SNOMED CT® for Providers

1. SNOMED CT® for Providers Howard Hays, MD, MSPH National Tribal Best Practices Conference Salt Lake City, UT July 24, 2012

2. SNOMED CT®… and MU stage 2 and ICD-10 • Meaningful Use is the primary driver for change to a different standardized terminology • ICD-10 is a separate but parallel project that is driving changes in RPMS and EHR • SNOMED CT® helps us move forward in our modernization of the RPMS EHR, iCare and other user interfaces but also helps us achieve Meaningful Use and bridge to ICD-10

3. Meaningful Use Stage 2 Overview

4. MU 2 Changes

5. MU 2 Changes

6. MU 2 Changes

7. Introduction to SNOMED CT®

8. What is SNOMED CT® ? Systematized Nomenclature of MedicineClinical Terms® (SNOMED CT®) • A comprehensive clinical terminology covering diseases, clinical findings, and procedures • Enables the computer to understand medical language and act on it • Extremely large set of concepts and descriptions representing many standard terminologies

9. What is SNOMED CT®? Owned and maintained by the International Health Terminology Standards Development Organisation (IHTSDO) in Denmark. USA is a member of IHTSDO and the US Extension of SNOMED CT ® is maintained by the National Library of Medicine (NLM) at the National Institutes of Health. Updates are released twice per year.

10. What is SNOMED CT®? SNOMED CT® terminology files consisting of: • Concepts • Descriptions • Relationships • Subsets • Extensions • Cross maps to numerous classification systems • Guidelines Relevant maps for current IHS projects: • SNOMED CT® to ICD-9 • SNOMED CT® to ICD-10 • ICD-9 to SNOMED CT® reverse map

11. Standardized Terminologies Integrated within SNOMED CT® ICD-9 and ICD-10 (UK) CPT SNOMED CT® LOINC ICNP NOC Omaha System PNDS NANDA NIC CCC

12. What is SNOMED CT®? Basic Components • Concept Codes – the computer readable “code” • Hierarchies –organize concepts into multiple levels of granularity • Descriptions or Terms – the human readable representation of the code • Relationships – link concepts

13. What is SNOMED CT®? Other Components • Cross Map – explicit links (cross maps) to health-related classifications and coding schemes in use around the world, e.g. diagnosis classifications such as ICD-9-CM, ICD-O3, and ICD-10, as well as the OPCS-4 classification of interventions • Reference sets – (aka Subsets) a collection of SNOMED CT® components and clinical descriptions for a particular purpose which narrows the focus • Extensions – incorporate concepts, descriptions and terms that are unique to a particular region or country

14. SNOMED CT® - Concept and Descriptions Concept: The concept is unit of meaning which is given a unique numeric string which is computer readable • e.g. 823660015 represents Common Cold (disorder) Description: This concept may have many descriptions that are humanly readable • Common cold (disorder) – fully specified name which is unique • Common cold – preferred term • Acute coryza – synonym • Acute infective rhinitis – synonym • Cold – synonym • Head cold – synonym And so on…

15. Hierarchies

16. Hierarchies – most commonly used

17. Relationships Relationships link concepts in SNOMED CT® (examples for diagnoses/conditions) 1) "Is_A" Relationship The “Is_A” relationship is used to create a hierarchical relationship between concepts, relating specific concepts to a more general category. For example: 2) "Causative agent" Relationship The "Causative agent" relationship identifies the direct cause of the disorder or finding. The causative agent is the bacterium, virus, toxin or environmental agent that causes the disorder. For example: "Injury to the optic nerve" "is_a" (kind of) "Injury to the visual pathway” "Staphylococcal eye infection" (has) "Causative agent" "Staphylococcus" From “The Structure of SNOMED” www.aao.org

18. SNOMED CT® is Enormous Extremely comprehensive, but scalable as needed Basic elements of SNOMED CT® • Concepts >310,000 concepts • Hierarchies 19 hierarchies with sub-hierarchies • Relationships >920,000 relationships • Descriptions >794,000 descriptions

19. Subsets (reference sets) Several have been developed and are available through NLM • CORE Problem List Subset: A subset developed by the CORE project (CORE = Clinical Observations Recording and Encoding), identifies codes most useful for documentation and encoding of clinical information at a summary level, such as problem list, discharge diagnosis or reason for encounter. • Nursing Problem List Subset: Intended to facilitate the use of SNOMED CT® as the primary coding terminology for nursing problems used in care planning, problem lists or other summary level clinical documentation. • Kaiser CMT Problem List Subset: A total of 2,613 concepts based on the most frequently used problem list concepts used by Kaiser Permanente plus a few related concepts, along with the ICD-9-CM code associated with the concept. Note: Additional CMT subsets focused on individual clinical domains are available, including to date: cardiology, endocrinology/urology/nephrology, hematology/oncology, mental health, musculoskeletal, neurology, and ophthalmology. (CMT = Convergent Medical Terminology)

