1. NHS Connecting for Health is delivering the National Programme for Information Technology SNOMED CT in the NHS Care Records Service Ian Arrowsmith NHS Connecting for Health Terminology workshop Sandefjord, Norway 3 rd November 2005

2. NHS Connecting for Health is delivering the National Programme for Information Technology Structure of presentation An overview of the NHS Care Record Service ‘Spine’ SNOMED CT NHS Implementation activities International Standards Development Organisation

3. NHS Connecting for Health is delivering the National Programme for Information Technology Will enable details of the key events of a persons healthcare history throughout their life to be; ●collected, stored & retrieved ●made available at all times ●across the whole country ●to those with authority to view “A better use of information and communication technology within the NHS would improve efficiency and cut costs” Wanless Report April 2002 The NHS Care Record Service ‘Spine’

4. NHS Connecting for Health is delivering the National Programme for Information Technology Simplified ‘Spine’ architecture

5. NHS Connecting for Health is delivering the National Programme for Information Technology Contractual arrangements National services (NASP) 5 regions (clusters) 4 main regional contractors (LSPs) 3 main sub-contractors Small number of other National sub- contractors Large number of existing/legacy system suppliers

6. NHS Connecting for Health is delivering the National Programme for Information Technology NHS CRS domain Patient care domain LSP Service Information Clinical Event Healthcare service Local System GP systems Hospital systems … etc.,. ●A clinical event takes place in a healthcare service ●The Local service requests information from Spine ●Information is used to inform current care ●Care given – details placed onto local system ●The Spine is also updated with recent care details A single clinical event … The Spine Example Spine Information Personal Details Previous Care Summaries Details of Clinical Events Clinical correspondence Discharge summaries Referral information Current Care Providers Medication Information

7. NHS Connecting for Health is delivering the National Programme for Information Technology LSP Patient info Broken Leg Patient visits A&E Patient info LSP Back Pain Patient visits GP LSP Patient info Chest infection Patient visits hospital Spine Multiple events over time…

8. NHS Connecting for Health is delivering the National Programme for Information Technology NCRS Spine ‘Vision’ The “Continuity of Care Record” –The NHS Care Record Spine is a universally accessible (to those with an authority to view) repository of Health Care information for every person in England. –The content of the record can be thought of as the minimum information required by a clinician when seeing a patient for the first time in the absence of a referral from a clinical colleague. That is not to say that the record will only be used in unplanned and emergency situations.

9. NHS Connecting for Health is delivering the National Programme for Information Technology SNOMED CT in the NCRS Ensuring the NHS is ready for SNOMED and….. –SNOMED is ready for the NHS) The challenge: –Pace of change –Scale of implementation –Lack of implementation experience (of SNOMED CT) –Large installed legacy terminology user base –Supplier resistance – contracts !!

10. NHS Connecting for Health is delivering the National Programme for Information Technology Traditional role of the NHS Terminology Service UK-specific SNOMED CT and READ codes maintenance Maintenance of dictionary of medicines and devices (dm+d) Production of SNOMED CT UK Edition on behalf of all 4 home countries Maintain cross-maps to UK-specific classifications Subset maintenance/management Clinical content enhancement Distribution Licensing

11. NHS Connecting for Health is delivering the National Programme for Information Technology Additional responsibilities Ensuring consistent approach across regions/supplier Ensuring consistent approach across work- streams Coordination of design activities Provide forum for risk and issue resolution Provide authoritative and explicit guidance/advice

12. NHS Connecting for Health is delivering the National Programme for Information Technology (some) Key activities/issues Subsets Model of use vs Model of meaning Managing legacy environment Training Distribution Contribution to related work Contribution to internationalisation effort

13. NHS Connecting for Health is delivering the National Programme for Information Technology Subsets A collection of terminology, selected and grouped for a particular purpose May be composed of anything from a single component to the entire set of concepts, descriptions or relationships Commonly needed for: –Data quality improvement –Message field validation –Simplified data entry and retrieval –Elimination of ‘noise’

