1. National E-Health Transition Authority nehta HIMAA SYMPOSIUM October 2006 NEHTA Clinical Terminologies and SNOMED CT Overview Alice Livingston-Vail – Project Lead Clinical Terminology

2. National E-Health Transition Authority nehta 1 What is NEHTA doing?

3. National E-Health Transition Authority nehta 2 Existing Infrastructure…. Can be limiting

4. National E-Health Transition Authority nehta 3 Solid foundations are essential

5. National E-Health Transition Authority nehta 4 Hospitals And Other Providers Administrators & Funders Researchers Results of lab tests Request lab tests Health record Event summary Consumers Longitudinal Health Record Health IT Vendors Clinicians Systems and people in healthcare need common specifications, languages and identification to successfully communicate NEHTA’s Mission is to Create a Platform for Reform

6. National E-Health Transition Authority nehta 5 Shared EHR Specifications User Authentication NEHTA’s Work Program Secure Messaging Hospitals And Other Providers Administrators & Funders Researchers Results of lab tests Request lab tests Health record Event summary Consumers Longitudinal Health Record Health IT Vendors Supply Chain Clinicians Interoperability Framework Clinical Terminologies Medical Product Directory Clinical Information Individual Healthcare Identifier Healthcare Provider Identifier Standards Implementation eHealth Policy Framework Benefits Realisation

7. National E-Health Transition Authority nehta 6 Objective: To identify, develop and promote the adoption of optimal standards and specifications for the exchange of clinical information which will improve the quality and efficiency of healthcare. Clinical Information

8. National E-Health Transition Authority nehta 7 Interchange Specifications Which Clinical Information Standards? Data Structures (Clinical Information Initiative) Terminologies

9. National E-Health Transition Authority nehta 8 Clinical Information Specifications - products Data Group Specifications ( information structures ) Structured Reports/ Event Summaries Interchange Specifications ( implementable technical specifications ) requirements analysis medication pathology imaging adverse reaction +... others discharge summary referral +... others (prescription, med. review, pathology results,...) AS4700.6 (HL7 v2) HL7 CDA? CEN 13606 ? conformant solutions Information technical Value Domains Terminology

10. National E-Health Transition Authority nehta 9 Data Group Specifications: Adverse Reaction Medication Pathology Episode Diagnostic Imaging Medical Alert Clinical Synopsis Immunisation Observation Reason for Encounter Problem/Diagnosis Clinical Intervention Person Identifiers Status : Released HIC 2006 Publication 2007 Clinical Information Initiative

11. National E-Health Transition Authority nehta 10 Hospital Discharge Summary Specialist Referral Community Referral Status: Publication 2006 Commencing Work Under Consideration Clinical Information Initiative Structured Reports Interchange Formats Discharge/ Referral E-Prescribing

12. National E-Health Transition Authority nehta 11 Identifying appropriate Terminology for Data Elements within Data Group Specifications Conducting field testing of NEHTA’s specifications using compatible e-health systems already in place, and for which significant benefits to adoption can be predicted, Establishing processes to support feedback from, and evaluation of, field implementations of NEHTA data group specifications Clinical Information - facilitating implementation Clinical Information

13. National E-Health Transition Authority nehta 12 Clinical Terminologies Objective: Ensuring consistency of language in Clinical communication as required to achieve semantic interoperability for critical communication Clinical Terminologies Clinical Information

14. National E-Health Transition Authority nehta 13 Clinical Terminologies Clinical Information Clinical Terminologies National Approach endorsed and funded by Council of Australian Governments NEHTA developing national capability to develop, maintain, distribute and support health terminology Global collaboration – working to establish an International Standards Development Organisation for ongoing management and development of Health Terminology and related standards

15. National E-Health Transition Authority nehta 14 SNOMED National License NEHTA has negotiated National licensing arrangements for SNOMED CT:  free national access available (terminologies@nehta.gov.au )terminologies@nehta.gov.au  Allows vendors to begin exploring opportunities Includes all core content, technical documentation and tool kits required for implementation NEHTA to approve the creation and assignment of SNOMED namespaces for use in Australia Upon termination, Australia retains perpetual rights to use the last version of SNOMED CT provided under the license

16. National E-Health Transition Authority nehta 15 SNOMED will be supplemented by specialised ‘Domain’ terminologies, customised to meet Australian needs These will be developed as an extension of SNOMED core Australia will liaise internationally on approach to ensure consistency Initial implementation may require mapping of existing term sets to SNOMED, but maintenance demands mean that ongoing mapping requirements should be minimised Migration is the preferred strategy Clinical Terminologies - Commissioning a national approach

