1. IHTSDO Education & Implementation Update Dr Linda Bird Implementation Specialist

2. Discussion Overview ▪IHTSDO Update ▪Education ▪Implementation ▪Terminology Binding Overview ▪IHTSDO HL7 FHIR Collaboration ▪Collaboration Overview ▪Terminology Binding Approach ▪Value Set Review Approach 2

3. IHTSDO Update 3

6. SNOMED CT E-Learning Server ▪Online Courses ▪SNOMED CT Foundation Course ▪SNOMED CT Implementation Course ▪SNOMED CT Content Development Theory Course (starts 2016) ▪Open Access Services ▪Starter Tutorials ▪SNOMED CT Challenge ▪Other Educational Materials ▪Member Education Resources ▪Showcase / Expo Presentations ▪Other Presentations

7. SNOMED CT Foundation Course ▪Provides authoritative coverage of a broad range of topics related to SNOMED CT at a relatively basic level ▪Prerequisite for more advanced SNOMED CT courses ▪Self paced requiring a total of 30 – 35 hours ▪May be completed in between 1 week and 4 months ▪E-Learning presentations ▪3 modules with 6 presentations per module ▪Online assessments ▪4 assessments (1 per module and 1 final practical assessment) ▪Completion certificate

8. SNOMED CT Foundation Course – Topics Module A ▪Learning about SNOMED CT ▪Introduction to SNOMED CT ▪SNOMED CT Benefits for Organizations ▪Why Clinical Terminology Matters ▪Introduction to IHTSDO ▪Exploring SNOMED CT Content Module B ▪SNOMED CT Components ▪SNOMED CT Licensing ▪Release Files and Formats ▪SNOMED CT Concept Model ▪Content Development ▪Introduction to Extensions Module C ▪Reference Sets ▪SNOMED CT Configurable Features ▪Translation and Language Preferences ▪Introduction to Mapping ▪SNOMED CT Expressions ▪SNOMED CT Implementation

9. SNOMED CT Implementation Course ▪Builds on knowledge gained during the SNOMED CT Foundation Course ▪Provides an understanding of SNOMED CT that is sufficient for those engaged in various parts of the implementation process ▪Six month course with new intakes every 3 months ▪Requires around 12-15 hours per month ▪Six modules (1 per month) ▪E-Learning presentations (6 - 12 per module) ▪Webinar tutorials (1 per module) ▪Assignments (1 per module) ▪Online assessments (1 per module and 1 final assessment)

10. Implementation Course – Topics (A, B, C) Module A – Adoption & Planning ▪Building the Business Case ▪Implementation Examples ▪Licensing and Distribution ▪SNOMED CT in EHRs ▪Implementation Overview ▪Implementation Approaches ▪Implementation Services & Tools Module B – Design (Terminology Content) ▪SNOMED CT Content Hierarchy ▪Concept Model Overview ▪Clinical Findings, Procedures ▪Pharmaceutical / Biologic Products ▪Substances, Physical Objects ▪Anatomy, Events, Specimen ▪Situation with Explicit Context Module C – Design (Terminology Services) ▪SNOMED CT Logical Design ▪Relationship Views and Transforms ▪Release Format 2 ▪Reference Sets ▪Expressions ▪Expression Constraints ▪Subtype Testing

11. Implementation Course – Topics (D, E, F) Module D – Design (EHR Services) ▪Information Models ▪Interface Terminology ▪Searching ▪Data Entry ▪Analytics ▪Communication ▪Storage Module E – Development ▪SNOMED CT Extensions ▪Handling Missing Content ▪Importing Release Files ▪Accessing Components ▪Mapping Basics ▪Mapping to ICD-10 ▪LOINC and SNOMED CT Module F – Deployment & Use ▪Creating, Distributing and Using Subsets ▪Maintenance and Change Management ▪Using Description Logic ▪Advanced Description Logic ▪Migration from Legacy Systems ▪EHR Tooling Case Studies ▪SNOMED CT Deployment Examples

12. SNOMED CT Content Development Theory Course ▪Audience ▪Those interested in learning more about SNOMED CT content and how changes to content are made ▪Prerequisite ▪Successful completion of the SNOMED CT Foundation Course ▪Duration ▪3 months ▪3 modules (1 per month) ▪E-Learning presentations (4 to 6 per module) ▪Webinar tutorials ▪Assignment ▪Online Assessment

