1. Introduction to SNOMED CT
Monday 18th June
Starting at 10:30
presented by Jo Oakes, Knowledge & Information Manager
Welcome to the Introduction to SNOMED CT webinar.

2. Agenda Introduction Where are we now and where are we going?
What does SNOMED CT look like?
SNOMED CT in more detail
Benefits and further resources
We will start with a brief introduction, then look at where we are now and where we’re going.
We’ve then got some actual screen shots of what SNOMED CT currently looks like in applications.
After that we will look at SNOMED CT in more detail and finish off with benefits and details of where you can find further resources.

3. Introduction
So let’s start with a brief introduction.

4. ‘Go-compare’
I’m sure that you’ve all at some point completed some information online. The example here shows the Go-Compare website where you enter standard information into text boxes or select from drop down lists. What’s important to note about the information you enter on this site is that all the insurance companies that want to offer you a quote must be able to use the information that you enter, so the information needs to be in a standard terminology. For example, when you enter your postcode you can find your address using the Find Address button. This ensures that all addresses are entered in the same format thus the insurance companies know how to expect them.
If we want to achieve the same thing in healthcare, thus improving patient care, then we also need to a standard terminology. The chosen terminology for the NHS in England is SNOMED CT which are looking at in this presentation.

5. Key Messages
We are seeing the biggest change in healthcare that we’ve seen in years
Care model is going to change
Electronic records are driving improvements in care
Shared care
Wherever the patient goes, the person treating them should have access to key information
We are seeing the biggest change in healthcare that we’ve seen in years.
The care model is going to change and electronic records are driving improvements in care.
There will be shared care with trusts, GP’s, patients, community etc. so that wherever the patient goes, the person treating them should have access to key information

6. Key Messages
Analysis of patient data throughout healthcare will be used to improve patient care
IT needed to support the growing knowledge that helps personalised patient care, e.g. NICE guidelines, stratified medicine
This will take time
Analysis of patient data generated at the actual patient/clinician encounter throughout healthcare will be used to improve patient care.
Increasingly we need IT to support the growing knowledge that helps personalised patient care, e.g. NICE guidelines, stratified medicine
Records may have multiple contributors over time and are increasingly likely to be shared with other health professionals as well as the patient themselves.

7. Where are we now and where are we going?
Let’s have a look at where we are now and where we are going.

8. Where are we now – Primary care?
The current situation is that Primary and secondary care are not as joined up as they could be. There are many local initiatives with processes that are familiar to them but with little or no ability to share this information electronically.
Primary care is already mainly electronic, however, use older terminologies such as Read codes and CTV3.
However, as the picture shows there is still a lot of communication via the phone to check or find information.

9. Where are we now – Secondary care?
Secondary care still predominantly use paper records or local IT systems with no common terminology.   

10. Where are we now?
Primary care and secondary care are not as well joined up as they could be
Primary Care
Secondary Care
As we’ve seen from the previous slides primary care is already predominantly electronic and secondary care predominantly use paper records or local IT systems with no common terminology. It is difficult if not impossible to share information without more human moderation in the current situation.
In order to move to a more patient centred environment information about the patient needs to be able to flow freely between all the different sectors where the patient is treated. SNOMED CT has been chosen as the terminology of choice for the NHS in England enabling patient information to be shared not just between primary and secondary care but also with other care sectors such as mental health and social care.

11. Strategy
Aim for the NHS: Patient centred – patients can view own records
Actions:
Interoperability – move data around electronically
Record once, use many times
All require a common standardised vocabulary
Moving onto the strategy behind this.
The aim is for everything to be patient centred so that patients are able to view their own records.
In order for this to be possible it is necessary for information to be easily accessible. Moving data around electronically will make it easier to share information.
And for all this to be possible we require a common standardised vocabulary.

12. Framework for Action
The National Information Board (NIB) document “Personalised Health and Care 2020: A Framework for Action”:
endorses the move to adopt a single clinical terminology – SNOMED CT – to support direct management of care
will actively collaborate to ensure that all primary care systems adopt SNOMED CT during the financial year of 2017 – 2018
The NIB framework supports the decision to adopt SNOMED CT as a single healthcare terminology, saying it will actively collaborate to ensure that all primary care systems adopt it during the financial year of 2017 – Currently SNOMED CT is the only terminology that can support all the NHS requirements.