17. National E-Health Transition Authority nehta 16 Implementation paths may vary Simplest implementation may be a pick-list True power of terminology comes through more sophisticated use of hierarchies and relationships allowing complex queries and decision support NEHTA will work with key stakeholders to develop a conformance framework with varying levels Clinical Terminologies - Commissioning a national approach

18. National E-Health Transition Authority nehta 17 NEHTA will undertake work in priority domains including: Medicines Pathology Radiology Adverse Reactions and Allergies Devices Procedures Problems/ Diagnoses Clinical Terminologies - Commissioning a national approach

19. National E-Health Transition Authority nehta 18 Pathology Terminology:Under Development  Review existing work in this Domain complete SNOMED, LOINC, AustPath  Mapping existing terms sets for order test names underway  Planned First release: Order test names February 2007 Radiology Terminology:Initiation Phase  Strategy development and staff recruitment underway Clinical Terminologies - Other Priority Domains

20. National E-Health Transition Authority nehta 19 An expert reference group has been formed The reference group has agreed upon editorial rules for the preferred term for pathology test names Comparison of Australian pathology test names to SNOMED CT has commenced Quality processes for development and review are being implemented Clinical Terminologies - Pathology Domain

21. National E-Health Transition Authority nehta 20 Medicines Terminology and Catalogue Objective: To provide a consistent approach to the identification and naming of medicines and devices which can support management and activity across the entire health domain Clinical Terminologies Medical Product Directory Clinical Information

22. National E-Health Transition Authority nehta 21 Australian Medicines Terminology: Under Development  Proof of concept: complete demonstration tool  Terminology specification complete Draft for comment released at HIC Aug 2006 UML Model Technical Specification  First release: Limited set of codes to PBS for Pharmbiz project August 2006 All PBS products January 2007 Extend to all TGA registered medicines June 2007 High risk/ high use other TGA listed products June 2007 Medicines Terminology

23. National E-Health Transition Authority nehta 22 Medicines Terminology- as an extension of SNOMED  Currently, different identifiers for regulatory (ARTG), prescribing, dispensing, reimbursement (PBS), procurement (GTIN)  Aim: uniquely identify medicines with common descriptors  Proof of Concept delivered  Build commenced Technical Workshop was held 30 March 2006 Liaison with UK and US continuing – papers presented to SNOMED Working Group June 2006 Medicines Terminology – Under Development

24. National E-Health Transition Authority nehta 23 Medicines- a key building block for e-prescribing Federal announcement - legislation change enables e- prescribing Medicines Data Group Specification  Specification for e-scripts & dispense notifications  Medicines Terminology  Product ID- both generic and brand prescribing  Includes GTIN (barcode) to support Barcode dispensing  PBS XML release to include map to AMT

25. National E-Health Transition Authority nehta 24 Adverse Reactions and Allergies:  Review harvested Australian termset  Review SNOMED Reference set for Allergens Devices:  Viewed as an extension to Medicines Terminology Problems, Diagnoses, Procedures:  Strategy for implementation – GP sector, MBS and PBS termsets, high frequency procedures etc. Clinical Terminologies - Other Priority Domains Planned

26. National E-Health Transition Authority nehta 25 Clinical Information - Issues Governance –  National and International  Need for distributed contribution network – within quality control framework Implementation –  Adoption approach – early days  Need for conformance framework Expertise –  NEHTA currently recruiting staff with an interest in terminologies

27. National E-Health Transition Authority nehta 26 Benefits Realisation Shared EHR Specifications Supply Chain Clinical Terminologies Medical Product Directory Clinical Information Individual Healthcare Identifier Healthcare Provider Identifier Benefits Realisation Secure Messaging User Authentication Dr Peter Sprivulis: Modeling benefits and costs associated with the paths of investment Benefits realisation plan

28. National E-Health Transition Authority nehta 27 High level benefits path Foundations Benefits

29. National E-Health Transition Authority nehta What is the need for terminology?

30. National E-Health Transition Authority nehta 29 The Current Situation: Paper Records Persist

31. National E-Health Transition Authority nehta 30 Current State of Healthcare Patients are treated in many settings across the continuum of healthcare Many healthcare facilities have limitations on which aspects of information they can electronically exchange within their facility or with other facilities Inability to access electronic patient record information is a barrier to delivering the best patient care

32. National E-Health Transition Authority nehta 31 Types of Coding Systems Classification systems (e.g. ICD-10-AM) Terminologies (e.g. SNOMED CT)

