SNOMED CT

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SNOMED CTSystematized Nomenclature Of Medicine – Clinical Terms

---An introduction ---Dr Karanvir Singh

MBBS, MS, FRCS (Glasgow)Chief Medical Information Office

Apollo HospitalsIndia

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Systematized Nomenclature of Pathology (SNOP)

1965 CAP

Broad clinical terms included (SNOMED)1975 CAP

Logic basedSNOMED-RT2000 CAP

Read codes1980s NHS UK

Read codes v3Clinical Terms v3

CTV31990s NHS UK

SNOMED-CT2007 IHTSDO

India became a member of the IHTSDO2014

SNOMED-CT2002CAP

NHS UK

US UK

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Most of us own smartphones…

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Now imagine the uses if you remove internet connectivity

Voice callsSMSCameraA few games

This is what we use them for

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An EMR alone is like a ‘dumb’ phoneSnomed CT is the internet of EMRsIt connects healthcare data across all entities

+Allows very granular clinical data captureProvides very powerful clinical analyticsIt supports clinical decision support

… and is used in over 50 countries. It is the best clinical terminology system today

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Let us see how it is better than existing healthcare coding systemsLet us compare it with ICD-10

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More clinical terms

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Codes for Ectopic Pregnancy in ICD-10 • ICD-10 has five codes (terms) only• Abdominal• Tubal• Ovarian • Others• Unspecified

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Terms for Ectopic pregnancy in SNOMED CT

Abdominal pregnancy Membranous pregnancy

Aborted ectopic pregnancy Mesenteric pregnancy

Angular pregnancy Mesometric pregnancy

Cervical pregnancy Miscarriage of tubal ectopic pregnancy

Combined heterotopic pregnancy Multiple pregnancy involving intrauterine pregnancy and tubal pregnancy

Combined intrauterine and ovarian pregnancy Mural pregnancy

Combined pregnancy Ovarian pregnancy

Combined tubal and intrauterine pregnancy Rudimentary horn pregnancy

Compound ectopic Ruptured ectopic pregnancy

Cornual pregnancy Ruptured tubal pregnancy

Delivery of viable fetus in abdominal pregnancy Secondary abdominal pregnancy

Fallopian pregnancy Simultaneous intrauterine and extrauterine pregnancies

Fallopian tube pregnancy Tubal abortion

Heterotopic pregnancy Tubal pregnancy

Intraligamentous pregnancy Unruptured tubal pregnancy

Intraperitoneal pregnancy Viable fetus in abdominal pregnancy

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Multiple ‘ancestors’

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Pneumonia – as classified in ICD-10

Section Code TitleInfectious disorders B01.2 Varicella pneumonia

Infectious disorders B05.2 Measles complicated by pneumonia

Infectious disorders B20.6 HIV disease resulting in Pneumocystis carinii pneumonia

Diseases of respiratory system J10.0 Influenza with pneumonia, other influenza virus identified

Diseases of respiratory system J11.0 Influenza with pneumonia, virus not identified

Diseases of respiratory system J12 Viral pneumonia, not elsewhere classified

Diseases of respiratory system J13 Pneumonia due to Streptococcus pneumoniae

Diseases of respiratory system J14 Pneumonia due to Haemophilus influenzae

Diseases of respiratory system J15 Bacterial pneumonia, not elsewhere classified

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Viral pneumonia

Infectious disease of lung

Lower respiratory tract infection

Disorder of lung

Disease

Viral infection

Infective pneumoniaViral respiratory

infection

Viral disease

Infectious disease

Poly-hierarchyLu

ng d

isor

ders

Infe

ction

s

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ICD is running out of codes• Since code numbers are the main stay of classification, and the

number of diseases are very large in number, ICD is running out of codes.• Multiple disorders are being grouped under one code

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ICD is running out of codes• Since code numbers are the main stay of classification, and the

number of diseases are very large in number, ICD is running out of codes.• Multiple disorders are being grouped under one code

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Snomed CT has no limits on the codes that can be usedNo sharing of codes by two different conditions

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Comparison of existing coding systems

Coding system ICD-10 ICD-10 PCS LOINC NANDA CPT4 SNOMED CT

Diagnosis Yes No No Partial No Yes

Procedures / operations

No (except pregnancy

related)Yes No No Yes Yes

Laboratory No No Yes No No Yes

Nursing No No No Yes No Yes

Special context (e.g not diabetic)

No No No No No Yes

Meaning based analytics

No No No No No Yes

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Will SNOMED CT replace ICD-10?Yes & No

• Clinical modules & analytics would benefit from SNOMED CT

• The medical records departments will continue ICD-10

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Let us look at the nuts & bolts of SNOMED CT

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These are four different conditions (clinical ideas)

1. Ischemic heart disease2. Angina3. Unstable angina4. Myocardial infarction5. Heart attack6. Cardiac infarction7. MI

Same clinical meaning (idea)

Each clinical idea is called a concept

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Each concept has a random concept number

1. Ischemic heart disease 414545008

2. Angina 194828000

3. Unstable angina 4557003

4. Myocardial infarction5. Heart attack6. Cardiac infarction7. MI

Same clinical meaning (idea) 22298006

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The same concept has different translations

