Solving the Health IT Interoperability Puzzle with SNOMED CT Dr. Michael Bainbridge Head of Clinical Engagement IHTSDO

The Problem

The examination question? How do you provide to me: Safe Effective Reproducible State-of-the-art 21st Century medicine Wherever I am Whatever the time Whatever is wrong with me And better still: Prevent me getting ill And don’t harm me in the process The examination question?

Why is this important ?

Workforce

The Complexities of Physician Supply and Demand: Projections Through 2025 Michael J. Dill and Edward S. Salsberg American Center for Workforce Studies November 2008

Consumer Demand

Australia Australia Korea

Knowledge Published medical knowledge doubles every 73 days Trans Am Clin Climatol Assoc. 2011; 122: 48–58. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116346/ Knowledge

Clinical Knowledge-Processing Burden “Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable” Crane and Raymond The Permanente Journal Winter 2003 Volume 7 No.1 Kaiser Permanente Institute for Health Policy Clinical Knowledge-Processing Burden Knowledge processing requirement This gap injures patients Knowledge processing capacity Years ago Today

Cost

“growth in health expenditures is the biggest single challenge for budget sustainability” http://grattan.edu.au/static/files/assets/ff6f7fe2/187_budget_pressures_report.pdf

The Solution is to Digitise Health Global solutions are necessary The Solution is to Digitise Health

Clinical Interoperability – what does it really mean? Data can be moved seamlessly between systems and across borders and it will mean the same thing regardless of what system it is located in. Patient Safety will improve because clinicians will be able to see the whole picture on a patient regardless of the system or the location. Unnecessary or duplicate tests will be reduced. Consistency in treatment protocols may be increased. Information can be used either retrospectively or in real time to allow decision makers to make smart decisions in the deployment of scarce resources.

How do we express and share clinical meaning?

Do we both Understand each other ? Clinical Interoperability Integration Engine Data Computer Application Integration Engine Data Computer Application Traditionally we’ve focused on the technical “integration challenge” of getting data from one software application to another in a form that can be consumed by the receiving software application. The current requirements and design documents focus on the information/data requirement and how that information is transformed into electronic messages. This misses the key elements of usability and user centered design which, when added to the existing process allows us to address the true interoperability challenge of transferring meaningful information from one user to another. The Technical View of Interoperability Do we both Understand each other ? Current Medication Intolerance Allergy and ADR ‘Primary’ Diagnosis ‘Indication’ Western medicine Presenting complaint Oriental Medicine

Why use a terminology? There are different ways to represent clinical ideas Free text Intuitive data entry Does not support meaning-based retrieval Structured data based on forms Well designed form can make data capture easy Effective retrieval requires common structure and consistent representation of clinical ideas Simple code systems Reduces variability of recording Enables retrieval of single specific clinical ideas May not support retrieval of ideas at different levels of detail Statistical classifications, e.g. ICD Clinical terminology, e.g. SNOMED CT myringotomy inflammation hearing aid earache otitis media

SNOMED Clinical Terms Health Records Terminology Reason for admission SNOMED CT Concept Body structure (body structure) Clinical finding (finding) Diagnosis Reason for admission Environment or geographical location Family history Event (event) Allergies Lab test results Observable entity (observable entity) Therapy Surgery Organism (organism) Medication Care plan Pharmaceutical / biologic product (product) Physical force (physical force) Physical object (physical object) Procedure (procedure) Qualifier value (qualifier value) Record artifact (record artifact) Situation with explicit context (situation) SNOMED CT Model Component (metadata) Health Records Social context (social concept) Terminology Special concept (special concept) Specimen (specimen) Stages and scales (staging scale) Substance (substance)

SNOMED CT acts as a bridge between other code systems Enables cross-domain queries and analysis ICD-10 LOINC ICD-9 SNOMED CT Free Text ICD-9 Local Codes ICD-O3 ICNP2

Concept A clinical idea with a unique identifier 22298006 Firstly, a SNOMED CT concept is a clinical idea (or clinical meaning) with a unique permanent identifier. This example shows the concept (or idea) of an “infarction (or necrosis) of the heart structure” - commonly known as a heart attack. Every concept, like this one here, has a unique identifier which is permanent and unchangeable for that clinical meaning. 22298006 Enable meaning- based queries

