So lets get started, Todays webinar is about SNOMED CT in QOF SNOMED CT in primary care Ian Spiers, Terminologist, NHS Digital Set up Int Browser – show descri ID – enlarge size ++ Thank you very much for joining us, we will be starting the webinar at 2.30   Good afternoon everyone – we will wait until 2.30 to give people chance to log in It is now 2.30 so I will make a start Welcome to SNOMED CT in QOF Webinar My name is Ian Spiers, this webinar will take about 25 mins with the opportunity for questions at the end of the presentation You will be able to ask questions in 2 ways Either take yourselves of mute (as everyone is automatically put on mute when on WebEx)– there is a microphone next to your name in the participants list on the right hand side If you click on the red microphone you can unmute yourself Alternatively you can use the chat box to type your question I have Catherine/Helen on the webinar as well who will help me in looking at any chat questions The presentation will be available after the webinar which we will email to you So lets get started, Todays webinar is about SNOMED CT in QOF

Contents SNOMED CT – Standards Requirements QOF Versions Expression Constraint Language (ECL) Rubric strings in SNOMED CT Expanded Clusters Lists in SNOMED CT Today we are going to cover A recap on the SNOMED CT – Standards Requirements Some details about the upcoming QOF Versions A basic introduction to Expression Constraint Language (ECL) Example of a Rubric strings in SNOMED CT Example of an Expanded Clusters List in SNOMED CT

SCCI standard SNOMED CT is a national standard (SCCI0034) under the Health and Social Care Act. The standard has required implementation dates for providers of healthcare: Systems used by GP service providers must adopt SNOMED CT as the clinical terminology within the system before the 1 April 2018. SNOMED CT must be utilised in place of the Read codes before 1 April 2018. Secondary Care, Acute Care, Mental Health, Community systems, Dentistry and other systems used in the direct management of care of an individual must use SNOMED CT as the clinical terminology before 1 April 2020. Social Care is in scope of the standard but there are currently no required implementation dates. This is expected in a future update to the standard. Read v2 was retired on 1st April 2016, CTV3 to be retired on 1st April 2018. No more Read codes to be created. In November 2016, required dates for implementing SNOMED CT were issued; this decision was taken by the National Information Board which consists of national organisations such as NHS England, Public Health England, NHS Digital, NHS Improvement, NICE etc. So national organisations and suppliers have known and been planning for this for some considerable time. You will see from this slide that all providers of healthcare are required to use SNOMED CT. The key dates for General practice are highlighted in yellow: 1st April 2018. In addition to the SCCI notice a letter has been sent from GPSoC to all suppliers on the GPSoC framework informing them of this national requirement. Substantial communication to CCGs, CSUs and other national providers has also been undertaken. Click Under separate notices, the retirement schedule for the Read codes was also issued in 2014 – this gave retirement dates for Read v2 of April 2016 (there have been no new Read v2 codes since that date), and for CTV3 in April 2018.

GPSoC Requirements Enable the user to use SNOMED CT wherever they currently use Read v2 / CTV3 Retain original Read v2 / CTV3 codes in records Enable to work correctly over historical data Convert all artefacts that use Read to SNOMED CT Use national mapping tables (NHS Data Migration) (Website enables user to lookup Read codes) QOF/GPES in Read for 2017/2018, in SNOMED CT for 2018/2019 Requirements have been issued to all suppliers by GPSoC – these are available on the GPSoC website under the programme section of GPSoC Those requirements include: For new codes to be provided through SNOMED CT rather than Read For the system to use SNOMED CT wherever it currently uses Read The original Read codes in patient records to be retained in addition to SNOMED CT Any new queries written in SNOMED CT should run correctly over historical data – which would have been captured in Read And that all existing reports, template etc should be converted to SNOMED CT. Tables that map from a Read code to an appropriate SNOMED CT code are provided nationally, all suppliers must use these. They are available for anyone to download if they wish – the link is on this slide There are also a number of websites that enable users to enter a Read code (or parts of a Read code) and be given the SNOMED CT code that it maps to. NHS Digital provide these look-ups as well as some external organisations. The link on this slide takes you to a webpage with links to those sites, the top two are NHS Digital and these are updated every time the mapping tables are updated.

SCCI0034: SNOMED CT Product Specification States “Data extractions (including reports) from the system using clinical and care related content to be specified using SNOMED CT………………national data returns (for example QOF - Quality and Outcomes Framework) or GPES (General Practice Extraction Service) in primary care, will be specified using SNOMED CT clinical terms and thus systems must provide reporting functionality that can incorporate queries written using clinical terms from SNOMED CT.”

QOF Versions As described in the slide QOF Business Rules Publication Date  Format Released  For Testing Only (System suppliers) Version 37 Published Normal document format in Read v2 / CTV3 Expanded Cluster Lists in Read v2 / CTV3 Expanded Cluster Lists in Read v2 / CTV3 / SNOMED CT Rubric Strings in Read v2 / CTV3 / SNOMED CT Version 38 January 2018 Version 39 Baseline 2018/2019 April 2018 Normal document format in SNOMED CT Expanded Cluster Lists in SNOMED CT Rubric Strings in SNOMED CT   As described in the slide Versions 37 and 38 will have the normal QOF document format in Read v2 and CTV3 and the expanded cluster lists There are Expanded cluster lists and Rubric strings in SNOMED CT that have given to system suppliers for test purposes only to allow them to get familiar with SNOMED in QOF Version 39 which is the baseline for QOF 2018/2019 will be released in April 2018 and will have the Normal document format, expanded cluster and rubric strings in SNOMED only This all depends on testing though, if the testing shows up issues etc. then it can be longer.

