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

2. 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

3. Housekeeping
Toilets
Fire
Refreshments
Introductions to NHSD team

4. 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.

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

6. 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

7. 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.

8. Ice Breaker

9. 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 ?

10. Understanding SNOMED CT and training practice staff

11. Understanding SNOMED CT and training practice staff
In pairs:
Workbook Sections (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

12. Data Quality

13. 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

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

15. Inactive concepts

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

17. Some current maps are to inactive codes

18. 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

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

20. 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

21. NOS, NEC, unclassified … Classification Terms
|Disorder of synovium (disorder)|
|Disorder of tendon (disorder)|
|Disorder of bursa (disorder)|
|Muscle pain (finding)|
|Myositis (disorder)|

22. Maps to higher level terms
E2B..
Depressive disorder NEC
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

23. 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)

24. 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 ( )
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

25. 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

26. Collaborative space - Delen
Area specifically for trainers to share information
If you don’t have access

27. Searches

28. 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

29. 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

30. 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)

31. Expressing a search We can express a search in two ways:
Use ECL and the hierarchy structure :
Concept and all of its descendants
<< | Acute posterior myocardial infarction (disorder) |
Cherry pick the codes (cluster list):
List each concept seperately
| Acute posterior myocardial infarction (disorder) |
| Acute myocardial infarction of posterobasal wall (disorder) |
| 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

32. Walkthrough – Example 1
Hip replacement

33. Search for hip replacement
Total
Revision
Partial

34. Where in the hierarchy do we search:

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

36. Would get patients on contraception …

37. Would get patients Not on contraception

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

39. 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

40. 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

41. 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 << | Diabetes mellitus (disorder) | May be ok Example: H33..% Asthma TO << | Asthma (disorder) | For example include Exercise induced Asthma , which may not wish to include

42. 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?

43. 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

44. 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

45. 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

46. 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 .

47. 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

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

49. 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

50. Supplier Update

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

56. Microtest Screens (1/3)

57. Microtest Screens (2/3)

58. Microtest Screens (3/3)

59. Post Coordination

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

61. 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

62. 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...

63. 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
|Family history of disorder|: |Associated finding| = |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

64. 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?

65. 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

66. 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 …

67. Workshop Roundup
Any questions?

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

69. Thank you …
Helpdesk:
We will you: