‘Implementation of SNOMED CT ’ Oct’ 2012 Denise Downs, Implementation & Engagement Lead

Some background on NHS Responsibility and ownership for IT solutions sits with healthcare providers Reporting and payment based on classifications Read Coding predominant in primary care Acute and community still significant use of paper and classifications coding Difficult to mandate SNOMED CT

Context By implementation mean: – Incorporation in products by trusts and vendors – Retrieval of data by informaticians – Adoption by clinical users Need to engage with all these players

Goal: in government strategy to enable quality data in patient records to safely flow between clinical systems enabling re-use of key clinical data and facilitating decision support and reporting direct from that data.

Requirements: SNOMED CT must be used as the representation for clinical terms in the patient record when communicated between systems. This ensures that all system suppliers use a single terminology as the reference terminology for the whole of the NHS; system interoperability being the main priority. SNOMED CT should be the terminology used to record clinical information in coded form within the electronic patient record; classification codes support aggregation of clinical data and should not be used by clinicians to record clinical data in the EPR. SNOMED CT should be the terminology presented at the user interface for data entry; within the system the supplier may record within the EPR using the coding system they choose but they have the responsibility to maintain clinically assured maps to SNOMED CT. As part of system acceptance tests must be undertaken to verify the clinical safety of any mappings to SNOMED CT. While systems may provide a subset of SNOMED CT to users for data entry, they should be able to accept and display all of SNOMED CT so that they can safely interoperate with other systems. We recommend that the receiving system undertaken a level of validation against code type and inactive codes to insulate their system against the variations in requirements within different systems.

Approach (1/2) Required SNOMED CT in national contracts Approved as an Information Standard Developed some clinical champions, working with professions Raised awareness Persuading national reporting to move towards SNOMED CT

Approach (1/2) Documentation Support first of type Look for small number of long term engagement – provides case studies and documentation

‘Cut and diced’ various ways: Visit: Training & Resources on UKTC website eLearningwebinarsCase studiesDocumentationSNOMED CT NHS network

Offerings varied to meet need: Supplier Engagement Forums/SIG Workshops Guidance/Technical reports Help keep abreast of developments... Trusts & Clinical Engagement Awareness eLearning Webinars Subset development... Curriculum and Professional training CPD modules University content Awareness...

Technical Products History substitution table Lexicon Navigation subsets... Guidance & Comms Migration roadmap Why SNOMED CT Attending events Articles Deployment & training SCT for coders SCT for clinical users SCT for medical staff Binding SNOMED CT to forms....

EHR Product Focus Influencers Senior clinicians Professional Bodies Purchasing Decisions Procurement Health Informatics Provision Suppliers Users Clinicans IM&T staff Clinical Coders Administrative/Practice staff

System Approach EHR GP Systems Secondary Care Systems Analytics Data Warehouses Business Intellegence tools 3rd Party suppliers Document management devices Decision Support (FDB and dm+d) Knowledge Bases Pathways (Map of Medicine) Research papers (NHS Evidence)

Messages All Healthcare; All Clinical Specialities... provides content for all healthcare professions and all the different clinical specialities. Dynamic so it continues to support today’s’ requirements. Improved Expressivity... provides the different levels of detail in clinical phrases required by both clinical specialities and general practitioners. For example, microbiology and radiography are more extensively represented in SNOMED CT than in Read v2. International... is an international terminology, which gives it potential to support cross border data communications and language translation; but also enables a more efficient market for systems development and technology offerings. Supports logical Analysis of data The features within SNOMED CT provide a wide range of analysis techniques to support clinical audit and research work. Today’s Technology, an evolution... has been developed with the knowledge of previous terminologies, while embracing the requirements of today’s technologies to ensure it can support features such as decision support, clinical alerts and knowledge base enquiries.

Lessons Learnt Difficult ~ need to get messages right, better dissemination and signposting Clearer expectations from suppliers Make ‘more concrete’ for users Even though have a system with SNOMED CT, doesn’t mean they are terming, and when they are doesn’t mean its right!

