snomed ct - the language for interoperable ehr

SNOMED CT – THE LANGUAGE FOR

EHRDr SB Bhattacharyya

MBBS, MBA, FCGP

Member, National EHR Standardisation Committee, MoH&FW, GoI

Member, Health Informatics Sectional Committee, MHD 17, BIS

Hony. State Secretary (2015), IMA Haryana

President (2010 – 2011), IAMI

Electronic Health Record

■ A longitudinal record of the health of an individual sequentially arranged from the very first medical record to the very latest

■ Consists of all health-related records like

– Medical Records – treatment and discharge summaries

– Immunisation Records

– Investigations (Laboratory & Imaging) Results & Reports

– Prescriptions

– Physician Notes

– Health Worker Notes

2Dr SB Bhattacharyya©

Records – why keep them?

■ For reuse

– As a source of historical data & information

– Information exchange among providers

– To anticipate future health problems

– As a record standard preventive measures

– To identify deviations from the expected

– As basis for clinical research – trials and observational

■ As legal evidence


Semantic Interoperability

■ Patient is having active tuberculosis

■ Patient had tuberculosis in the past that has since been successfully treated

■ The two statements above are significantly different as is the treatment to be administered

Dr SB Bhattacharyya© 4

Case summary

During early spring, a 45 year old male presented with complaints of fever accompanied by a runny nose, cough without expectoration along with feeling of malaise and generalised body ache for the past one day. There were no other complaints although the patient kept on insisting that he had “cold”.

The patient had a past history of infection with Koch’s bacilli for which he successfully underwent ATT. In family history, both his parents and his two siblings – elder brother and sister – all suffer from NIDDM.

On examination he was found to have an oral temperature of 38°C, bilaterally clear chest, normal heart sounds, doughy feel of abdomen, liver and spleen not enlarged, and plantar reflex negative. Based on the findings, a clinical diagnosis of seasonal influenza was made.


Case summary

He was advised CBC, RBS, CXR, Mantoux Test, and Urine RE/ME. He was prescribed oral form of acetaminophen 500mg stat and PRN, oral form of diphenhydramine hydrochloride 25mg 8 hourly for three days, plenty of fluids orally and bed rest.

He reported back with his test reports the next day stating that he was feeling better. All investigation results and reports were unremarkable, except his RBS was 200 mg/dL. He was advised to consult a diabetologist without delay, complete his medications and report back only if fresh problems arose.

There were no further follow-ups by the patient for this particular episode.


Pertinent Questions

■ When the patient said he had “cold”, what exactly was he trying to say?

■ What is infection with “Koch’s bacilli”?

■ How accurate was the clinical diagnosis? How likely was this diagnosis to have turned out to be a laboratory diagnosis should the appropriate tests based on evidence based medicine have been run?

■ Did the patient require to undergo all the tests as advised, particularly given the fact that most were “unremarkable”, or could some of them been safely avoided without risking the patient?

■ Were any investigation or further examination missed?

■ Based on his previous history of Koch’s infection and concomitant strong family history of NIDDM, did he merit more aggressive treatment with antibiotics?


Pertinent Questions

■ Was there any delay in referring the patient to a diabetologist, particularly in view of the fact that he had such a strong family history of NIDDM and that he was already 45 years old? Was it also alright to test him only for RBS or should Fasting Blood Sugar, Postprandial Blood Sugar and Test for Glycosylated Haemoglobin tests should additionally have been carried out before referring?

■ What do these acronyms ATT, CBC, RBS, CXR, RE/ME, and NIDDM actually mean?

■ Was the treatment plan the right one for the patient or could it have been designed better and that too just for him?

■ Could the answers to the questions above been made available while the patient was sitting in front of the doctor?

■ Was it wise to have suggested to the patient that he did not need any further follow-ups for this complaint unless any fresh problems arose?

■ What if this clinical summary needs to subsequently be read in Spanish by someone who does not know a word of English? Can this be done without any loss in meaning?


