Barriers to Implementing SNOMED CT Siew Lam

Background Question: “What do you perceive as your biggest barrier to the wide scale national implementation of SNOMED CT, which is likely to be overcome or significantly mitigated by activity of the IHTSDO?” Up to 3 barriers was requested Letter was sent to the members of the GA on December 21st 2010 requesting a response by January 4th 2011

Responses There were 5 responses from the GA: Singapore Australia United Kingdom Netherlands Canada

Barriers for Singapore Lack of vendor capability (and attendant costs) to implement, search and display SNOMED CT Optimized search capability and search designs for usability in a clinical setting Data entry capability that takes advantage of SNOMED CT to handle pre-coordinated and post-coordinated expressions Tools to help integrate legacy systems (e.g., map legacy terminology) Capability to leverage and use SNOMED CT as a reference terminology

Barriers for Singapore Lack of tools and processes to support the governance of code sets or SNOMED CT Reference Sets Lack of change management processes during system implementation

Barriers for Australia Lack of simple business and technical understanding of problems that need solving in wide-scale national implementation of SNOMED CT, to help define how SNOMED CT can solve the problem and identify the derived benefits

Barriers for Australia Lack of SNOMED CT adoption pathway for both technical implementation and benefits realization Lack of recommendations for implementing and using SNOMED CT in phases Each phase should be simple and the benefits clearly stated Implementing one phase should make implementing the next easier

Barriers for Canada Lack of implementation expertise and documentation to lend support to issues relating to implementing SNOMED CT Lack of standards for terminologies to support user interfaces in applications, when the terms are not appropriate to add to SNOMED CT

Barriers for Canada Lack of clear guidance documentation and tools for the creation and maintenance of Reference Sets using Release Format 2 (RF2)

Barriers for United Kingdom Lack of enumerations of the types or categories of implementation and how SNOMED CT can support each of the types or categories Each of the types or categories may contain subtypes or subcategories

Barriers for United Kingdom The lack of enumerations of functions that accompany types or categories of implementation and how SNOMED CT can be implemented to provide support for these functions Enumerations of the functions should range from simple to complex

Barriers for Netherlands Size of the content of SNOMED CT makes it a challenge to implement Lack of small functional Reference Sets of useful content Current billing systems do not use SNOMED CT Current Electronic Health Record systems do not use SNOMED CT

Results of Survey to Gather the Use, Benefits and Tools of SNOMED CT

Background Part of 2010 I&I Work Plan Work started in the Implementation SIG resulting in a set of questions for the survey Questions were posted on I&I Committee Forum, Member Forum and Affiliate Forum for feedback

Background Based on feedback, refinement of questions was undertaken by James Case of US National Library of Medicine One comment was that the original survey was too long and had open-ended questions Final survey contains 38 questions and is expected to take an average of 10 minutes to complete

Survey Questions Designed to cover a broad range of topics Structured into 3 sections First: survey respondent’s organization’s characteristics Second: respondent’s project that use SNOMED CT (collecting up to 4 projects per respondent) Third: SNOMED CT implementation details, tools and benefit realization Complete list of questions is listed in report

Survey Approach – Not Adopted Methods to conduct the survey were evaluated Word document with checkboxes for answering the questions Not easy to fill out form and responses must be manually tallied Word document with embedded macros allowing for selection lists Took too long to load (up to 2 minutes) before responses can be collected

Survey Approach – Adopted Web based survey Support selection boxes, drop down lists and free text entries Easy to navigate Support simple rules Only requires a browser Easily accessible Simple submission process upon completion

Results: Demographics – Countries There were 48 respondents from 10 countries Country Response Count Percentage (n=48) Australia 6 12.5% Canada 14 29.1% Denmark 1 2.1% Netherlands 2 4.2% Singapore Spain Sri Lanka Sweden United Kingdom 7 14.5% United States 13 27.1%

Results: Demographics – Organization Respondents were mainly from government institutions and vendors Type of Organization Response Count Percentage (n=48) Government Institution 17 35.4% Vendor 11 22.9% University 7 14.6% Health Care Enterprise 5 10.4% Consulting 4 8.3% Medical Clinic 2 4.2% Other