Current Normal Document Format PDF Here is an example of some of the clusters in the current Normal document format (pdf) which are in Read v2 and CTV3 – you will be familiar with this format- The rubrics strings are expressed in a % format - which means include the code and all its code descendants (Click) For example 9hA.. % as shown in slide includes codes 9hA.., 9hA1. and 9hA2. The next slide shows the expanded clusters that are also published

Current Expanded Cluster Lists xlxs Currently the expanded clusters are also in Read v2 and CTV3 in an excel format – these expand the rubric strings to show which Read codes are actually included in QOF and give the Read code terms In this example all the Read v2 codes that are included as part of the Asthma diagnosis cluster are shown I have also shown on the right v2 Rubric for Asthma diagnosis codes A similar table is provided for CTV3 and the first 3 lines are shown on this slide

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) Expression Constraint Language - Specification and Guide Going forward the QOF rubrics in SNOMED will use the ECL (Expression Constraint Language) which is shown here This is similar to the original % type rubrics but uses different symbols and has a few more logical operators such as OR Expression Constraint Language link on slide – there are many more operators but these are the ones that are mostly likely to be used in QOF

Test Rubric Strings (xlsx) Expression Constraint Language (ECL) will be used to specify QOF in SNOMED CT Read v2 and CTV3 have different structures to SNOMED CT and so not as straight forward as replacing one code for another in rubric strings Only SNOMED CT Rubric String will be in Version 39 QOF 2018/2019 specification This slides shows an example of a test Rubric string for Smoker Codes Expression Constraint Language (ECL) will be used to specify QOF in SNOMED CT Looking at the slide what are most noticeable differences in the way Rubric strings are expressed are Comma’s are replaced with the Logic expression OR % are replaced by << (double arrows) Excluding is replaced by MINUS And that SNOMED CT ID’s are not recognisable like they were for Read v2 codes, e.g. 160613002 does not indicate which hierarchy it belongs to unlike 137.. Please Note Read v2 and CTV3 have different structures to SNOMED CT and so not as straight forward as replacing one code for another in rubric strings Only SNOMED CT Rubric String will be in Version 39 QOF 2018-2019 specification

SNOMED CT Browser This concept would be included in Smoker codes As you can see the SNOMED CT Concepts codes are shown in the rubric strings You can use the SNOMED CT Browser to look at some of the codes in the rubric strings This is good when you are trying to identify which concepts are included in the specification and their hierarchical structure Also it is useful to see what is deliberated excluded from QOF as well For example 134406006 when searched for in the browser shows the concept Smoking reduced (finding) As you can see this concept has no descendants (children) but in the future it might and they could then be included in the QOF specification if applicable

SNOMED CT Browser Looking at another example in the SNOMED CT Browser For example 77176002 when searched for in the browser shows the concept Smoker (finding) As you can see this concept has 7 direct descendants (children) which also have further children

SNOMED CT Browser Expanding the hierarchy under Smoker (finding) All these could be included in QOF return unless they were specifically identified as not to be included You can use the SNOMED CT Browser To look at all descendants (children ) of the concept Smoker (finding) As you can see this concept and its 7 direct descendants (children) have many more children that would be included unless they were specifically identified as not to be included

SNOMED CT Browser This concept would be excluded in Smoker codes In this example 698289004 | Hookah pipe smoker (finding) has been specifically been excluded from the Smoker Codes

Test Expanded Cluster (xlsx) Note Version 39 will only have SNOMED CT in expanded cluster To save you having to work out what all the rubric strings mean in terms of which SNOMED CT concepts are included An expanded cluster list will also be provided in excel format and this is your true reference of what concepts are included A test example is shown in this slide Please Note Version 39 will only have SNOMED CT in expanded cluster

SNOMED CT Codes Version 39 – This is the ‘baseline’ release for SNOMED CT and so will not contain inactive concepts based on UK SNOMED CT October 2017 release. However, releases after v39 could contain inactive concepts Any SNOMED CT concepts that are inactivated in the bi-annual release during the QOF year period still need to be included in QOF returns if in the published expanded cluster list Any new SNOMED CT concepts that are added in the bi-annual release during the QOF year period may be included in QOF returns. This depends on the impact analysis processes that take place for each code release (April and October). If a code is deemed to be valid for inclusion in the service, it will be added to the expanded cluster list and published and will be valid for use. Always follow the published QOF business rules for a given QOF release Version 39 – This is the ‘baseline’ release for SNOMED CT and so will not contain inactive concepts based on UK SNOMED CT October 2017 release. However, releases after v39 could contain inactive concepts Any SNOMED CT concepts that are inactivated in the bi-annual release during the QOF year period still need to be included in QOF returns if in the published expanded cluster list Any new SNOMED CT concepts that are added in the bi-annual release during the QOF year period may be included in QOF returns. This depends on the impact analysis processes that take place for each code release (April and October). If a code is deemed to be valid for inclusion in the service, it will be added to the expanded cluster list and published and will be valid for use. Always follow the published QOF business rules for a given QOF release

SNOMED CT in QOF – Points to note QOF Version 39 – Baseline 2018/2019 Will be published April 2018 and include Normal document format (pdf), Expanded Cluster (xlsx), Rubric Strings (xlsx) all in SNOMED CT only Expression Constraint Language (ECL) will be used to specify QOF in SNOMED CT System suppliers will use Version 39 QOF 2018/2019 specification in systems which will capture the SNOMED CT data that is entered

NHS Digital Training & Education Resources Useful Information on SNOMED CT Further education and other presentations Short Video Clips Documentation Requesting new content or changes to SNOMED CT Find on : NHS Digital SNOMED in Primary Care Helpdesk: snomedprimarycare@nhs.net