The Practical Challenges of Implementing a Terminology on a National Scale Professor Martin Severs

Key Lessons Terminology implementation is difficult and expensive The implementation of a terminology exposes data practices Data practices are not well developed It is easier to blame the terminology than face the data practice shortcomings Patient real time access to their record, the cost of data collection and decision support are the most likely stimuli for better terminology production and data practice

From the Micro-perspective PatientClinician Consultation

From the Micro-perspective PatientClinician Patient Record

From the Micro-perspective PatientClinician Patient Record No uniform routine synchronous or asynchronous access by the patient Definitions Lay Terms Short Forms Impact on Terminology [T]

From the Micro-perspective PatientClinician Patient Record No uniform Routine synchronous or asynchronous access by the patient No Profession or inter- professional [team] standard syllabus for record keeping Definitions Lay Terms Short Forms Clinical Authority for definitions and preferred terms Priority on work items Quality of relationships

From the Micro-perspective PatientClinician Patient Record SECONDARY PURPOSES Audit Central Returns Registers Other dataset demands

From the Micro-perspective PatientClinician Patient Record SECONDARY PURPOSES Audit Central Returns Registers Other dataset demands Manual Transcription of record and human interpretation of source and target data Secondary purposes completely miss the recording challenges

From the Micro-perspective PatientClinician Patient Record SECONDARY PURPOSES Audit Central Returns Registers Other dataset demands Manual Transcription of record and human interpretation of source and target data Poorly costed ‘normal practice’ Semantic interoperability not important Data quality driven by specific secondary purpose Poor policy drive for terminology Overall data quality poor Aggregate data items Definitions may be different from that in record

From the Micro-perspective PatientClinician Patient Record SECONDARY PURPOSES Audit Central Returns Registers Other dataset demands Secondary purposes completely miss the recording challenges Specified in aggregate data items Human readable form not clear enough for terminological expression No standard format for expression No testing of system implementation This step missed out in costing

From the Micro-perspective PatientClinician Patient Record Secondary Purposes

From the Micro-perspective PatientClinician Patient Record Secondary Purposes PRIMARY PURPOSES Clinical Communications Clinical Audit Order Communications Knowledge Support Common User Interface Automated Decision Support Referral Discharge Notifications Death Certs. Record transfer Emergency Sum.

From the Micro-perspective PatientClinician Patient Record Secondary Purposes PRIMARY PURPOSES Clinical Communications Clinical Audit Order Communications Knowledge Support Common User Interface Automated Decision Support Referral Discharge Notifications Death Certs. Record transfer Emergency Sum. Significant drivers BUT Reliance on other standards Quality and quantity tensions in terminology Management of clinical phrases Consistent implementation challenge

From the Macro-perspective Data Migration Patient Safety Terminology Shared risk Terminology Shared costs Terminology Capacity The global citizen Conversion of development to implementation Policy versus technology versus clinical care

SNOMED CT & SDO helps the Macro-agenda More costly develop alternative [$25-50m] Delay the e-health agenda by developing an alternative [<5 years] Vendor costs would increase with multiple standards Avoid huge cost of data migration later [$28B] Avoid patient safety risks from data migration [both deaths and injury]

SNOMED CT & SDO helps the Macro-agenda Commercial Benefits Costs are minimal (compared to an Electronic Patient Record System ~ $100s of millions) Charges are affordable and shared, and based on the ability to pay Charges reduce as new Members join OR greater investment in improvement The investment risks are significantly reduced Protect Healthcare IT investment now

SNOMED CT & SDO helps the Macro-agenda Improved Governance Validated Product Shared Ownership Localisation Support Global Collaboration Compatible with Other Standards Enhanced Contribution Sustainable Model Code of Conduct Simple Licensing Vendor Engagement Clear and transparent management processes

SNOMED CT & SDO helps the Micro-agenda Validated Product BUT it needs to be better Leading Global Terminology from independent assessment [Problems noted] Most ready for Local Implementation $100 million already invested in SNOMED CT [let us build on the intellectual & financial resources]

Management Board Finance & Operations Committee Harmonisation Boards SNOMED SDO Structure Research Teams Vendor Forum Research & Innovation Committee Technical Committee Content Committee Task & Finish Groups Working Groups GENERAL ASSEMBLY

SNOMED CT helps the Micro- agenda Int. SNOMED SDO National Release Centre Local/National Health Entities Shared technology environment enables collaboration National Release Centre National Release Centre National Release Centre

Key Lessons Terminology implementation is difficult and expensive The implementation of a terminology exposes data practices Data practices are not well developed It is easier to blame the terminology than face the data practice shortcomings Patient real time access to their record, the cost of data collection and decision support are the most likely stimuli for better terminology production and data practice

Questions ?