13. ▪Covering: ▪Hierarchy content and concept models ▪Content development theory ▪Requirements ▪Development of new content ▪Changes to content ▪Challenges and things to be aware of ▪No practical authoring component ▪Pilot starting: mid November 2015 SNOMED CT Content Development Theory Course

14. Implementation Activities ▪Data Analytics with SNOMED CT (http://snomed.org/analytics)http://snomed.org/analytics ▪Reviews current approaches, tools and techniques for performing data analytics using SNOMED CT ▪SNOMED CT Family of Languages ▪A consistent family of computable languages to support SNOMED CT related activities ▪SNOMED CT Compositional Grammar (http://snomed.org/compgrammar)http://snomed.org/compgrammar ▪SNOMED CT Expression Constraint Language (http://snomed.org/expressionconstraint)http://snomed.org/expressionconstraint ▪SNOMED CT Query Language (under development) ▪SNOMED CT Templates (under development) ▪IHTSDO / HL7 FHIR Terminology Binding Collaboration ▪To develop and test an approach to model meaning binding and value set review in FHIR resources

15. SNOMED CT Expressions A structured combination of one or more concept identifiers used to represent a clinical meaning. Example: Right hip 182201002 | hip joint | : 272741003 | laterality | = 24028007 | right | Use Cases 1.Expressions in health records 2.Expressions in messages 3.Precoordinated concept definitions 4.Expression associations with LOINC

16. SNOMED CT Expression Constraints A computable rule that can be used to define a bounded set of clinical meanings. Example: Lung disorders with morphology a type of edema < 19829001 | disorder of lung | : 116676008 | associated morphology | = << 79654002 | edema | Valid Concepts: Concept IdTerm 233709006Toxic pulmonary edema 11468004Postoperative pulmonary edema 19242006Pulmonary edema 61233003Silo-fillers’ disease 40541001Acute pulmonary edema 89687005Postimmersion-submersion syndrome 67782005Adult respiratory distress syndrome

17. SNOMED CT Expression Constraints A computable rule that can be used to define a bounded set of clinical meanings. Example: Lung disorders with morphology a type of edema < 19829001 | disorder of lung | : 116676008 | associated morphology | = << 79654002 | edema | Valid Expressions: Expression 19829001 |disorder of lung|: 116676008 |associated morphology| = 79654002 |edema| 19829001 |disorder of lung|: 116676008 |associated morphology| = 40829002 |acute edema| 275504005 |lung cyst|: 116676008 |associated morphology| = 103619005 |inflammatory edema|

18. SNOMED CT Expression Constraints A computable rule that can be used to define a bounded set of clinical meanings. Example: Lung disorders with morphology a type of edema < 19829001 | disorder of lung | : 116676008 | associated morphology | = << 79654002 | edema | Use Cases 1.Terminology binding 2.Intensional reference set definitions 3.SNOMED CT content queries 4.SNOMED CT concept model specifications

19. SNOMED CT Expression Constraint Language

20. Terminology Binding Overview 20 EHR Model

21. Terminology Binding ▪A link between an information model artifact and a terminology artifact ▪Includes additional metadata about the binding EHR Model 21

22. Purpose of Terminology Binding Terminology binding is important whenever the link between information model and terminology is significant in achieving specific business or clinical objectives. ▪Data capture ▪Retrieval and querying ▪Information model library management ▪Semantic interoperability 22

23. Types of Terminology Binding ▪Value set binding: Records a set of possible values which can populate a coded data element or attribute in an information model ▪Model meaning binding: Defines the meaning of an information model artifact using a concept or expression from the terminology EHR Model 23

24. Value Set Binding - Example Fracture type value set 123735002displaced 307184009undisplaced 52329006open 20946005closed Fracture location value set 71341001femur 85050009humerus 118645006pelvis... Fracture laterality value set 7771000left 24028007right 51440002bilateral value set 24

25. Model Meaning Binding - Example 125605004 fracture of bone 116676008 associated morphology 363698007 finding site 272741003 laterality meaning 25

26. Types of Value Set Binding ▪Extensional – defined by enumeration ▪Intensional – defined by a query ▪Simple – uses a single value set ▪Conditional – value set used is determined by a condition ▪Dependency – value of one element depends on another ▪Compositional – value of element is composed from others 26