14. NHS Connecting for Health is delivering the National Programme for Information Technology Subsets - approach Devolved responsibility National control Provide effective tools: –Simple to use and individually configurable to allow subsets to be created/edited with the minimum of effort (including tutorials) –Ability to set permissions/rights to allow viewing and/or editing rights –Workflow elements –The tool must support multiple synchronous users –To support the distributed working environment it must be possible to undertake all of the above processes over the www

15. NHS Connecting for Health is delivering the National Programme for Information Technology Typical subset creation Methodology 2 main variants –1) Select directly from SNOMED –2) Describe in own words and compare with SNOMED

16. NHS Connecting for Health is delivering the National Programme for Information Technology Direct interaction

17. NHS Connecting for Health is delivering the National Programme for Information Technology Clinicians creating raw content Subset Processing by authorised subset authors able to invite clinicians who are not so computer literate and those who may not have any knowledge of SNOMED terminology In your own words….

18. NHS Connecting for Health is delivering the National Programme for Information Technology Need to create a subset of a list of “Orthopaedic procedures of the knee joint” In this instance, Orthopaedic Clinicians are invited by email to give their input on the content for this subset Clinicians are asked to give their input in a simple format – Such as a spreadsheet using their own words First steps

19. NHS Connecting for Health is delivering the National Programme for Information Technology

20. A team of authorised subset authors will map the clinicians words to a SNOMED equivalent concept The mapped list is then distributed back to the clinicians to validate that the SNOMED CT description chosen is unambiguous and that it has retained the meaning of the clinician’s words At no stage during this process clinicians are exposed to the coding element of Terminology Next step

21. NHS Connecting for Health is delivering the National Programme for Information Technology

22. Subset

23. NHS Connecting for Health is delivering the National Programme for Information Technology Model of use vs Model of meaning Model of Meaning – What is known and can be inferred about the instances of a given concept Models of Use – When, where and why to use, store, or display a concept or group of concepts

24. NHS Connecting for Health is delivering the National Programme for Information Technology Managing ‘Legacy’ issues Mixed economy –Paper based systems –Non-compliant electronic systems –Partially compliant electronic systems –Totally integrated electronic systems –Alternative coding systems –Secondary uses Principles –Maximum use of existing information –No interruption to existing flows –Information entered only once

25. NHS Connecting for Health is delivering the National Programme for Information Technology Translation/mapping There will be no widespread mapping exercise to enable non- SNOMED systems to be able to send clinical information to the Spine. Centrally maintained formal mapping between Read codes and SCT will be utilised to allow translation of clinical content in local systems for messaging to NCRS Spine Exceptions for Pathology and Radiology Examining use case for reverse mapping from classifications

26. NHS Connecting for Health is delivering the National Programme for Information Technology Training – who needs it ? Health record and communication practice standards What sort of staff need to understand about SNOMED CT How much do they need to know Whose responsibility is it to train them Where are the gaps

27. NHS Connecting for Health is delivering the National Programme for Information Technology What sort of users are there ? ‘Typical’ front-line user Users of legacy terminology Front-line application support (super-user) Enthusiasts Basic trainer Analysis experts (clinical audit, clinical coder etc) Advanced trainer Application configuration expert (tailoring) System developer/configuration expert Policy developer/implementer National experts

28. NHS Connecting for Health is delivering the National Programme for Information Technology Distribution Aim = more frequent release –Tooling/processes –Synchronisation/distribution –Core vs extension –New partners Subsets Distribution formats Non NPfIT suppliers Relationship with legacy products

29. NHS Connecting for Health is delivering the National Programme for Information Technology Parallel work Common user interface –Rendering –Post-coordination –Search strategies Cultural change/implementation terminfo

30. NHS Connecting for Health is delivering the National Programme for Information Technology In conclusion…. SNOMED CT (in the NHS CRS) will facilitate the sharing of electronic patient records to provide clinical support across all care settings SNOMED CT is part of the solution, not part of the problem…..

