolved from the Read codes – we didn’t throw everything away and start again. Everything that is current and in Read you will find in SNOMED – its just more extensive as it supports more than general practice. It also supports some data that wasn’t addressed by Read for example allergies

Approach 2: Not fully automatic A previous search cannot not be converted automatically as contains content not in Read, this needs a human to check Example: C10..% Diabetes mellitus TO << 73211009 | Diabetes mellitus (disorder) | May be ok Example: H33..% Asthma TO << 195967001 | Asthma (disorder) | For example include Exercise induced Asthma , which may not wish to include

Steps for Approach 2 Expand current query to all Read codes Expand list to all terms for all codes Map each to SNOMED CT Reduce to the list of unique SNOMED CT concepts Are there any other Read codes that map to these concepts ? How do we then extend this to be a SNOMED CT search?

How can this be transformed into SNOMED CT? Approach 2: example Take the previous search codes and map these to SNOMED CT Following example illustrates the approach and why some results may be different once data entry moves to SNOMED CT How can this be transformed into SNOMED CT? The first approach does not attempt to convert on a code by code basis, is the simplest, this uses all of SNOMED CT so not all concepts will have a corresponding Read code. The first part of the presentation used this approach The second approach will convert on a code by code basis. So far we’ve looked at how to find SNOMED CT codes to create a search from scratch but for converted searches lets look at why they may produce different results in SNOMED CT to Read

Approach 2: term level and map Expanded to 73 Read codes Which map to 67 SNOMED CT concepts Notice two different Read codes go to the same SNOMED CT concept

Considering historical data In simple terms we have performed the following: Are there any other Read codes that map to our list of SNOMED CT concepts? We can use the Delen look-up to find out Original search We need to consider these as they would be picked up by the converted search but not by the old search

Back to the example of Diabetes mellitus When checking the forward mapping tables for the 67 concepts in the converted search we find there are other Read codes not in the original specification Original Read v2 specification: 73 codes Converted SNOMED CT specification: 67 concepts Review codes that also map to these: 138 codes The tables show the maps at read code term code level to SNOMED CT concepts and descriptions. However the search would only be executed at concept level This is one example of the result of the ‘round trip’ So running the search in SNOMED CT would in effect be searching over more Read codes than the original search . However we have not yet been able to test on patient level data so a converted search specifying DM for example may or may not result in a different number of patients being returned by the search .

Other mapping features One Read v2/CTV3 code may go to different SNOMED CT concepts as synonyms were not always true synonyms in Read v2/CTV3 H330. Read code links to 3 different SNOMED CT concepts due to the mapping tables taking into consideration that the synonyms were not true synonyms

Practical Working in pairs, take an element of one of your searches and go through Approach 2 to see any differences you get

Supplier Update 15:15 Supplier updates Delen closed space – share presentations How do they want this space to be used – your space!!!! We are there to facilitate not control/manage Task to do over next 2 weeks 1 thing you find out / question a practice asks you … Other resources 16:00 Finish

Supplier Update

EMIS Code picker Available to download via their Support Centre Not the final version, but close to it

Microtest Screens (1/3)

Microtest Screens (2/3)

Microtest Screens (3/3)

Post Coordination

What about: Left / right Planned / done Family history … Under the care of

Post coordination toe mild toe moderate finger severe Lung chronic infection inflammation Lung chronic acute bacterial exertional angina cough ischaemic viral This ‘decompositional’ analysis suggests that a better way to manage things might be to keep track of the relevant characteristics of an accident, and their allowed values, and enable people to define the detailed concept they want from a set of more basic pieces. Alan Rector coined the term ‘conceptual lego’ for this approach: you can build – compose, or ‘post-coordinate’ - almost anything from a relatively small number of different types of pieces, subject to any rules governing how things can be assembled. phlegm

Different user interfaces Structured Data Entry File Edit Help FRACTURE SURGERY Reduction Fixation Fixation Open Open Closed Femur Tibia Fibula Ankle More... Radius Ulna Wrist Humerus Femur Left Left Right More... Gt Troch Shaft Neck Neck To provide simple interfaces for clinicians which can support their day to day clinical care...

Representing context in a health record Context can be expressed in a health record using: Pre-coordinated expressions 2. Context-specific section or field 3. Separate context field 4. Post-coordinated expressions Family history of diabetes mellitus Family History: Diabetes mellitus Problem: Context: Diabetes mellitus Family history 281666001 |Family history of disorder|: 246090004 |Associated finding| = 246090004 |Diabetes mellitus| Context can be expressed in a health record in a number of ways. Firstly, a pre-coordinated expression can be used in which the context is captured in the meaning of the concept. For example “Family history of diabetes mellitus”. Alternatively, a post-coordinated expression can be used. This is where the meaning is expressed by combining codes in a structured way using SNOMED CT Compositional Grammar. For example: ‘Family history of disorder’ with ‘associated finding’ equal to ‘diabetes mellitus’. A third way to express context is to use a context-specific section or field, such as a ‘Family history section’, which captures the context in the meaning of the section or field name. In this example, the field name is ‘Family history’ and the value used is ‘Diabetes mellitus’. The combination of the field name and the field value gives us the meaning ‘Family history of diabetes mellitus’. And lastly, it is also possible to use two separate fields -one which captures the finding ‘Diabetes mellitus’, and the other which captures the context ‘Family history’. Ref. A SNOMED International Education Slide

Currently – no post coordination Replace one Read code with one SNOMED CT Can get Snomed concepts with more than one ‘thought’ A concept provided is known as pre coordination BUT, over time, this will change and post coordination will start to be introduced, primarily for areas not well covered or where there are long list with very similar concept descriptions ... Likely areas: Left /right Family history Any suggestions?

Next Steps … 15:15 Supplier updates Delen closed space – share presentations How do they want this space to be used – your space!!!! We are there to facilitate not control/manage Task to do over next 2 weeks 1 thing you find out / question a practice asks you … Other resources 16:00 Finish

Delen : SNOMED CT in Primary Care Trainers workspace This is your space Have you looked ? What would be useful? Task for next 2 weeks – post on forum one thing you find out or a question a practice asks Delen closed space – share presentations How do they want this space to be used – your space!!!! We are there to facilitate not control/manage Task to do over next 2 weeks 1 thing you find out / question a practice asks you …

Workshop Roundup Any questions?

Next steps Data Quality regular webinar (monthly) ?? Scope of these ? QOF webex – walkthrough of QOF in SNOMED CT Anything else you need?

Thank you … Helpdesk: snomedprimarycare@nhs.net We will email you: