1. Implementing a Clinical Terminology David Crook Subset Development Project Manager SNOMED in Structured electronic Records Programme NHS Connecting for Health

2. Content What is a clinical terminology? What are we implementing? Make the terminology usable The terminology does not sit alone.

3. What is a Clinical Terminology? A structured collection of descriptive terms for use in clinical practice. Allows consistent use, communication and analysis of clinical data. SNOMED CT adopted in England and will replace or subsume existing code systems.

4. What Are We Implementing?

5. What are we implementing? The terminology? A clinical system? or SUPPORT FOR HEALTHCARE PROCESSES

6. Why change? Changing a process has costs There must be benefit The benefits must be relevant to clinicians.

7. What are the potential benefits? Unambiguous communication/interoperability Clinical process support -Care pathways -Decision support Analysis -Evidence based practice & clinical audit -Research -Planning

8. Focus on the benefits Where in the clinical process will the benefits accrue? What benefits can the system support? How do you get clinical buy in? -Involve clinicians in the design -Communicate the potential and let clinicians identify and own the benefits

9. Make The System Usable

10. Coverage SNOMED CT coverage: Over 350 000 individual healthcare concepts Ability to combine concepts (post-coordinate) Mayo Clinic: - 5000 most common terms (95% of all terms used) ->50% represented without post-coordination ->90% represented with post-coordination

11. Remove the “clutter” Subsets or rules: -May only require a small set - the rest irrelevant -Easier to find if irrelevant terms filtered out User interface design: -Form design e.g. embedded check boxes and drop down lists -Free text parsing

12. Form design Diabetic assessment Ulcer details Location left ankle right ankle left foot right foot

13. SNOMED coding in the background 422183001 | diabetic skin ulcer | : 363698007 | finding site | = 418380001 | skin structure of medial malleolus | : 272741003 | laterality | = 7771000 | left |

14. Free text parsing

15. Analysis A terminology offers more detail. e.g. hip prosthesis audit: -Now - use OPCS to pick notes for hip replacement. -Clinical terminology - identify specific prosthesis and assess outcomes Skills required enhanced: -Now - OPCS knowledge and skill in analysing notes. -Clinical terminology - also need terminology and more IT analytical skills

16. The Terminology Does Not Sit Alone

17. The whole picture Not just the terminology. Meaning can reside in: -User interface -Record architectures -Messages Supporting interoperability relies on the ability to generate and transform messages.

18. Clinical scenario Hospital doctor records adverse reaction to new drug Information included in discharge summary sent via spine to GP Information is integrated to the GP system Audit proves drug is dangerous and it is withdrawn Alert triggered when GP subsequently prescribes a related drug to that patient

19. Interoperability Hospital doctor records adverse reaction to new drug -User interface and data storage Information sent via spine to GP -Entry and storage consistent with message structure Information is integrated to the GP system -GP system able to transform, store and represent information without loss of semantics

20. Analysis and decision support Analysis proves the drug is dangerous and it is withdrawn: -Understand context -Ability to query and aggregate data Alert triggered when GP subsequently prescribes a related drug -Manage context -Rules for dealing with retired drugs -Ability to manage drug categories

21. Summary A clinical terminology is implemented to support healthcare processes Implementation has both technical and cultural aspects Understanding how the terminology fits into the technical infrastructure is essential to ensure information is meaningful and interoperable. Successful implementation depends on clinical ownership of the benefits