SNOMED CT in the NHS Care Records Service

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

2. Structure of presentation • An overview of the NHS Care Record Service ‘Spine’ • SNOMED CT NHS Implementation activities • International Standards Development Organisation

3. The NHS Care Record Service ‘Spine’ • 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

4. Simplified ‘Spine’ architecture

5. 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. Local System • GP systems • Hospital systems … etc.,. Example Spine Information Personal Details Referral information The Spine Previous Care Summaries Medication Information Details of Clinical Events Clinical correspondence Discharge summaries Clinical Event Current Care Providers A single clinical event … Patient care domain NHS CRS domain Information Healthcare service LSP Service • 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

7. Broken Leg Back Pain Chest infection Spine Multiple events over time… Patient info Patient info LSP Patient visits A&E LSP Patient visits GP Patient info LSP Patient visits hospital

8. 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. 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. 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. 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. (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. 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. 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. Typical subset creation Methodology • 2 main variants • 1) Select directly from SNOMED • 2) Describe in own words and compare with SNOMED

16. Direct interaction

17. In your own words…. Processing by authorised subset authors Clinicians creating raw content Subset able to invite clinicians who are not so computer literate and those who may not have any knowledge of SNOMED terminology

18. First steps 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

20. Next step 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

22. Subset

23. 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. 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. 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. 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. 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. 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. Parallel work • Common user interface • Rendering • Post-coordination • Search strategies • Cultural change/implementation • terminfo

30. 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. SNOMED® Standards Development Organisation[SNOMED SDO]

32. 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. SNOMED SDO top-level Structure Management Board Content Com. Technical Com. Finance & Ops. Com Research & Innov. Com

34. 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. 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. 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. 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. 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. Full SNOMED SDO Structure Harmonisation Boards Management Board Vendor Forum Content Com. Technical Com. Finance & Ops. Com Research & Innov. Com Support Organisation Working Groups Working Groups Task & Finish Research Teams

40. National Release Centre National Release Centre National Release Centre SNOMED SDO [Core] NRC [Core and Extension] New SNOMED Enterprise Model Local/National Health Entities Shared Infrastructure to enable collaboration

41. Component Definitionof 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. SNOMED SDO Technical Infrastructure • Configuration management • Workflow management • Modelling tool • Lexical tools • Subset tool • Mapping tools • Content submission tools • Data communications environment • Support and maintenance processes

43. 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, 11th November 2005 – contact sarah.bagshaw@cfh.nhs.uk

44. Further information http://www.cfh.nhs.uk http://www.snomed.org