To effectively address these…

■ Semantically interoperable standardised clinical vocabulary needs to be used

■ Currently (2016), SNOMED CT fits the bill best

■ So, what is SNOMED CT?

■ Since April 2014 India is a member of IHTSDO

■ This entitles any one in India – EHR/EMR vendors and their users –to access and use SNOMED CT for free within the country


SNOMED CT

■ SNOMED CT stands for Systematized Nomenclature of Medicine –Clinical Terms

■ SNOMED is now an acronym

■ Owned, maintained and distributed by IHTSDO

■ IHTSDO stands for International Health Terminology Standards Development Organization


SNOMED CT

■ Based on the concept-based approach, SNOMED CT considers every clinical term to relate to a clinical concept like fever, which

– is a body temperature above reference range, and

– interprets body temperature

■ SNOMED CT is a semantically interoperable polyhierarchical subtype multi-lexical clinical terminology system that is able to deliver robust benefits to the health care services


SNOMED CT

■ It is the richest vocabulary currently available to describe clinical findings, diseases, procedures, etc.

■ Contains more than 300,000 concepts, more than 1 million descriptions and more than 900,000 relationships (July 2014 International Release).

■ SNOMED-CT aims at transmitting all concepts that have been expressed throughout history in the healthcare domain, unambiguously.


SNOMED CT

■ Provides clinical content and expressivity for clinical documentation and reporting.

■ Used to code, retrieve, and analyze clinical data.

■ The terminology is comprised of concepts, terms and relationships with the objective of precisely representing clinical information across the entire spectrum of health care.


SNOMED CT

■ Concepts are defined using the meronomic “IS-A” sub-type relationships

■ Concepts are also additionally defined using the “HAS-A” attribute type relationships

■ Example: Fracture of tarsal bone (disorder)

– | IS A | Fracture of foot (disorder)

– “has a” FINDING SITE of Bone structure of tarsus (body structure)

– “has a”(n) ASSOCIATED MORPHOLOGY of Fracture (morphologic abnormality)


Supports Synonyms Aplenty

■ Myocardial infarction

■ Cardiac infarction

■ MI – Myocardial infarction

■ Heart attack

■ Infarction of heart

■ Myocardial infarct


Few more SNOMED CT Examples…

■ Disease

– Diabetes mellitus

■ | is a | disorder of endocrine system

■ | is a | disorder of glucose metabolism

■ Procedure

– Percutaneous transluminal angioplasty (procedure)

■ | is a | Transluminal angioplasty

■ | is a | Catheter procedure

■ | is a | surgical repair procedure by device


18

Cellulitis of Foot

Is a

Disorder of foot

Cellulitis of lower limb

Has a

Associated morphology =

Cellulitis

Finding site =

Lower limb structure

Dr SB Bhattacharyya©

Pain in upper limb

Is a

Finding of sensation of upper limb

Pain in limb

Has aFinding site

= upper limb structure


Electronic Encounter Record

HISTORY: Present Illness

Add Another Investigations Diagnosis Treatment

CloseCancel Clear Redo Save Draft

St. Somewhere ClinicPatient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 01 (New)

Unique ID: 9991 2345 6789 Allergies: No Known Allergies (NKA) Primary Physician: Dr X Y Zed

Chief Complaint Search for chief complaints Accompanied By Search for conditions

Followed By Search for conditions And By Search for conditions

Relieved By Search for interventions Accompanied By Search for interventions



Investigations TreatmentHistory

Diagnosis Type DiagnosisSearch for diagnosis types Search for diagnosis

Primary Diagnosis


St. Somewhere ClinicPatient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 01 (New)


Interpretation: Diagnosis

Diagnosis Type Search for diagnosis typesDiagnosis

Secondary Diagnosis

Search for diagnosis


Treatment type Treatment Route of administration

Medication Tablet Chloroquine Phosphate 250mg Oral

Medication Table Primaquine Phosphate 15 mg Oral

Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 01 (New)