20. Example of SNOMED CT® Search • Search returns “fully specified name” • Clicking + displays synonyms for the “fully specified name • The relationship is displayed to help user choose between terms

21. Example of SNOMED CT® Search • Search returns synonyms • The relationship and the “fully specified name” is displayed to help user choose between terms

22. How is SNOMED CT® Different from ICD

23. What is the Difference? ICD • Clinical terms in clinicians’ vernacular • Multidisciplinary language represented • Medicine, Nursing, Lab, Pharmacy, etc. • Describes what you see, hear, do, assess and diagnose • Unambiguous • Mapped to unique computer readable code • Can be highly granular • Single term may incorporate >1 ICD • Multiple terms combined may describe one ICD • Describes diagnoses and procedures • Medical/Surgical focus • Based on entirety of visit documentation • Used for reimbursement and utilization • May be ambiguous or conversely highly granular • Requires significant training and experience to code efficiently • Some can be done using computer software but often requires human review and assignment of codes SNOMED CT®

24. SNOMED CT®Reduces Ambiguity This is particularly important for health information exchange but also extremely important for improved documentation, communication between members of the health delivery team, decision support, clinical quality measures and research.

25. EHR CertificationforMeaningful UseStage 1 (2011) vs Stage 2 (2014)

26. SNOMED CT®in Stage 1 vs. Stage 2 MU stage 2 MU stage 1 • SNOMED CT® used for event codes in Adverse Reaction Tracking • SNOMED CT® optional for CQM’s – allowed to map terms to local vocabularies • Extraordinary amount of work to map our local vocabularies to SNOMED CT • SNOMED CT® required for Problem List diagnoses • SNOMED CT® required for Family History diagnoses • SNOMED CT® required for some CQMs • SNOMED CT® (and LOINC) required for cancer registries

27. Stage 1 CQM Mapping • For Stage 1 MU, EHR developers were required to program all of the Clinical Quality Measures for EP and EH. • Most of these were derived from expert sources such as the National Quality Forum (NQF) • Measure logic for denominators, numerators, inclusions, exclusions - all provided, but most often in SNOMED terms, not ICD or CPT • This required IHS to "reverse engineer" all of the logic to ICD-9, CPT, HCPCS, and RPMS-specific code sets - extremely labor-intensive • For 2014 Certification, it will be MUCH easier to program CQM using the "native" logic, i.e. SNOMED CT®

28. RPMS EHRIntegrated Problem List

29. Why the Change? • Stage II meaningful use • SNOMED CT® for problem list • Care planning • Clinical Quality Measures • Stabilize the user interface in advance of ICD-10 changes to reduce impact on clinical users • Improve clinical documentation of problems and encounter diagnoses • Support interdisciplinary problem focused documentation

30. What is a “Problem List”? ONC/CMS description Problem List – problems for patient that have been documented Problem List includes current and active diagnoses (chronic, episodic, and problems requiring follow-up) IHS (currently) Problem List – chronic problems POV – episodic problems, chronic problems addressed at current encounter Particularly with both SNOMED CT® required for “problems” and the institution of “care plan” we feel we need to shift how we utilize the Problem List to better align with the new requirements AND improve workflow in SNOMED CT®/ICD-10.

31. IPL New Features • De-duplicated list of problems (based on unique SNOMED CT® Concept) • Used for ALL problems addressed for patients – chronic, episodic, sub-acute • Used by ALL clinicians who document care for patient • Clinician uses only SNOMED CT® to document diagnoses/problems/indications • Additional field of “Provider Text” will allow clinicians to add clarification • No free text entries allowed, a SNOMED CT® must be entered • POV’s for visit are selected from Problem List • Ability to select multiple problems for POVs, update statuses, SNOMED, provider text and care plan en masse

32. IPL New Features • Change Status of Problems • Nationally vetted and released Pick Lists • Clinical Indications for orders selected from Problem List • Care planning done from Problem List

33. Mock-up: IPL Main Display

34. Mock-up: Add/Edit Problem

35. IPL Proposed Fields

36. IPL Proposed Fields

37. IPL Button Options

38. Mock-up: Update/Select Multiple POV The concept is to click “Select POV’s” and be offered a single dialog where multiple problems may be selected for use as POV and care plan data may documented as well as E&M to expedite documentation.