13. Primary Care – current situation
The four main suppliers will deliver updates over a number of releases
Deployment is in two main phases:
Phase 1 – behind the scenes changes
Phase 2 – includes user functionality
More details about the deployment schedule can be found here
Each of the four principal clinical system suppliers (EMIS, TPP, Vision and Microtest) will deliver updates over a number of releases. The phases and the functionality provided in each release will differ per supplier.
Deployment is in two main phases:
Phase 1 is ‘behind the scenes’ changes to enable systems to interoperate in SNOMED CT i.e. to exchange data with other systems
Phase 2 includes user functionality that enables users to record and report in SNOMED CT i.e. provision of data entry, templates and searches

14. Framework for Action The National Information Board (NIB):
States the entire health system should adopt SNOMED CT by April 2020
During this time, we must also work with local authorities to understand and address the implications of this for social care.
The document also states that the entire health system should adopt SNOMED CT by April 2020, and says the NIB will work with local authorities to understand and address how the move will affect social care.

15. Transfer of Care Initiative
This diagram illustrates some scenarios where information about a patient is exchanged.
The Transfer of Care Initiative is a project that aims to improve patient care by driving the establishment and uptake of professional and technical document standards.
Using standards in electronic health care records allows clinical information to be recorded, exchanged and accessed consistently across care settings in order to deliver high quality care to patients.
SNOMED CT is the clinical terminology standard that will be used.

16. Any Questions

17. What does SNOMED CT look like?

18. SNOMED CT in Action
The following sections contain screen shots from applications that use SNOMED CT
We are grateful for their kind permission to use these as without them it is sometimes difficult to envisage what SNOMED CT looks like in use
The following are screen shots from applications that use SNOMED CT. We are grateful to them all for their kind permission to use their screen shots as without them it is sometimes difficult to envisage what SNOMED CT looks like in use.

19. Moorfields Eye Hospital – Open Eyes software
The following slides show where SNOMED CT is used in an application designed by Moorfields Eye Hospital. The application is used across several sites so that information can be easily shared. They currently record diagnoses and procedures using SNOMED CT terms.

20. SNOMED CT in Action
Click on the drop down list to see a list of common diagnoses which are all SNOMED CT terms
We will start with adding a diagnosis for the patient. To view a list of common diagnoses click on the drop down list.

21. SNOMED CT in Action
Diagnosis can be selected from a list of common diagnoses which are all SNOMED CT terms
A predetermined list of terms is available to select from which are all SNOMED CT terms.

22. SNOMED CT in Action
Alternatively type in what you are looking for and a list of SNOMED CT terms containing the text will appear
However, if the diagnosis being looked for is not in the list then you can search for it by typing in the diagnosis search box. A list of diagnoses containing the text you have entered will appear. In this example you can see a list of diagnoses that contain ‘glaucoma’.

23. SNOMED CT in Action
The same can be done for procedures, select from a list of commonly used procedures which are all SNOMED CT terms
Procedures can be selected in a similar way to diagnoses by selecting from a predetermined list of procedures by clicking on the drop down list to display the commonly used procedures which are all SNOMED CT terms.

24. SNOMED CT in Action
You can also type in the procedure you are looking for and the list that appears will all be SNOMED CT terms
Alternatively, if the procedure being looked for is not in the list then you can search for it using the procedures search box. A list of procedures containing the text you have entered will appear. In this example you can see a list of procedures that contain ‘cataract’.

25. NHS e-Referral Service
The following slides show where SNOMED CT is used in the NHS eReferral Service. e-Referral is a national electronic referral service which gives patients a choice of place, date and time for their first outpatient appointment in a hospital or clinic. 

26. Making an Appointment
GPs can use e-Referral to make appointments for their patients who can then make their decision based on choices such as ease of travel or nearest location
In e-Referral the reason for the appointment is chosen from a list of SNOMED CT terms

27. SNOMED CT in Action
The Clinical Term is selected from a list of SNOMED CT terms
The Clinical Term or reason for the appointment is selected from a list of SNOMED CT terms

28. SNOMED CT in Action Type in the term to be searched for
Type in the term that you are looking for and click on the search button next to it.

29. SNOMED CT in Action A list of terms appears
A list of terms relating to what you’ve typed appears

30. SNOMED CT in Action
The selected term is shown below with its parents and children
Once a term is selected it is displayed below with its parents and children giving you the opportunity to select a more detailed term (children) or a more generic one (parent).

31. SNOMED CT in Action Select the required term
Once the correct term has been selected click on the Done button to add the term.

32. SNOMED CT in Action
The selected term then appears in the Clinical Term box
The selected term then appears in the Clinical Term box

33. CSC Lorenzo
CSC’s Lorenzo displays and stores a lot of information as SNOMED CT terms. The following slides show where SNOMED CT is used in CSC’s Lorenzo.