Description 22298006 Assist in searching and finding concepts FSN myocardial infarction (disorder) 751689013 SYN myocardial infarction 37436014 SYN cardiac infarction 37442013 The second core component type in SNOMED CT is a Description, which is a human-readable term linked to a concept. Each concept (or clinical idea) has 2 or more descriptions – which create a permanent link between each term and the concept. Most descriptions are categorized as either Fully Specified Names or Synonyms. The Fully Specified Name (or FSN) is a term that unambiguously identifies the concept – in this case it is ‘myocardial infarction (disorder)’. Every Fully Specified Name ends with the name of hierarchy in which it’s located in brackets. This is called the ‘semantic tag’. The ‘semantic tag’ in this example is “disorder”. This tells us that this concept can be found in the “disorder” hierarchy. The other type of description is called a Synonym. Synonyms provide an alternative way of describing the concept – for example ‘cardiac infarction’, ‘heart attack’ etc. Every description also has a unique and unchangeable identifier, which is permanently linked to the same concept. SYN heart attack 22298006 37333015 SYN MI – Myocardial infarction 1784872019 Assist in searching and finding concepts Enhance string- matching in NLP Multi-lingual support SYN myocardial infarct 1784873012 Human-readable term linked to a concept

Relationship finding site 74281007 We’ve looked at Concepts and Descriptions. Now the last core type of component in SNOMED CT is the ‘Relationship’. Relationships link concepts together and, in doing so, can express the defining characteristics of a concept. For example, a ‘myocardial infarction’ has a finding site of ‘myocardium structure’ and an associated morphology of ‘infarction’. Technically speaking, a relationship is actually a triple containing the Source Concept (in this case ‘myocardial infarction’), the relationship type (such as ‘finding site’) which is itself also a concept and the target concept (for example ‘myocardium structure’). These relationships triples provide the logic-based definitions of the clinical meanings in SNOMED CT, which enables much of the powerful inferencing and analytics that it supports. associated morphology myocardium structure (body structure) 22298006 myocardial infarction (disorder) Can express the defining characteristics of a concept 55641003 Support queries based on defined meaning Infarct (morphological abnormality)

Relationship 414545008 57809008 609410002 ischemic heart disease myocardial disease necrosis of anatomical site is a is a is a Relationships are also used to create a subtype hierarchy from the most general concepts at the top, down to the most specific concepts at the bottom of the hierarchy. Hierarchies are defined using the ‘is a’ relationship type, which says for example that a ‘myocardial infarction’ is a ‘myocardial disease’, it is a ‘ischemic heart disease’, and it is a ‘necrosis of anatomical site’. SNOMED CT is said to be a ‘polyhierarchy’ because each concept can have more than one parent, or more general concept. 22298006 myocardial infarction ‘is a’ relationships form a subtype ‘polyhierarchy’

Subtype Relationships SNOMED CT concept To aggregate concepts To query detailed content stored in EHRs using more abstract concepts is a clinical finding is a finding by site is a cardiovascular finding Subtype relationships can be used to aggregate groups of concepts together, or to perform queries using abstract concepts (such as ‘heart disease’), which are able to match against any of the more specific concepts that may be stored in a clinical record (such as acute myocardial infarction). is a cardiac finding is a heart disease QUERY CRITERIA is a myocardial disease is a MATCHING EHR DATA myocardial infarction is a acute myocardial infarction is a acute myocardial infarction of anterior wall

Why use SNOMED CT? SNOMED CT based clinical information benefits individual patients and clinicians as well as populations and it supports evidence based care. The use of an Electronic Health Record (EHR) improves communication and increases the availability of relevant information. If clinical information is stored in ways that allow meaning-based retrieval, the benefits are greatly increased. The added benefits range from increased opportunities for real time decision support to more accurate retrospective reporting for research and management.

Questions and Discussion Contact: info@ihtsdo.org Website: www.ihtsdo.org