Results: Demographics – Employees Most respondents were from small organizations Size of Organization Response count Percentage (n=47) 49 or fewer Employees 17 36.2% 100-499 Employees 10 21.3% 500-999 Employees 5 10.6% 1,000-4,999 Employees 8 17.0% 5,000-9,999 Employees 4 6.4% 10,000 and Over Employees 3 8.5%

Results: Use of SNOMED CT 40 of the 48 respondents used SNOMED CT The 8 respondents who did not use SNOMED CT was not required to answer the rest of the survey

Project Overview Section Contains 7 questions to gather information about respondents’ projects that use SNOMED CT First question allows the respondents to list up to 4 of their highest priority projects Questions 2 to 7 collect information on each of these projects Each question allows the respondent to select all the items that apply to the project being surveyed

Project Overview – Project Description Respondent was asked to state up to 4 projects in order of importance Total of 62 individual projects were listed by 31 respondents Number of Projects Described Response Count 1 31 2 18 3 8 4 More than 4

Project Overview – Type of Projects For each project, there were 4 options to indicate the project type Type of Project Response Count Percentage (n=53) Proof of Concept 14 26.4% Pilot 15 28.3% Production 22 41.5% Enhancement 2 3.8%

Project Overview – Implementation For each project, there were 3 options to indicate the extent of implementation Extent of Implementation Response Count Percentage (n=41) National 16 39.0% Regional 10 24.4% Local 15 36.6%

Project Overview – Implementation Phase For each project, there were 5 options to indicate its implementation phase Implementation Phase Response Count Percentage (n=63) Planning 6 9.5% Analysis 9 14.3% Design 14 22.2% Construction 15 23.8% Maintenance 19 30.2%

Project Overview – Facilities For each project, there were 6 options to indicate the type of facilities the project is implemented in or planned for Type of Facility Response Count Percentage (n=61) Hospital 22 36.1% Physician Group/GP 12 19.7% Independent Laboratory 6 9.8% Public Health Organization Patient-Driven Organization 3 4.9% Research 19.7

Project Overview – Time Frame For each project, there were given 5 options to indicate the time frame of implementation Time Frame of Implementation Response Count Percentage (n=41) In Production Now 21 51.2% Lee than 1 Year 13 31.7% 1 to 2 Years 4 9.8% 3 to 5 Years 2 4.9% Greater than 5 Years 1 2.4%

Project Overview – Budget For each project, there were 6 options to indicate the budget for implementation, excluding operating costs Budget for Implementation Response Count Percentage (n=39) Less then $100,000 15 38.5% $100,000 to $1M 10 25.6% $1M to $3M 1 2.6% Greater than $3M 2 5.1% Decline to State Don’t Know 9 23.1%

SNOMED CT Implementation Section Contains 18 questions to gather information on the respondent’s implementation experience and use of SNOMED CT

SNOMED CT Implementation – Systems There were 14 options to indicate the type of systems where SNOMED CT was implemented (# 1 to 8 shown below) Type of System Response Count Percentage (n=32) Clinical Documentation (CPOE, Nursing) 18 56.3% Research 16 50.0% Terminology Server / Services 14 43.8% Reporting (Registries, Infectious Disease) 13 40.6% Decision Support 9 28.1% Quality Assurance Data Warehouse/Analytics Interoperability/Interface Engine 28.1

SNOMED CT Implementation – Systems There were 14 options to indicate the type of systems where SNOMED CT was implemented (# 9 to 14, plus “others”, shown below) Type of System Response Count Percentage (n=32) Personal Health Record 7 21.9% Laboratory Information System 6 Pharmacy 5 15.6% Reimbursement Radiology 3 9.4% Genomics 2 6.3% Others 18.8%

SNOMED CT Implementation – Use Cases There were 11 options to indicate the use cases for SNOMED CT (# 1 to 8 shown below) Use Case Response Count Percentage (n=30) Clinical Documentation 19 63.3% Problem List 16 53.3% Mapping to Other Classifications (ICD9, ICD10) 14 46.7 Patient Summary/Discharge 13 43.3% Medication List 9 30.0% Allergy List Medication/Allergy Management Continuity of care/Discharge Plans

SNOMED CT Implementation – Use Cases There were 11 options to indicate the use cases for SNOMED CT (# 9 to 11, plus “not applicable” and “others”, shown below) Use Cases Response Count Percentage (n=30) Public Health including Notifiable Diseases 8 26.7% Order Communication and Results Reporting 7 23.3% Meaningful Use 6 20% Not Applicable 4 13.3% Others