34. Type in what you are looking for and then click on the search button
To search for a problem or diagnosis type in what you are looking for and click on the search button. In this example we are looking for a diagnosis containing the text ‘fracture femur’.

35. Select the required term
A list of problems, which are all SNOMED CT terms, containing that text will appear. As we are in the Problem/Diagnosis screen your list will only display preferred terms or synonyms from the Diagnoses subset. There is no point searching the whole of SNOMED CT as we are only interested in Problems or Diagnoses. Select the required diagnosis and then click on the OK button.

36. Select certainty from the drop down list
Select the certainty from the drop down list, which are all SNOMED CT terms.

37. Find the term you require
Find the term you require and then click on it to select it.

38. Select severity from the drop down list
Severity can also be selected in the same way by clicking on the drop down list to display a list of SNOMED CT terms.

39. Select severity from the drop down list
Select the required term from the list.

40. Type in the body site and click to search for it
The body site affected then needs to be selected.
Type in the body site and click to search for it.

41. Select body site from the list displayed
A list of body sites containing the text you typed in and relating to the diagnosis will appear. These are all SNOMED CT terms. Select the required body site and then click on OK.

42. Select laterality from the drop down list
Select laterality from the drop down list which are all SNOMED CT terms. This is only available if the body site has a laterality, e.g. appendix would not have a laterality, however, neck of femur does as it could be a left or right neck of femur.

43. Select laterality from the drop down list
Select the required laterality from the list displayed.

44. Click on add to add the body site
Click on the add button to add the selected body site to the record.

45. Click on Finish to complete save
Once all the information has been entered, click on the Finish button.

46. Start to type the procedure you are looking for
Procedures are added in the same way, so start to type the procedure you are looking for.

47. Click on the search button to display the procedures
Click on the search button to display a list of procedures containing the text you typed in. Like the Problem/Diagnosis screen before the search doesn’t search the whole of SNOMED CT but is limited to the Procedures subset.

48. Click to use the advanced search
If the procedure you are looking for is not listed you can use the advanced search option.

49. Children of the term are displayed allowing you to select a more detailed term
Using the advanced search allows you to start with a slightly more generic term and then use the parents and children options to find more detailed or less detailed terms.

50. Select the term to display even more detailed terms

51. Further terms are displayed
Children of the selected term are displayed which are more detailed.

52. Select the required term

53. Click on Finish to add it to the record
Click on finish to add your selection to the record.

54. The other fields can be completed in the same way as for diagnosis
The other pieces of information can be completed in the same way as was used in the diagnosis area.

55. Click on Finish to complete save
Click on the finish button to save the record

56. This screen shows all the information completed relating to the procedure together with information pulled through from the diagnosis screen.

57. SNOMED CT in Applications
SNOMED CT has been implemented in many applications and as has been shown in the previous slides should not make things complicated
Clinicians should just see terms they are familiar with using and not even realise they are SNOMED CT terms
As the previous slides have shown SNOMED CT has been implemented in many applications and should not make things complicated. Clinicians should just see terms they are familiar with using and not even realise they are using SNOMED CT.

58. Any Questions

59. SNOMED CT in more detail

60. SNOMED CT Content Clinical Findings Causes of Disease Procedures
Disease and deformity – scar
Symptoms – difficulty breathing
Social – finding of walking aid use
Examination findings – tachycardia
Clinical Findings
Forces – pressure change
Events – road traffic accident
Organisms – herpes simplex virus
Causes of Disease
Laboratory
Therapy
Clinical Investigation
Surgical procedure
Procedures
These two slides give a general overview of what sort of content is in SNOMED CT and how SNOMED CT is structured. There are 19 hierarchies in SNOMED CT and rather than go through each one individually this groups the most clinically relevant hierarchies to give you a feel for the type of coverage of content. If you require more detailed information about the hierarchies it can be found on our website.
So on this slide we have
Clinical findings which includes areas such as diseases, symptoms and examination findings
Causes of disease includes areas such as forces, events and organisms
Procedures are pretty self explanatory but include items such as operations, investigations and therapies

61. SNOMED CT Content Anatomy Observations Products Normal – knee joint
Abnormal – ganglion cyst
Lesions – bony callus
Anatomy
Vital signs – blood pressure
Body product observable – colour of urine
Values - present
Observations
Drugs – paracetamol
Substances – latex
Devices – bedpan
Products
On this slide we look at
Anatomy which includes both normal and abnormal anatomy
Observations include items such as vital signs and values
And finally products include devices and drugs, that is the drugs we are familiar with together with the individual ingredients that go to make up those drugs

62. A Concept in SNOMED CT
Fully specified name: heart disease (disorder) Preferred term: heart disease Synonym: cardiac disorder Synonym: cardiopathy Synonym: morbus cordis Synonym: disorder of heart
In this example we can see one of the components of SNOMED CT, the concept heart disease.
These are all different ways, known as descriptions, of referring to heart disease. The fully specified name is the unique human readable form, the preferred term the most common way of referring to this term and the synonyms are other expressions with the same meaning.