Search for treatment

Add Another Investigations DiagnosisHistory



St. Somewhere Clinic

Treat with

Treatment


Investigation Results

Investigation Result

Peripheral blood smear examination, light

microscopy

Confirmed presence of Plasmodium vivax

Plasmodium falciparum was absent

Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 03


History Diagnosis Treatment






HISTORY: Present Illness


St. Somewhere ClinicPatient Name: Ms B Cee Dee Age: 55 years Gender: Female Episode: 39 Encounter: 01 (New)

Unique ID: 9999 8765 4321 Allergies: Allergic to Penicillin Primary Physician: Dr Em No

What is the Complaint? Search for complaints

Go

User enters “Pain” here…


In clinical medicine, “Pain”…

■ Is associated with an anatomical site (body structure) or it may be generalised like a body ache

■ Has sensation quality, aka “character”, like “aching”, “burning”, “colicky”, “dull”, etc.

■ Can have a pattern like “acute”, “chronic”, “constant”, “diffused”, etc.

■ Can have severity like “mild”, “moderate”, “severe”, etc.

■ Can be induced (precipitated / brought on) by certain aggravating factors that may be one to several

■ Can be relieved (made to go away) by certain methods including administration of medication


Pain [contd.]

■ It can also be associated with the following:

– This could be the very first time ever the patient has experienced such a sensation in the affected body part or it could a recurrent phenomenon

– It will have a clinical course like “gradual onset”, “cyclical”, “non-progressive”, etc.

■ Other than some clinicians who deal with pain findings either on a regular basis or often enough, it can safely be assumed that most will fail to note and consequently not capture all the details associated with pain. EHR systems using SNOMED CT can consequently help all clinicians in this regard irrespective of the care setting, specialisation or ability and experience thereby improving quality of care overall.




Details of Pain



Add Aggravating Factors Add Relieving Factors

Associated with Search for body structure Sensation quality Search for pain sensation quality

Pattern Search for pattern of pain Severity Search for severity

Occurrence Search for occurrence Clinical Course Search for clinical course


Add Add Relieving Factors

Aggravating Factors

<none entered yet>

Aggravating Factor

Patient Name: Ms B Cee Dee Age: 55 years Gender: Female Episode: 39 Encounter: 01 (New)




Details of Aggravating Factors of the Pain


Search for aggravated by observable entity


Relieving Factors

<none entered yet>

Relieving Factor



Details of Pain Relieving Factors



Add Add Aggravating Factors

Search for pain characterised by relieving factor


Benefits of Using SNOMED CT in EHR

■ Analyse every part of a record: from history to treatment

■ Support for

– Conducting outcomes research

– Evaluating the quality and cost of care

– Designing effective treatment guidelines

■ Providing more easily accessible and complete information pertaining to the health care process (medical history, illnesses, treatments, laboratory results, etc.), thereby resulting in improved patient outcomes

■ No challenge in migrating from one version to another – it is seamless and most often an automated process


Introduction to SNOMED CT by Dr SB Bhattacharyya available at

■ http://www.amazon.com/Introduction-SNOMED-CT-S-B-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269681&sr=8-1&keywords=introduction+to+snomed+ct – hardcopy only

■ http://www.amazon.in/Introduction-SNOMED-CT-2016-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269722&sr=8-1&keywords=introduction+to+snomed+ct – hardcopy only

■ http://www.springer.com/gp/book/9789812878939 – ebook and hardcopy

■ http://link.springer.com/book/10.1007/978-981-287-895-3 – chapter-wise online access only


http://www.amazon.com/Introduction-SNOMED-CT-S-B-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269681&sr=8-1&keywords=introduction+to+snomed+ct

http://www.amazon.in/Introduction-SNOMED-CT-2016-Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269722&sr=8-1&keywords=introduction+to+snomed+ct

http://www.springer.com/gp/book/9789812878939

http://link.springer.com/book/10.1007/978-981-287-895-3

[email protected]


snomed ct - the language for interoperable ehr

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