SNOMED CT Implementation – Users There were 8 options to indicate the type of system users Type of System User Response Count Percentage (n=32) Clinicians 26 81.3% Researchers 19 59.4% Medical Record / Health Information Management Specialist 17 53.1% Information Technologist 12 37.5% Administrators/Management 9 28.1% Patients 6 18.8% Educators Health Policy Makers 5 15.6% Others 2 6.3%

SNOMED CT implementation – Hierarchies Respondents were asked to select the SNOMED CT hierarchies used SNOMED CT Hierarchies Response Count Percentage (n=32) Clinical Findings 18 56.3% Procedures 17 53.1% Disorders 14 43.8% All Hierarchies 12 37.5% Body Structures 10 31.3% Specimens 9 28.1% Observable Entities 8 25.0% Events 7 21.9% Pharmaceutical/Biologic Product 6 18.8% Qualifier Value

SNOMED CT Implementation – Hierarchies Respondents were asked to select the SNOMED CT hierarchies used (continuing previous table) SNOMED CT Hierarchies Response Count Percentage (n=32) Substances 5 15.6% Attributes 4 12.5% Staging and Scales Organisms Social Context 3 9.4% Physical Forces 2 6.3% Context Dependent Categories Physical Objects

SNOMED CT Implementation – Tools Examples of tools SnomedBrowser.com Snapper Vendor tools In house developed tools Use of Terminology Specific Tools Response Count Percentage (n=32) Yes 20 62.5% No 12 37.5%

SNOMED CT Implementation – Subsets Number of subsets / Reference Sets in use ranged from 1-168; highest were 169, 100+ and 80 Use of Subsets Response Count Percentage (n=33) Yes 19 57.6% No 14 42.4%

SNOMED CT Implementation Use of Natural Language Processing Technology Response Count Percentage (n=33) Yes 7 21.2% No 26 78.7% Use of SNOMED CT Extensions Response Count Percentage (n=33) Yes 17 51.5% No 16 48.5% Mapping of SNOMED CT to Other Classifications Response Count Percentage (n=33) Yes 24 72.7% No 9 27.3%

SNOMED CT Implementation – Browsers Use SNOMED CT Browser Response Count Percentage (n=33) Yes 31 93.9% No 2 6.1% Browser Use Extensively Use Occasionally Never Use Response Count Cliniclue 64.3% (18) 25.0% (7) 10.7% (3) 28 NCI Terminology Browser 4.5% (1) 27.3% (6) 68.2% (15) 22 SNOB 15.0% (3) 25.0% (5) 60% (12) 20 SnoFlake 0% (0) 21.1% (4) 78.9% (15) 19 Virginia Tech Browser 5.0% (1) 20% (4) 75% (15) Other 56.3% (9) 12.5% (2) 31.3% (5) 16

SNOMED CT Implementation - Benefits Benefit Category Response Count Percentage (n=32) No Benefit 2 6.2% Little Benefit 0% Some Benefit 8 25% Moderate Benefit 6 18.8% Large Benefit Very Large Benefit 4 12.5% Not Yet Implemented 5 15.6% Don’t Know 1 3.1%

SNOMED CT Implementation – Acceptance User Acceptance Response Count Percentage (n=32) No Acceptance 2 6.2% Little Acceptance Some Acceptance 4 12.5% Moderate Acceptance 8 25% Large Acceptance 7 21.9% Very Large Acceptance 0% Not Yet Implemented 3 9.4% Don’t Know 6 18.8%

SNOMED CT Implementation – Difficulty Level of Difficulty Response Count Percentage (n=33) Very Easy 2 6.1% Easy 0% Moderately Easy 4 12.1% Moderately Difficult 14 42.4% Difficult 8 24.2% Very Difficult Not Yet Implemented Don’t Know 1 3.0%

SNOMED CT Implementation – Information Availability and Quality of Information Response Count Percentage (n=32) None Available 0% Very Poor 1 3.1% Poor 3 9.4% Moderately Poor 9 28.1% Moderately Good 11 34.4% Good 6 18.7% Excellent 2 6.3%

SNOMED CT Implementation – Awareness Aware of Resources Available from IHTSDO Response Count Percentage (n=31) Yes 27 87.1% No 4 12.9%

Thank You! Questions?