63. A concept in SNOMED CT
Fully specified name: heart disease (disorder) Preferred term: heart disease Synonym: cardiac disorder Synonym: cardiopathy Synonym: morbus cordis Synonym: disorder of heart
In SNOMED CT all these descriptions are associated with one concept ID, in this case
We’re now going to look at this concept in a browser so that we can see what it looks like and what other information is available relating to this concept.

64. Browser Demo SNOMED CT browser demo
Use clinical examples and avoid hierarchies that won’t be used in patient records.
Talk about relationships, hierarches and attributes.

65. A concept in SNOMED CT Concept
fully specified name preferred term synonyms
Attributes
Relationships
So to recap each concept has at least a fully specified name and preferred term and may have synonyms, with all being descriptions with the same meaning.
As well as that we’ve seen that each concept has attributes and relationships which further define the concept. We’ve seen how we can use the hierarchies to show how one concept may have multiple parents and/or children.

66. Finding site: heart structure
A concept in SNOMED CT
Fully specified name: heart disease (disorder) Preferred term: heart disease Synonym: cardiac disorder Synonym: cardiopathy Synonym: morbus cordis Synonym: disorder of heart
Finding site: heart structure
Is a – cardiac finding Is a – disorder of mediastinum Is a – disorder of cardiovascular system
So let’s look at heart disease again.
You can see the fully specified name, preferred term and synonyms.
As well as that you can see the attributes and relationships associated with this concept. Heart disease has a finding site of heart structure and it is a cardiac finding as well as a disorder of the cardiovascular system.

67. Bacterial infectious disease Respiratory tract infection
Disorder by body site
Infection by site
Disorder of trunk
Bacterial infectious disease
Respiratory tract infection
Disorder of thorax
Bacterial infection by site
Disorder of lung
Lower respiratory tract infection
Lung consolidation
Bacterial respiratory infection
Pneumonia
Infectious disease of lung
Infective pneumonia
Bacterial lower respiratory infection
Speaking of relationships, this diagram is a simple example showing how SNOMED CT concepts can be linked to more than one concept, however, all linked concepts will always be in the same hierarchy, e.g. procedures.
We looked at these in the hierarchies area of the browser. The pale blue boxes show the concepts that would most likely be used in patient record, the others are less suitable and are used for organising the hierarchies.
Bacterial pneumonia

68. Success with SNOMED CT
Things are normally in the singular, e.g. eye not eyes
When searching don’t always use full words, e.g. diab would return both diabetic and diabetes
Don’t enter words like “and”, “to” and “the”
If you are using a browser then the following approaches will help you find the terms that you want:
Things are normally in the singular so when searching for terms use the singular, for example, search for eye not eyes.
Just type the start of a word as the ending may be slightly different, for example, diab would return both diabetic and diabetes, but make sure you enter enough characters to differentiate it.
Don’t enter words like “and”, “to” and “the”.

69. Success with SNOMED CT
Use techniques similar to how you currently search the internet and medical publications
Search for significant words and don’t worry about the order, e.g. implant lumbar cath would return implantation of lumbar epidural catheter
Try common abbreviations, e.g. PID for prolapsed intervertebral disc
Use techniques that you are familiar with already, for instance when you search the internet or medical publications.
Search for significant words in a phrase and don’t worry about the order, for example, when looking for “implantation of lumbar epidural catheter” search for “implant lumbar cath” which will provide a small number of options to pick from.
If there is a commonly used abbreviation, try that first. You won’t find just the abbreviation, but it may help find the term you want, for example, if looking for “prolapsed intervertebral disc”, search for “PID”.

70. Subsets
What is a SUBSET?
SNOMED CT is extensive – it is supporting a common vocabulary for all healthcare specialisms, and all healthcare professionals, as well as keeping up to date with current practice
A subset is ‘smaller set of SNOMED CT ‘ that meets a particular requirement
A SNOMED CT subset can be a group of concepts, descriptions or relationships chosen for relevance under certain conditions or in certain contexts
Thinking about the previous diagram, I think it’s fair to say that we’ve established SNOMED CT is comprehensive and covers large amounts of clinical information. It is supporting a common vocabulary for all healthcare sectors, and all healthcare professionals, as well as keeping up to date with current practice.
It is often useful to be able to group together like items into a smaller list and these are known as subsets.
A SNOMED CT subset can be a group of concepts, descriptions or relationships chosen for relevance under certain conditions or in certain contexts.
So if not all of SNOMED CT needs to be visible in a clinical system, using subsets helps limit what is presented to only that which is relevant.

