snomed ct in the nhs care records service

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

SNOMED CT in the NHS Care Records Service

Ian ArrowsmithNHS Connecting for Health

Terminology workshopSandefjord, Norway3rd November 2005


Structure of presentation

• An overview of the NHS Care Record Service ‘Spine’

• SNOMED CT NHS Implementation activities• International Standards Development

Organisation


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’


Simplified ‘Spine’ architecture

SecondaryUses

Service

Transaction &Messaging Service

ElectronicBookingService

PersonDemographics

Service

PersonalSpine

InformationService

HL7

v3

Social Care Primary /Community Mental Health Acute Care Pathology Ambulance


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


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 SpineInformation

Personal Details

Previous Care Summaries

Details of Clinical EventsClinical correspondenceDischarge summaries

Referral information

Current Care Providers

Medication Information


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…


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.


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 !!


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


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


(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


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’


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


Typical subset creation Methodology

• 2 main variants– 1) Select directly from SNOMED– 2) Describe in own words and compare with

SNOMED


Direct interaction


Clinicianscreating raw

contentSubset

Processing byauthorised 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….


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


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


Subset


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


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


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


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


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


Distribution• Aim = more frequent release

– Tooling/processes– Synchronisation/distribution– Core vs extension– New partners

• Subsets• Distribution formats• Non NPfIT suppliers• Relationship with legacy products


Parallel work

• Common user interface– Rendering– Post-coordination– Search strategies

• Cultural change/implementation• terminfo


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…..


SNOMED® Standards Development Organisation

[SNOMED SDO]


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.


SNOMED SDO top-level StructureManagement Board

Content Com.

Technical Com.

Finance & Ops. Com

Research & Innov. Com


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


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


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


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


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


Full SNOMED SDO StructureManagement Board

Content Com.

Technical Com.

Finance & Ops. Com

Research & Innov. Com

Vendor Forum

Harmonisation Boards

Support Organisation

Working Groups

Working Groups

Task & Finish

Research Teams

Paul Frosdick

Voting and what is the votable unit came up as a concern of the Content Steering Committee


New SNOMED Enterprise Model

National Release Centre

SNOMED SDO [Core]

NationalReleaseCentre

NRC[Core and Extension

]

NationalReleaseCentre

Local/National Health Entities

Shared Infrastructure to enable collaboration


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


SNOMED SDO Technical Infrastructure

1. Configuration management2. Workflow management3. Modelling tool4. Lexical tools5. Subset tool6. Mapping tools7. Content submission tools8. Data communications environment9. Support and maintenance processes


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 [email protected]


Further information

http://www.cfh.nhs.ukhttp://www.snomed.org

http://www.cfh.nhs.uk/

http://www.snomed.org/

snomed ct in the nhs care records service

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