1. SNOMED mapping for Pan-Canadian Surgery Templates Elaine Maloney January 27, 2015 ITHSDO Implementation SIG

2. Overview Background on Synoptic Reporting Initiative Approach to developing Informatics Standards Lessons learned during SNOMED mapping process 2

3. Synoptic Surgery Reporting Initiative 3 The Synoptic Surgery Reporting Initiative aims to advance the development and implementation of synoptic standards for cancer surgery reporting. Goal: To standardize synoptic surgical reporting for 8 disease sites across 4 provinces (Alberta, Manitoba, Ontario and Nova Scotia) Enablers: Funding from Canada Health Infoway Engagement with the surgical community and provincial partners

4. A Narrative Operative Report 4

5. A Synoptic OR Report

6. Surgical Reporting Standards 6 Clinical StandardsInformatics Standards  Developed by Clinical working groups  Includes Templates, Flows and Indicators  Developed to support standardized reporting in electronic implementation  Includes SNOMED CT mapping of data elements linked to indicators

7.  Generic template: Rick Nason (MB) with input from clinical leads  For each disease site, clinical working groups convened to develop the clinical standards  Cross-jurisdictional membership for each working group  Clinical leads by disease site: The Team: Disease-Site Leads for development of clinical standards 7 Disease SiteLeadProvince BreastGeoff PorterNS ColorectalDebrah WirtzfeldMB ColorectalDon BuieAB GyneBarry RosenON GynePrafull GhatageAB LungChristian FinleyON ProstateDarrel DrachenbergMB ThyroidJanice PasiekaAB

8. Mandatory versus Optional data elements Mandatory: Defined as data elements that are necessary to meet medical, legal and reporting requirements, reflect current standards of practice for surgery, and populate selected indicators. Optional: Defined as data elements recommended by the group for implementation at the discretion of local facilities.

9. Current Standards – An Example Breast Cancer 9 Clinical templates are divided into sections:

10. Current Standards – An Example Breast Cancer 10 Each section captures generic & disease site-specific content as follows:

11. Current Standards – An Example Breast Cancer 11 Some templates have flow documents to guide implementation of data elements:

12. Current Standards – An Example Breast Cancer 12 Clinical Working groups identified key indicators:

13. Current Standards – An Example Breast Cancer 13 Data elements related to indicators were mapped to SNOMED CT to create informatics standards:

14. Approach to Mapping 14 1 1 2 2 3 3 4 4 5 5 6 6 Validation of Template and Indicator content Work with Clinical Leads to validate content and capture assumptions Preliminary Mapping of Elements Map elements related to indicators to SNOMED CT. Questions for CHI and clinical leads captured Consultation with Clinical Leads Work with clinical leads to review mapping and address specific issues Iterative process with step 4 Consultation with CHI Standards Collaborative Team Review mapping with CHI SC team to address questions and discuss RFCs Iterative process with step 3 Request RFCs for values requiring SNOMED CT extensions Upload RFCs to JIRA and work with CHI SC team to address questions and finalize values/hierarchy Finalize and distribute standards to project team

15. RFC Summary 178 RFC requests made – 110 new concepts – 62 new descriptions – 6 new relationships 15

16. RFC Summary RFCs reflected unique changes Changes could affect values on more than one template One value could have more than one RFC associated with it 16

17. Details of SNOMED RFC requests  Extensions required as a result of:  Level of granularity required for template & need not to post- coordinate (e.g. Right Mastectomy, Left Breast Conservation was required for Breast template)  Context around hierarchy (e.g. ductal carcinoma in situ currently appeared as body structure but surgical template context was morphological abnormality)  Addition of synonym to reflect preferred surgical context (e.g. appendiceal cancer was added as synonym to primary malignant neoplasm of appendix currently in SNOMED CT core) 17

18. NEW CONCEPTS 18

19. Examples of New Concepts Intraoperative Complications concept of intraoperative complication did not exist within SNOMED Example: 19 ValueParent (s) in coreFound in coreSuggested PatternParent Bleeding requiring transfusion  Bleeding · complication of surgical procedure intraoperative hemorrhage (disorder)Bleeding during surgery requiring transfusion (disorder) intraoperative hemorrhage (disorder) ValueParent(s) in Core Found in CoreSuggest PattenParent Bleeding requiring transfusion Bleeding complication of surgical procedure Intraoperative hemorrhage (disorder) Bleeding during surgery requiring transfusion (disorder) Intraoperative hemorrhage (disorder)

20. NEW DESCRIPTIONS 20

21. Examples of New Descriptions 21 Thyroid Template: near total/total thyroidectomy added as synonym of total thyroidectomy (13619001) Issue: there is a difference in terminology between SNOMED and how surgeons are using data

22. Example 2 – new descriptions Thyroid template: Preoperative ultrasound values Radiologist directed – added as synonym to under care of radiologist (305497003) Surgeon directed – added as synonym to under care of surgeon (305525000) 22

23. NEW RELATIONSHIPS 23

24. Examples of New Relationships Breast template Unilateral mastectomy Relationship changed from situation with explicit context to procedure to align with surgical template 24

25. Lessons Learned Clinical engagement required throughout mapping process Essential to keep track of requests if submitting in different batches using JIRA 25

26. Clinical impact: Synoptic report data informs treatment decision for Ovarian Cancer in Ontario  NACT should be reserved for patients who could not tolerate surgery  Gyn Oncologists need to be committed to debulking to zero residual  Hospital resources need accommodate advances related to improved survival

27. %  Aids in understanding populations and informs treatment decision-making  No significant association between type of surgery and BMI (controlling for age, tumor size, cup size, detection method) Overall = 18.6% Clinical impact: Synoptic report data used in research study for Breast Cancer in Nova Scotia

28. Questions? surgery@partnershipagainstcancer.ca