Implementation framework Awareness Raising: Provide overview with key messages Interested: Want more details Bought in: Committed and wish to progress Implementing: Implementing SCT Aim: All using EHRs understand basics

Awareness Bought In Implementing Volumes: 10,000+ Approach: Push Methods: Events, web articles, eLearning, utube, web content Volumes: 100+ Approach: Pull Methods: Brochures, Documentation, eLearning, Commissioning requirements, presentations, master classes, web content Volumes: 10+ Approach: Pull Methods: Training, Courseware, Documentation, OSS, web content

Why SNOMED CT The NHS Strategy on terminologies Finding out more… Webinar 1 – Introduction to SNOMED CT Brochure: Language of Health Case Studies eLearning – Introduction to the Structure of SNOMED CT Start at the beginning Webinar 2: A walkthrough for those implementing ‘Where to start’ – a walkthrough of where to find the details required‘Where to start’ – a walkthrough of where to find the details required Guidance to support user interface development Give me a technical overview The international documentation The distribution portal - TRUD Show me the technical documentation Browsers for SNOMED CT data The eViewer to inspect subset content How do I view SNOMED CT content? Resources to help develop an understanding of SNOMED CT UKTC website: Network site: SNOMED CT NHS NetworkSNOMED CT NHS Network

Information Standards Notice: The standard applies to: Healthcare professionals providing care to patients receiving NHS care in England. All NHS staff interacting with patients should use SNOMED CT to record and exchange coded clinical information. Other stakeholders who may be required to use SNOMED CT will include staff at any other organisation that delivers care on behalf of the NHS. This may include public health, social care, health related services delivered in the education sector, as well as the independent sector. The standard may be used to support clinical management of the patient in the following ways: In messages that are used to transfer patient related data from one system to another. Patient Summaries including Discharge summary. Problem lists. Allergy Lists and Allergy Management. Clinical Documentation. Order Communication and Results reporting. Care Plans; in particular for clinical content that will be transferred between systems. Keyword lists for metadata in care pathways, research documents, evidence based content. Information Strategy: 3.58 At the moment different areas of the health and care system use different coding terminologies – this means that information cannot flow around the system well, and the way data and terminologies are described is often inconsistent. Reducing the number of inconsistent or incompatible terminologies from 2015 (via the ‘route-map’) will allow better integration between systems and across health and social care, and better information to support care and improvement of care. In due course, for patient care purposes, all relevant systems should use the same terminology to exchange coded information; SNOMED CT, adapted to fit all necessary uses, is the appropriate terminology to base this on. Similarly, to allow drugs to be consistently referenced, systems will consistently use the electronic drugs dictionary (dm+d). Action: The NHS Commissioning Board will lead and coordinate work on developing commissioning data sets (the main data collection from secondary care) to allow data returns in SNOMED CT from April Return to Diagram

Awareness Aim: future messages from suppliers/trusts Plan: move to more ‘pull’ than ‘push’

Adoption in products Achieved: – Number of products now have SNOMED CT Aim: Increase take-up by wider range of suppliers Plan: Focus more on engagement with small companies and ‘added value’ products

Adoption within a trust New What does this mean and how Aim: To have some guidance available Plan: to work with a small number of trusts to help gather the knowledge to develop guidance – UHB and Moorfields

Increase efficiencies in Classifications Coding Aim: to have clearer guidance and experience in relation to mapping to the classifications Plan: – Efficiency in current process: have 4 trusts we are talking to in relation to this. – Desire to have statistics from out-patients. Work with Information Centre and subsets.

Adoption by clinical staff Achieved: – Increased Awareness – Approach they want is via subsets Aim: greater understanding by clinical staff and why beneficial to use Plan: CPD materials for adoption and promotion by the professional bodies/HEIs

Content Need confidence that content is there to support the different professions and is of quality Plan: development of a number of professional subsets in clinical sub-speciality areas – and identify additional terms required

Analytics Achieved: – Some clinical awareness through articles – Some queries that clinical staff interested in that use SNOMED CT modelling for discussions with vendors Aim: To have more products that support analytics by clinical staff and ICT staff Plan: Workshop later in the year to raise awareness in suppliers

Data Migration Achieved: – Technical Report Aim: Robust guidance & feedback on use Plan: work with international interested in this. Event in UK to get feedback with view to ensuring products we have best meet needs

Primary Care Focus: QOF, GPSoC, electronic Discharge summaries, Requirements for systems that relate to SNOMED CT (in collaboration with the JGPITC)

Other actions Re-consider compliance and testing Get clearer requirements captured