31. NHS Connecting for Health is delivering the National Programme for Information Technology SNOMED ® Standards Development Organisation [SNOMED SDO]

32. NHS Connecting for Health is delivering the National Programme for Information Technology Vision Statement The SNOMED CT ® Standard is necessary for international interoperability, conformance and decision support. The SNOMED CT Standard is managed by The SNOMED ® Standards Development Organization in such a way that uptake, collaboration, alignment, contributorship and the ability to meet local terminology needs are encouraged.

33. NHS Connecting for Health is delivering the National Programme for Information Technology SNOMED SDO top-level Structure Management Board Content Com. Technical Com. Finance & Ops. Com Research & Innov. Com

34. NHS Connecting for Health is delivering the National Programme for Information Technology Management Board: Function Management Board is responsible for: –All the decisions taken in and by the SNOMED SDO; it is the authority –All aspects of the SNOMED SDO structure, process, outputs, governance, financial sustainability and legal standing –Upholding the vision, values, principles and articles of the SNOMED SDO

35. NHS Connecting for Health is delivering the National Programme for Information Technology Content Committee: Function Be responsible for the quality of the content of the international terminology, [the core] Set the requirements for the concept modelling and editing processes with the Technical Committee Submit to the MB an annual fully funded business plan which is fully conformant to the overall SDO business plan

36. NHS Connecting for Health is delivering the National Programme for Information Technology Technical Committee: Function Lead and recommend the technical strategy for the SDO Lead the specification, contracting, testing, supporting and managing of the global technical components for the SDO. At a minimum this would include: –The SNOMED CT distributed modelling and editing environment –The SDO terminology distribution systems –The internal automated quality assurance processes

37. NHS Connecting for Health is delivering the National Programme for Information Technology Finance & Operations Committee: Function Assuring all MB and Executive Board papers are prepared and submitted to MB to time and specification Ensuring all support functions especially finance are fully detailed and reported to the Management Board Initially investigating and reporting to the MB all adverse incidents including complaints, adverse publicity, and delays in projects. Drafting operational policies and procedures as recommended by the MB and managing their implementation Monitor progress and delivery from Committees

38. NHS Connecting for Health is delivering the National Programme for Information Technology Research & Innovation Committee: Function Responsible for: –Developing the Research Strategy for terminology world wide in consultation with research colleagues outside the SDO –Recommending costed activity to the MB for either in- house or externally commissioned research, this could be via an annual business plan –Commissioning external R&I and accounting for SDO money spent

39. NHS Connecting for Health is delivering the National Programme for Information Technology Full SNOMED SDO Structure Management Board Content Com. Technical Com. Finance & Ops. Com Research & Innov. Com Vendor Forum Harmonisation Boards Support Organisation Working Groups Task & Finish Research Teams

40. NHS Connecting for Health is delivering the National Programme for Information Technology New SNOMED Enterprise Model National Release Centre SNOMED SDO [Core] National Release Centre NRC [Core and Extension ] National Release Centre Local/National Health Entities Shared Infrastructure to enable collaboration

41. NHS Connecting for Health is delivering the National Programme for Information Technology Component Definition of SNOMED Enterprise SNOMED Standards Development Organisation [SDO] –All components needed for international conformance, interoperability & maintenance of the principles National Extensions –All components needed for national, but not international conformance, interoperability & maintenance of the principles

42. NHS Connecting for Health is delivering the National Programme for Information Technology SNOMED SDO Technical Infrastructure 1.Configuration management 2.Workflow management 3.Modelling tool 4.Lexical tools 5.Subset tool 6.Mapping tools 7.Content submission tools 8.Data communications environment 9.Support and maintenance processes

43. NHS Connecting for Health is delivering the National Programme for Information Technology Other key points ‘Not for profit’ organisation Different levels of membership CAP initially contracted as support organisation New structures anticipated by April 2006 European workshop in London, 11 th November 2005 – contact sarah.bagshaw@cfh.nhs.uk

44. NHS Connecting for Health is delivering the National Programme for Information Technology Further information http://www.cfh.nhs.uk http://www.snomed.org