33. National E-Health Transition Authority nehta 32 ICD-10-AM Classification Systems Groups concepts Concepts are categorized by where they fall in the classification system Category coding

34. National E-Health Transition Authority nehta 33 SNOMED CT: A Standardized Clinical Terminology Provides codes with explicit formal definitions of their meaning Can be implemented in software applications to represent clinically relevant information

35. National E-Health Transition Authority nehta 34 Why we need standardized terminology? Summarizes medical information Facilitates use of medical data  Selective retrieval for aggregation and analysis (e.g. “How many new cases of breast cancer have we seen this month?” “Is this person’s blood sugar improving?”)  Automated reasoning (i.e. clinical decision support)

36. National E-Health Transition Authority nehta 35 SNOMED CT advantages Information can be recorded at the appropriate level of detail not forced to be either too general or too specific Consistency over time and across boundaries Transmission of information without loss of meaning Aggregation at more general levels, and along multiple different perspectives Can be interpreted by automated systems

37. National E-Health Transition Authority nehta 36 SNOMED CT Systematized Nomenclature of Medicine Clinical Terms ® A comprehensive, scientifically validated terminology and infrastructure for healthcare Allows for a consistent way of indexing, storing, retrieving and aggregating clinical data across specialties and sites of care Healthcare terminology with content for a variety of clinical domains

38. National E-Health Transition Authority nehta SNOMED CT Concept Clinical Finding Procedure Context-dependant categories Observable Entity Body Structure Organism Substance Pharmaceutical/Biologic Product Specimen Physical Object Physical Force Events Environment and geographical Location Social Context Staging and Scales Linkage Concept Qualifier Value Special Concept Record Artifact 19 upper levels (top hierarchies)

39. National E-Health Transition Authority nehta 38 Basic elements of SNOMED CT Concepts – the basic unit of SNOMED CT Hierarchies – represent concepts organized under a “root concept” Relationships – link concepts within a hierarchy (parent-child, attribute) Descriptions – terms or names assigned to a concept (synonyms)

40. National E-Health Transition Authority nehta 39 What is a Concept? “Unit of meaning” Each SNOMED CT concept is a collection of terms and a set of relationships SNOMED concepts are assembled in “logical definitions”

41. National E-Health Transition Authority nehta 40 What is a Description? Terms or names assigned to a concept Human readable Each concept has one: Fully Specified Name (FSN) Preferred Term (display term) Many concepts have: One or more synonyms

42. National E-Health Transition Authority nehta 41 Concepts differ from descriptions A single concept may have multiple descriptions Separate concepts may share the same description  E.g. “cold” is a synonym for: Common cold Cold sensation

43. National E-Health Transition Authority nehta 42 What are Relationships? A relationship is an association between two concepts Two types of relationships: Is_a relationships: Relationships that link concepts within a hierarchy Attribute relationships (roles): Allow links between concepts across hierarchies

44. National E-Health Transition Authority nehta 43 Graceful evolution Content and structure evolve as knowledge grows and as quality issues are revealed Avoid radical change Provide history tracking of elements

45. National E-Health Transition Authority nehta 44 Examples of Applications Using SNOMED CT Electronic medical records Provider order entry  e-prescribing  lab order entry Problem lists Disease templates Evidence-based practice Assessment flow sheets Nursing documentation A&E charting Cancer reporting Therapeutic decision support Genetic databases Radiology image bank Autopsy databases Literature encoding Clinical research Global benchmarking Surgical procedure lists

46. National E-Health Transition Authority nehta 45 Current NEHTA SNOMED CT Release: July 2006 Concepts Table Descriptions Table Relationship table History table ICD 10 mapping table

47. National E-Health Transition Authority nehta 46 Current NEHTA SNOMED CT Release: July 2006 More than 300,000 active concepts organized into hierarchies More than 770,000 active descriptions More than 900,000 relationships 3 language editions – use of UK English edition for Australian purposes Several cross mappings/integrations

48. National E-Health Transition Authority nehta 47 Current NEHTA SNOMED CT Release: July 2006 Technical Reference Guide Technical Implementation Guide Developers Toolkit

49. National E-Health Transition Authority nehta 48 Current NEHTA Recruitment Strategy Looking for staff with an interest in the area and willing to learn We will provide training and tools Flexible on location May work part time Encourage secondment or LWOP from current positions Please check out NEHTA website for more information about the positions:  www.nehta.gov.au/

50. National E-Health Transition Authority nehta Questions?