Harnessing Clinical Terminologies and Classifications for Healthcare Improvement

1. Harnessing Clinical Terminologies and Classifications for Healthcare Improvement Janice Watson Terminology Services Manager 11th April 2013

2. Why do we need terminologies and classifications in healthcare? • Clinical coding underpins the analyses for creating Scottish national healthcare intelligence reporting – it facilitates aggregation and comparison – you can count it • Without accurate clinical coding our analyses would be flawed • Without accurate analyses we cannot support effective decision making to improve patient care

3. The Information Process • SMR records are SUMMARY records of hospital encounters • Patient admitted - procedures performed & diagnosis made • Clinician writes up case notes and discharge summary • Clinical coders translate clinical text into coded information using coding rules and SMR definitions • Coded information is entered into hospital’s Patient Administration System by coders, extracted into SMR format, validated and transferred to national data warehouse • Information analysed – national reporting • Information used for policy making, performance management, healthcare planning and costing, research and epidemiology in order to improve Scotland’s health and healthcare Acute Care – the Scottish Morbidity Record (SMR)

4. Which systems do we use? Classifications • ICD10 (WHO owned) ~12,000 codes – used to record morbidity and mortality. International use • OPCS4 (UK) for recording clinical interventions – from assessment to transplants ~ 8,000 codes Both of the above are used to describe in-patient activity Terminologies • Read Terminology (V2 UK based) ~ 80,000 terms Used in Primary Care systems • SNOMED CT – international -not widely used in Scotland yet ~ 400,000 terms Not used widely in Scotland yet but expected to be used in future

5. Benefits to patients • Shared clinical meaning can help to improve continuity of care e.g. facilitating safe transfer of clinical information between primary and secondary care • Services can be compared and contrasted and benchmarked against national standards to promote better patient care • Patients with given conditions and risk factors can easily be identified for proactive anticipatory care – e.g. currently developing extensions to ICD10 coding system to improve identification of patients with specific types of myocardial infarction and heart failure; SPARRA tool can be used to identify patients at risk of readmission

6. Problems and Issues Classifications • Structured with rules – easier to compare and analyse • Not good at incorporating up-to-date clinical language • Not designed to record routine clinical care • Require an understanding of coding rules and dependent on getting the right information from the patient record • Perception that secondary use information not a clinical priority Terminologies • Good at incorporating up-to-date clinical language • Could be used to record routine clinical care in fine detail • Electronic based – can embed in systems and record at point of care by clinicians • Too many choices and no rules – hard to compare • Systems not sufficiently developed to constrain choices • Difficult to aggregate and analyse Cross maps help but require clinical verification

7. Future Developments • New services for research purposes – secure area and validation processes to allow researchers access to anonymised national data for research purposes and a new support service for researchers (eDRIS) • Integration of health and social care data and expansion of analytical services to support other public bodies • New GP extraction service to utilise national primary care information • Our name is changing – amalgamation of ISD with Health Protection Scotland to form the Public Health and Information Services Strategic Business Unit (part of National Services NHS Scotland)

8. Terminology Services • Terminology and classification training, advice and support to coders, analysts, clinicians etc • Terminology and classification maintenance (e.g. developing terms for new national vaccination programme and managing ICD10 update nationally) • Communications and publications (e.g. publication of Scottish Clinical Coding Standards to promote more consistent coding practice) http://www.isdscotland.org/terminology Clinical Coding helpdesk operates Tues-Thursday 9am-5pm Tel 0131-275-7283 or email NSS.terminologyhelp@nhs.net