27. Types of Model Meaning Binding ▪Simple – meaning of each model (with explicit context) ▪Concept domain – SNOMED CT domain of values ▪Attribute and range – Attribute and concept domain ▪Compositional – meaning of data group instance 27

28. IHTSDO HL7 FHIR Collaboration 28

29. IHTSDO / HL7 FHIR Terminology Binding Collaboration Purpose ▪For IHTSDO to provide SNOMED CT expert input to assist HL7 International with its efforts to ensure the quality and appropriateness of use of SNOMED CT in value sets and bindings specified for use in international FHIR resources ▪The intention is that the HL7 International Terminology Authority (HTA) takes responsibility for the resulting international value set and binding work, with advice being provided by IHTSDO 29

30. IHTSDO / HL7 FHIR Terminology Binding Collaboration Scope ▪Phase 1 – Development of approach (April – Sep 2015) a)Model meaning binding: Develop an approach for SNOMED CT model meaning binding for the ‘Condition’ resource b)Value set review: Review one SNOMED CT value set in FHIR to develop a reproducible review process ▪Phase 2 – Testing of approach (Sep 2015 – June 2016) a)Model meaning binding: Test approach on ‘Observation’, ‘Goal’, ‘AllergyIntolerance’, ‘Family history’ and ‘Specimen’ resources b)Value set review: Test the value set review process ▪Phase 3 – Adoption of approach (July 2016 onwards) ▪HL7 will use the approaches developed to develop model meaning bindings and review value sets for remaining FHIR resources, consulting IHTSDO for guidance where required 30

31. HL7 FHIR ‘Condition’ Resource 31

32. Resource Condition – Scope and Usage ▪Used to record detailed information pertinent to a clinician’s assessment and assertion of a particular aspect of a person’s state of health ▪Uses include: ▪Recording a problem, diagnosis, health concern or health issue during an encounter ▪To populate a problem list of a summary statement such as a discharge summary ▪Also used to record certain health states which does not normally present negative outcome, e.g. pregnancy 32

33. Resource Condition – Boundary and Relationships ▪Not to be used to record information about subjective and objective information that might lead to the recording of a condition, e.g. signs and symptoms that are typically captured using the Observation resource ▪However, in some cases a persistent symptom (e.g. fever, headache) may be captured as a condition before a definitive diagnosis can be discerned by a clinician. ▪Specifically excludes Allergy Intolerance ▪Referenced by ▪CarePlan, ClinicialImpression, DiagnosticOrder, Encounter, EpisodeOfCare, Goal, MedicationOrder, MedicationStatement, Procedure, ProcedureRequest, RiskAssessment, VisionPrescription 33

34. Use of Condition.code ▪ Many code systems (e.g. SNOMED CT) will provide codes that define not only the condition itself, but also a particular stage, location, or causality as part of the code. ▪ The Condition.code may also include such concepts as "history of X" and "good health", where it is useful or appropriate to make such assertions. It can also be used to capture "risk of" and "fear of" in addition to physical conditions. ▪ When the Condition.code specifies additional properties of the condition, the other properties are not given a value - instead, the value must be understood from the Condition.code. 34

35. Summary of Approach - Model Meaning Binding 1.Simple binding to single SNOMED CT code ▪404684003 | clinical finding | ▪With context: 413350009 | finding with explicit context | ▪246112005 | severity | 2.Binding to a SNOMED CT expression constraint ▪… MINUS << 420134006 | propensity to adverse reactions | … 3.Binding to SNOMED CT Expression Template ▪413350009 | finding with explicit context | : 246090004 | associated finding | = ( [[ $Condition.code ]] : 246112005 | severity | = [[ $Condition.severity ]], 363698007 | finding site | = [[ $Condition.bodySite ]] … 35

36. Model Meaning Binding – Simple / Attribute Approach ▪Binding to a single code (no context) ElementTypeSNOMED CT Binding ConditionDomainResource404684003 | clinical finding | Condition.codeCodeableConcept116680003 | is a | Condition.severityCodeableConcept246112005 | severity | Condition.bodySiteCodeableConcept363698007 | finding site | Condition. evidence.code CodeableConcept47429007 | associated with | 36