71. Ophthalmic procedures
Why Subsets?
In an ophthalmic theatre department
SNOMED CT
Procedures
Ophthalmic procedures
Imagine if you worked in an ophthalmic theatre department, you wouldn’t want to search through the whole of SNOMED CT, it would be useful to just see a list of ophthalmic procedures and subsets let you do this. They group the like items together so that in an ophthalmic theatre department you would just see a list of ophthalmic procedures and nothing else.
In an ideal world the ophthalmic subset could be developed by a royal college or professional body and then everyone could use the same subset which would lead to further consistent data recording.

72. How Applications use Subsets
Supports easier navigation
Can be used to limit to specific SNOMED CT codes
Can act like a ‘favourites’ for the end user
Can be used nationally or locally –synchronised national releases
Access to subsets may be role based
Applications can use subsets in different ways:
Subsets can make using SNOMED CT easier to navigate
They can be used to limit choice to specific SNOMED CT concepts
They can act like a favourites list for end users
They can be used nationally or locally
Access to subsets can be role based

73. Current Subsets Examples
Allergens
Diagnoses
Laterality
Radiology procedures
Subsets can be very large or very small.
The diagnosis and radiology subsets shown here will obviously be quite large, but you can just as easily create small subsets such as the laterality subset.

74. Any Questions

75. Benefits and further resources

76. Across Professions
Across different specialisms: orthopaedics, cardiology, renal, microbiology, histopathology ...
Renal
Cardiology
Orthopaedics
Moving on to the benefits of SNOMED CT
SNOMED CT will mean the ability to transfer information across different professions without the worry of misinterpretation.

77. Across Professions
Synonyms – same concept said in different ways to support cross discipline working
Patient – black eye
Doctor – contusion of eye
Nurse – bruise of eye
Synonyms will support the way different professions refer to the same clinical term

78. Across Professions
Across primary, secondary, community, social care, mental health
Patient Data
Primary Care
Secondary Care
Community
Mental Health
Information can be shared across primary, secondary and other care sectors such as prisons and Ministry of Defence.

79. Communication – “Connect all”
Seamless transfer - coded information to be electronically communicated - without mapping
SNOMED CT Data
Primary Care
Secondary Care
Community
Mental Health
With SNOMED CT as the standard, the transfer of information can be done easily without the need to map between different terminologies.

80. Communication – “Connect all”
Translated into different languages: Spanish, French, Swedish, Danish ... Work starting in Lithuanian, Polish
morphine allergy
morfin allergi
SNOMED CT has already been translated into different languages meaning that in the future there is the possibility of transferring information internationally

81. International
Suppliers in different countries using the same terminology
Potential for improved functionality of systems as supporting just one terminology
Collaborative effort: more cost effective
Links with other international standards – eg. World Health Organisation
From a suppliers point of view the fact that SNOMED CT is an international product means that systems they develop can be marketed in a number of countries that use SNOMED CT without having to redevelop using different terminologies. Very cost effective!!
It also means that the different standards organisations can work collaboratively for their standards to be compatible.

82. How can I look at SNOMED CT?
There are various free to use browsers available on the market. Details of those that support the UK Edition of SNOMED CT can be found in the UKTC:
Free to use browsers
So how can you look at SNOMED CT?
We have already seen one of the free to use browsers earlier in the presentation but there are several available
Those that support the UK edition of SNOMED CT can be found at this website

83. Learn more about SNOMED CT
Visit: Training and Resources on UKTC website
eLearning
Webinars
SNOMED CT NHS network
Documentation
Case studies
There are many different ways to learn about SNOMED CT some of which include
Elearning
Webinars, such as this one, and others that are detailed on our website.
The SNOMED CT NHS network has been created and is a place where the slides for this presentation can be found plus a discussion board for users to share their experiences.
There is documentation available on websites such as the UKTC and IHTSDO websites
As well as that case studies relating to SNOMED CT can be found on the UKTC website
We are keen to hear your comments about this webinar and any suggestions that you have to improve them.

84. Any Questions

85. UKTC Website
SNOMED CT Training and Resources
For Information Standards Service Desk call or