1. Barriers to Implementing SNOMED CT
Siew Lam

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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%

20. 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

21. Results: Demographics – Employees
Most respondents were from small organizations
Size of Organization
Response count
Percentage (n=47)
49 or fewer Employees 17
36.2%
Employees 10
21.3%
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%

22. 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

23. 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

24. 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

25. 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%

26. 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%

27. 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%

28. 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

29. 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%

30. 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%

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

32. 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

33. 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%

34. 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

35. 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

36. 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%

37. 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

38. 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

39. 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%

40. 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%

41. 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%

42. 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

43. 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%

44. 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%

45. 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%

46. 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%

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

48. Thank You! Questions?