Karen Gibson

 Significant investment in eHealth is underway  Clinical records: ◦ Not only a record for the author ◦ Essential to inform the next person in the care team  Clinical safety risks of poor quality, ambiguous communication  Desire to: ◦ make systems more interoperable ◦ improve data quality ◦ improve ability to re-use information for reporting, management etc.

 Clinical Terminology is complex  Humans spend 4-10 years learning medical terminology at University!  We need to make their language computable  No silver bullets

 Clinicians say things in many different ways ◦ Sometimes legibly ◦ Often in shorthand  Terminology needs to maintain fidelity of information – be true to what clinician is trying to say

 EHR’s need to source information from many different systems ◦ Legacy systems with legacy data ◦ Legacy terms and ways of coding (if coded at all)  How do we begin to bring this together?  And do so in a way which ensures stakeholders can be confident that the information is accurate and capable of being aggregated and reused.

 SNOMED CT ◦ Most comprehensive clinical terminology available ~ 350,000 concepts ~ 1,000,000 terms ◦ Purchased and maintained by a group of collaborating nations for use in their eHealth initiatives (IHTSDO)  Only part of the answer: ◦ Supplemented by other terminologies – eg. medicines and administrative ◦ Knowledge of the information model (context) ◦ Other emerging technologies (eg. NLP)

 SNOMED CT ◦ Complexity ~ 350,000 concepts ~ 1,000,000 terms  Only part of the problem ◦ Lack of implementation knowledge ◦ Lack of tools to assist ◦ Lack of funding to meet costs of implementation ◦ ? Lack of will

IHTSDO has addressed (or is working to address):  International Governance  Open Standard  Intellectual Property  Quality  ? Mapping to other standard terminologies/ classifications Others are being tackled by NEHTA:  Cost – free to use in Australia (as member of IHTSDO)  ‘Australianisation’  National reference sets  Medicines component

 Do look to SNOMED CT-AU first ◦ It is endorsed by COAG ◦ It is the most comprehensive clinical terminology available ◦ It is supported by NEHTA and IHTSDO

SCTID:  A concept and its descriptions Myocardial infarction Synonym MI - Myocardial infarction SCTID: Synonym Infarction of heart SCTID: Synonym Cardiac infarction SCTID: Synonym Heart attack SCTID: Fully Specified Name Myocardial infarction (disorder) SCTID: Preferred term Myocardial infarction SCTID:

Myocardial infarction SCTID: Injury of anatomical site SCTID: Structural disorder of heart SCTID: Myocardial disease SCTID: Is a Myocardium structure SCTID: Finding site Infarct SCTID: Associated morphology Relationships Links concepts within SNOMED CT Ensures unambiguous meaning Create hierarchies which aid navigation and retrieval

 Consider the user interface carefully: ◦ Don’t show Fully Specified Names to users  They’re intended to provide a unambiguous reference point for computability  They are not worded in a way clinicians speak ◦ Do choose a preferred term

Fully specified name Preferred term (Australia) Amebic appendicitis (disorder) Amoebic appendicitis US Spelling Semantic tag: indicates hierarchy not needed at clinical level Unambiguous Reference Point

 Consider the user interface carefully: ◦ Don’t show all of SNOMED CT in a drop down list (too many terms!) ◦ Unless you have tools to assist searching ◦ Do use Reference sets to assist implementation:  Reduce the complexity for the user  Speed identification of the correct term

Problem/diagnosis : Select term SNOMED CT in Drop down list without any parameters implemented

Problem/diagnosis : Appendi Improved searching – limited to clinical finding hierarchy Could be further improved through Refset development

 Reference sets Do require maintenance  Therefore: ◦ Do use NEHTA reference sets wherever possible (because NEHTA maintain them!) ◦ Do use the hierarchies of SNOMED CT to guide creation of RefSets wherever possible ◦ Recognise that if you pick ad hoc terms across hierarchies you will need to manually maintain the list ◦ Sometimes there is no choice – eg. allergies – but there is a cost

 Minimise mapping and data translation: ◦ There is a safety risk introduced every time the clinician’s language is translated (Chinese whispers…)  If you do need to map or translate: ◦ Do keep the original wording/ data entry as well as the mapped equivalent

 Trap for new players: ◦ Synonyms may be found in the wrong hierarchy (different meaning) ◦ This is why when translating SNOMED CT translators look at the words within the hierarchy to establish true meaning ◦ However, this trap is not just for translators, but also when mapping or creating reference sets.

 Even simple use of SNOMED as a flat code list can add value: ◦ Allows meaningful exchange of data ◦ Both end-points can cross-reference to a standard unambiguous definition ◦ Simple decision support can be enabled  For example – US Centre for Disease Control, HITSP and NHS all publish simple lists

 But for those up to the challenge, more advanced use of SNOMED CT offers further potential value

 Ability to Exchange data knowing it can be explicitly and accurately interpreted  Ability to improve data quality: ◦ More structured data entry ◦ Agreed constraints can be applied

Ability to run externally developed queries: ◦ For example:  Automatically run mandatory reporting  Identify at-risk populations  Identify cohorts for clinical trials  Trigger presentation of evidence based guidelines when first released Note Kaiser Permanente have a central area which develop queries/ scripts which are then distributed throughout the organisation

 Ability to utilise external decision support engines: ◦ Already happening in medicines area ◦ Opportunity for improved decision support applications in other areas  Ability to contribute to PCEHR

 Ultimate aim is improving health outcomes and patient safety: ◦ Through better sharing information ◦ Ensuring accuracy of information ◦ Identifying those at risk

 Perhaps speaking to the converted, but unless we can agree and implement consistent terminology we will never achieve the goal of better information sharing….  We’ll just be sharing data….