1. HL7 Vocabulary TC October 02 NHS Terminology Update Paul Frosdick Principal Pharmacist, NHSIA HL7 Vocabulary TC Baltimore Wyndham Hotel 03rd October 2002

2. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Strategic Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

3. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Strategic Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

4. HL7 Vocabulary TC October 02 NHS environment Diversity and instability > 300 new Primary Care Trusts (PCTs) 28 new Strategic Health Authorities New contractual arrangements for family doctors General Election in 3 - 4 years Government commitment to NHS IT Aggressive targets around 2005 Review of implementation approach Centralist management Ruthless standardisation Procurement through 2 - 5 primary suppliers.

5. HL7 Vocabulary TC October 02 NHS terminology development 1980s - multiple schemes appeared Read Codes, Egton, OXMIS 1988 - professional endorsement of Read Codes 1990 - Read codes purchased by NHS 1992-95 - Clinical Terms v3 (Read Codes) 1996-98 - inquiries into Read Codes 1998 - review of terminology options 1999 - agreement with CAP to develop SNOMED CT 2002 - first release, evaluation & foundation programmes.

6. HL7 Vocabulary TC October 02 NHS terminology development 1980s - multiple schemes appeared Read Codes, Egton, OXMIS 1988 - professional endorsement of Read Codes 1990 - Read codes purchased by NHS 1992-95 - Clinical Terms v3 (Read Codes) 1996-98 - inquiries into Read Codes 1998 - review of terminology options 1999 - agreement with CAP to develop SNOMED CT 2002 - first release, evaluation & foundation programmes.

7. HL7 Vocabulary TC October 02 Review of terminology options (1998) Option 1 - dont use a standard terminology Option 2 - continue to use Read Codes Option 3 - use off-the-shelf alternative (e.g. SNOMED) Option 4 - collaborate with SNOMED Option 5 - collaborate with someone else.

8. HL7 Vocabulary TC October 02 Review of terminology options (1998) Option 1 - dont use a standard terminology Option 2 - continue to use Read Codes Option 3 - use off-the-shelf alternative (e.g. SNOMED) Option 4 - collaborate with SNOMED Option 5 - collaborate with someone else.

9. HL7 Vocabulary TC October 02 High level terminology implementation goals Nation-wide roll out Multi-purpose use Direct and indirect care Multi-professional uptake Doctors, nurses, allied health Multiple environments Primary care, hospitals, community Extensibility Patient access, Social care. Information for Health (1998) Building the Information Core (2001)

10. HL7 Vocabulary TC October 02 Strategic targets By April 2003 - clinical information systems start to use SNOMED Clinical Terms Users/suppliers are advised not to develop new Read Code based systems from April 2003 Building the Information Core Section 4.8

11. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Strategic Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

12. HL7 Vocabulary TC October 02 Medical devices dictionary Secondary care drug dictionary Snomed CT clinical Snomed CT drug core Primary Care Drug Dictionary UKCPRS - traditional model

13. HL7 Vocabulary TC October 02 Snomed CT drug core Drug and devices dictionary Medical Device Dictionary Primary Care Drug Dictionary Secondary Care Drug Dictionary UKCPRS - updated model

14. HL7 Vocabulary TC October 02 Virtual Medicinal Product Virtual Medicinal Product Pack Actual Medicinal Product Pack Actual Medicinal Product Drug dictionary model Virtual Therapeutic Moiety Atenolol 50mg tablet (Cox) Atenolol 50mg tablets x28 (Cox) Atenolol 50mg tablets x28 Atenolol Atenolol 50mg tablet

15. HL7 Vocabulary TC October 02 The integrated model Virtual Therapeutic Moiety Virtual Medicinal Product Actual Medicinal Product Actual Medicinal Product Pack Virtual Medicinal Product Pack

16. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Strategic Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

17. HL7 Vocabulary TC October 02 NHS environment Diversity and instability > 300 new Primary Care Trusts (PCTs) 28 new Strategic Health Authorities New contractual arrangements for family doctors General Election in 3 - 4 years Government commitment to NHS IT Aggressive targets around 2005 Review of implementation approach Centralist management Ruthless standardisation Procurement through 2 - 5 suppliers.

