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

2. The Problem

3. 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?

4. Why is this important ?

5. Workforce

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

7. Consumer Demand

8. Australia
Australia
Korea

9. Knowledge Published medical knowledge doubles every 73 days
Trans Am Clin Climatol Assoc. 2011; 122: 48–58.
Knowledge

10. 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

11. Cost

13. “growth in health expenditures is the
biggest single challenge for budget sustainability”

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

16. 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.

17. How do we express and share clinical meaning?

18. 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

19. 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

20. 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)

21. 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

22. 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.
Enable meaning- based queries

23. Description 22298006 Assist in searching and finding concepts
FSN
myocardial infarction (disorder)
SYN
myocardial infarction
SYN
cardiac infarction
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
SYN
MI – Myocardial infarction
Assist in searching and finding concepts
Enhance string- matching in NLP
Multi-lingual support
SYN
myocardial infarct
Human-readable term linked to a concept

24. Relationship
finding site
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)
myocardial infarction (disorder)
Can express the defining characteristics of a concept
Support queries based on defined meaning
Infarct
(morphological abnormality)

25. Relationship
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.
myocardial infarction
‘is a’ relationships form a subtype ‘polyhierarchy’

26. 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

27. 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.

28. Questions and Discussion
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