39. Mock-Up: Update/Select Multiple POV

40. Problem List Migration • Routine will utilize the IHTSDO released ICD-9 to SNOMED CT® reverse map and will populate SNOMED CT® where there is a 1:1 match. • When the user highlights and selects Edit, the Edit a Problem dialog will be presented to the user. • If the SNOMED CT® FIELD is empty then the user may search for a SNOMED CT® code and the ICD search will be grayed out OR may launch a pick list. • Alternately, the user will be offered potential matches returned the IHTSDO released ICD-9 to SNOMED CT® reverse map after clicking “Get SCT” • User may also select “Get SCT” and ALL problems with no SNOMED CT® will return the reverse map results based on the ICD-9 for selection.

41. Mock-up: Problem List Migration This would retrieve the problem entries that do not have a SNOMED term and return potential matches based on existing ICD code The concept is to provide a way to assist the user with problems that do not map automatically (with a 1:1 from ICD to SNOMED CT). The system would retrieve the SNOMED terms that map to the ICD code and the user can select one or search for a new SNOMED CT term.

42. Transition to ICD-10

43. ICD-10 Transition in a SNOMED-CT® Enabled EHR Clinicians document diagnoses and purposes of visits using clinical human readable language that the computer can read via the Integrated SNOMED CT® based Problem List • SNOMED CT® preferred terms or synonyms along with provider text The computer uses established maps to assign an ICD-10 code based on the SNOMED CT® preferred terms Coders review the ICD-10 code and visit documentation and refine the ICD-10 when necessary Clinicians document clinical care… coders code However… clinicians and coders will be co-dependent with the goal of improving documentation for ICD-10.

44. Benefits of SNOMED CT® • SNOMED CT® interface stabilizes the user interface in advance of ICD-10, reducing impact on clinical users • Automatic mappings to ICD-10 codes will assign approximate ICD or uncoded diagnoses • SNOMED CT® is multidisciplinary so better supports documentation for disciplines other than medicine (such as nursing, pharmacy, etc) • Reduces ambiguity particularly for health information exchange • Potential for improved decision support tools using SNOMED CT

45. Tools for ICD-10 Transition Mappings used by problem list to ICD code: SNOMED CT® to ICD-9-CM SNOMED CT® to ICD-10-CM (rule-based) • First 2,000 and viewer, trial version, Feb 2012 • Additional 15,000 – June 2012 Mapping used to assist clinicians in problem list migration from ICD to SNOMED CT Frequently used ICD-9-CM to SNOMED CT® • Released 5/15/12

46. SNOMED CT® to ICD Mapping 1:1 – this means that one or more ICD codes exactly describe the SNOMED CT® term. • These will be mapped automatically. • If additional documentation supports more granular code, the coding staff may change the assignment on the POV. Narrow to Broad – this means that there is a not direct ICD match for a SNOMED CT® term and the proposed match is less granular. • These will be mapped automatically. • These will require coder to review documentation to potentially more granular code on the POV.

47. SNOMED CT® to ICD Mapping Broad to Narrow - No direct ICD match for a SNOMED CT® term and the proposed match is more granular. • These will not be used and a .9999 uncoded diagnosis will be assigned. • Coder will review documentation and assign ICD code. Partial overlap – Overlap exists, and additional patient data and rules are necessary to select mapping. • These will not be used and a .9999 uncoded diagnosis will be assigned. • Coder will review documentation and assign ICD code. Unmapped – No mapped ICD code for the SNOMED CT® term • These will not be used and a .9999 uncoded diagnosis will be assigned. • Coder will review documentation and assign ICD code.

48. Summary SNOMED CT®: • Stabilizes the EHR and other user interfaces in advance of ICD-10, ICD-11 • Minimizes impact of these changes for clinical user • Opens up new potential for decision support tools • Supports interdisciplinary documentation (nursing, pharmacy, PT, etc) • Improves interoperability

49. Useful Websites • International Health Terminology Standards Development Organisation (IHTSDO) • www.ihtsdo.org/snomed-ct/ • U.S. National Library of Medicine • www.nlm.nih.gov/research/umls/Snomed/snomed_main.html • SNOMED CT User Guide • www.snomed.org/ug.pdf

50. Discussion