18. HL7 Vocabulary TC October 02 NHS environment Diversity and instability > 300 new Primary Care Trusts (PCTs) 28 new Strategic Health Authorities New contractual arrangements for family doctors General Election in 3 - 4 years Government commitment to NHS IT Aggressive targets around 2005 Review of implementation approach Centralist management Ruthless standardisation Procurement through 2 - 5 suppliers.

19. HL7 Vocabulary TC October 02

20. National Strategic Programme Provision of enabling infrastructure National Prescriptions Service Integrated Care Record Service E-booking

21. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Implementation Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

22. HL7 Vocabulary TC October 02 Standards approval structure Information Standards Board Clinical Info Standards Board Technical Info Standards Board Management Info Standards Board

23. HL7 Vocabulary TC October 02 Standards process User requirement Specification Development Approval as draft standard Approval as full standard Conformance testing/monitoring.

24. HL7 Vocabulary TC October 02 ISB advice for SNOMED CT Need requirements e.g. Records Specialist domain e.g. diabetes Performance management e.g. NSFs Need technical specification Migration plan.

25. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Implementation Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

26. HL7 Vocabulary TC October 02 Information for Health Inter-sector clinical messaging Electronic transfer of EPRs by GPs Electronic transfer of prescriptions between GP, Community Pharmacy and PPA Data aggregation for performance assessment, Clinical Governance and management from clinical systems Interoperability between clinical decision support systems. Integral component of electronic records The strategic context

27. HL7 Vocabulary TC October 02 The NHS Plan NHS Direct nurses helping patients manage medicines Monitoring of drug treatment in standard protocols Failure to link diagnosis to treatment Reporting of adverse reactions. Assessment of new medicines and getting them into use more quickly The strategic context

28. HL7 Vocabulary TC October 02 Building the Information Core Integration with SNOMED ® Clinical Terms Development into clinical systems from April 2003 A Spoonful of Sugar Fulfilling the identified need of a standard national system for coding medicines across the NHS to support medicines management. Delivering Information The strategic context

29. HL7 Vocabulary TC October 02 Outline Historical context NHS terminology development Drug and devices focus Strategic context National Implementation Programme Information Standards Board Drug and devices focus NHS position on terminology selection.

30. HL7 Vocabulary TC October 02 Technical properties Mostly non-controversial Well-rehearsed desiderata backed up by academic and standards work: Cimino (1989, 1997) CEN ISO GALEN Many advanced technical features appear superfluous for users short- to medium-term requirements.

31. HL7 Vocabulary TC October 02 Business aspects Market forces - supply and demand Financial structure Long-term viability of provider.

32. HL7 Vocabulary TC October 02 Market forces - supply and demand Little real demand from end users: Need the product AND willing to pay Reflected in limited commercial supply of large comprehensive schemes Lack of clarity about scope, purpose & benefits: Perception of central rather than local benefits Commercial business model non-viable Intellectual property is only valuable if people are willing to pay.

33. HL7 Vocabulary TC October 02 Financial structure General criteria are mutually exclusive: Timely updates Flexible and adaptive Relatively inexpensive Any new endeavour needs $20 - 30m capital Plus guaranteed income stream (hard money) Circa $15m per annum on current projections for a global scheme And... needs to be non-commercial.

34. HL7 Vocabulary TC October 02 Long-term viability of provider Switching costs potentially high So any low-viability model is high risk Open contributorship model: Subscriptions to cover costs National level support Core product as public good within the subscribing community Extensions to core, and subsets for local needs.

35. HL7 Vocabulary TC October 02 Summary Since 1992, the NHS has remained committed to using a single comprehensive scheme, now SNOMED CT Provision of extension, subset and mapping mechanisms addresses many of the counter- arguments Global business model needs to be: Open, contributory and non-predatory Underpinned by central (government) support Terminology is not an end in itself Needs to add value to something else.

36. HL7 Vocabulary TC October 02 Helping to Modernise the NHS