37. Model Meaning Binding – Simple / Attribute Approach ▪Binding to a single code (with explicit context) ElementTypeSNOMED CT Binding ConditionDomainResource 413350009 | finding with explicit context | Condition.codeCodeableConcept116680003 | associated finding | Condition.severityCodeableConcept246112005 | severity | Condition.bodySite CodeableConcept363698007 | finding site | Condition. evidence.code CodeableConcept47429007 | associated with | 37

38. ▪Binding to an Expression Constraint (no context) Model Meaning Binding – Concept Domain Approach ElementTypeSNOMED CT Binding ConditionDomainResource < 404684003 | clinical finding | MINUS << 420134006 | propensity to adverse reactions | MINUS << 473010000 | hypersensitivity condition | MINUS << 79899007 |drug interaction| Condition.codeCodeableConcept Condition.severityCodeableConcept< 272141005 | severities | Condition.bodySiteCodeableConcept < 442083009 | anatomical or acquired body structure | Condition.stage. summary CodeableConcept< 385356007 | tumor stage finding | Condition. evidence.code CodeableConcept< 404684003 | clinical finding | 38

39. ▪Binding to an Expression Constraint (with explicit context) Model Meaning Binding – Concept Domain Approach ElementTypeSNOMED CT Binding ConditionDomainResource < 413350009 | finding with explicit context |: 246090004 | associated finding | = (< 404684003 | clinical finding | MINUS << 420134006 | propensity to adverse reactions | MINUS << 473010000 | hypersensitivity condition | MINUS << 79899007 |drug interaction|), 408732007 |subject relationship context| = 410604004 |subject of record|, 408731000 |temporal context| = 410512000 |current or specified time| 39

40. Model Meaning Binding – Compositional ▪Binding to an Expression Template (Part 1) ElementTypeSNOMED CT Binding Condition Domain Resource IF $Condition.code = < 404684003 | clinical finding | THEN 413350009 | finding with explicit context |: 246090004 | associated finding | = ([[ $Condition.code ]]: 246112005 | severity | = [[ $Condition.severity]], 363698007 | finding site | = [[ $Condition.bodySite]], 47429007 | associated with | = [[ $Condition.evidence.code ]]) 408732007 | subject relationship context | = 410604004 | subject of record |, 408731000 | temporal context | = 410512000 | current or specified time |, 408729009 | finding context | = [[ ?? ]] 40

41. Model Meaning Binding – Compositional ▪Binding to an Expression Template (Part 2) ElementSNOMED CT Binding Condition ELSEIF $Condition.code = < 413350009 | finding with explicit context | THEN [[ $Condition.code ]]: 246090004 | associated finding | = (404684003 | clinical finding |: 246112005 | severity | = [[ $Condition.severity ]], 363698007 | finding site | = [[ $Condition.bodySite ]], 47429007 | associated with | = [[ $Condition.evidence.code ]]), 408732007 | subject relationship context | = 410604004 | subject of record |, 408731000 | temporal context | = 410512000 | current or specified time |, 408729009 | finding context | = [[ ?? ]] 41

42. Effect of Context Values on Bindings ▪Condition.patient ▪Is the scope restricted to conditions about subject of record? ▪Condition.category ▪Complaint, symptom, finding, diagnosis ▪Do these change the value set or model meaning bindings? ▪Condition.clinicalStatus ▪Active, relapse, remission, resolved ▪Condition.verificationStatus ▪Provisional, differential, confirmed, refuted, entered-in-error, unknown ▪How do both these statuses effect the finding context? ▪Condition.dateAsserted ▪Temporal context = << 410512000 |current or specified time| ? 42

43. Summary of Approach - Value Set Review ▪Checks for SNOMED CT value set reviews: 1.‘Display’ text is a valid synonym for the given ‘code’ 2.All concepts in international value sets are active in current international edition of SNOMED CT 3.Concepts in the value set are consistent and appropriate for the intended use 4.The situation context is clear and represented consistently either using SNOMED CT situation concepts in the value sets, or by the surrounding model context. 5.There are no obvious gaps in the content of the value sets 6.The values are consistent with the model-meaning binding ▪Requires accompanying strategy for handling updates to SNOMED CT 43

44. Questions and Discussions