1. Ischemic heart disease 414545008 - cardiopatía isquémica

2. Angina 194828000 - angina de pecho

3. Unstable angina 4557003 - síndrome preinfarto

4. Myocardial infarction5. Heart attack6. Cardiac infarction7. MI

Same clinical meaning (idea) 22298006 - infarto de miocardio

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Independent system of classificationConcept Concept IDIschaemic Heart Disease 414545008Angina 194828000Unstable Angina 4557003Myocardial Infarction 22298006Heart Attack 22298006Cardiac Infarction 22298006MI 22298006

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Viral pneumonia

Infectious disease of lung

Lower respiratory tract infection

Disorder of lung

Disease

Viral infection

Infective pneumoniaViral respiratory

infection

Viral disease

Infectious disease

Poly-hierarchyLu

ng d

isor

ders

Infe

ction

s

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Thus…• Each clinical idea is a concept and has a unique concept number• Each concept number has multiple terms for it• In different languages…• There is no limit on the number of concepts. Hence different

conditions do not have to share the same code• Concepts are connected to other concepts (parents / children)

independent of their codes – multiple relationships• There are other relationships also, defining different properties of a

concept

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How do multiple relationships help?

Cellulitis of foot

Disorder of foot

Cellulitis of lower limb

Is aIs a

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Multiple types of relationships

Cellulitis of foot

Disorder of foot


CellulitisFoot structure

Is aIs a

Associated morphologyFinding site

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Cellulitis of foot

Disorder of foot



Is aIs a


Cellulitis of toe

Cellulitis of heel

Is a

Is a

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Cellulitis of foot

Disorder of foot



Is aIs a


Cellulitis of toe

Cellulitis of heel

Is aIs a

Toe structureFinding

site

CellulitisAssociated morphology

Is a

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Cellulitis of foot

Disorder of foot



Is aIs a


Cellulitis of toe

Cellulitis of heel

Is aIs a


site

Heel structureFinding

site



Is aIs a

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Cellulitis of foot

Disorder of foot



Is aIs a


Cellulitis of toe

Cellulitis of heel

Is aIs a


site


site



Is aIs a

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Cellulitis of foot

Disorder of foot



Is aIs a


Cellulitis of toe

Cellulitis of heel

Is aIs a


site


site



List me all patients with cellulitis

Is aIs a

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Associated morphology = Cellulitis*Cellulitis of footCellulitis of foot excluding toeCellulitis of forearmCellulitis of foreheadCellulitis of gingivaCellulitis of groinCellulitis of handCellulitis of hand excluding fingerCellulitis of headCellulitis of heelCellulitis and abscess of lower legCellulitis and abscess of lower limbCellulitis and abscess of neckCellulitis and abscess of nose (external)Cellulitis and abscess of perineumCellulitis and abscess of shoulderCellulitis and abscess of submandibular regionCellulitis and abscess of temple region

Conditions with the word “Cellulitis” within it

*Partial data

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Associated morphology = Cellulitis*Cellulitis of footCellulitis of foot excluding toeCellulitis of forearmCellulitis of foreheadCellulitis of gingivaCellulitis of groinCellulitis of handCellulitis of hand excluding fingerCellulitis of headCellulitis of heelCellulitis and abscess of lower legCellulitis and abscess of lower limbCellulitis and abscess of neckCellulitis and abscess of nose (external)Cellulitis and abscess of perineumCellulitis and abscess of shoulderCellulitis and abscess of submandibular regionCellulitis and abscess of temple region

Beat kneeChronic recurrent streptoccocal erysipelasCutaneous erysipeloidDisseminated cutaneous erysipeloidErysipelasErysipelas of lower limbErysipeloidFacial erysipelasLocalized cutaneous erysipeloidLudwig's anginaOnychia of fingerPhlegmonPostpartum AND/OR puerperal erysipelasRecurrent erysipelasSeal finger

Conditions with the word “Cellulitis” within it Conditions even without the word “Cellulitis”

*Partial data

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How relationships help in decision support

Pick up all cases of cerebrovascular accident for consideration for thrombolytic therapy

Use it to identify potential cohorts for clinical trials for a new breast cancer drug.

Warn if the patient has any type of diabetes AND any type of kidney disease

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How is it used in a hospital’s EMR?

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The hospital’s EMR software Snomed CT

Record services (EMR) Terminology services (Snomed CT)

Patient Ram Lal, age 56, admitted with a diagnosis of HerniHerniaInguinal herniaIndirect inguinal herniaIndirect inguinal hernia with obstruction

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Leveraging relationshipsWe can show all the SubType concepts of E in the operation list of a foot surgeon

Operations on the foot

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SubTypes (All descendants)Operations on the foot

Foot joint operations

Foot incision

Division of muscle of

foot

Tenotomy of abductor hallucis muscle

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Value set binding: SNOMED supplies the lists

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How will clinicians benefit from it?

ICD-10 has very limited search – no synonyms• The doctor may search for any of these terms for the same diagnosis• Renal calculus• Renal stone• Nephrolith• Calculus in kidney• Kidney stone• Kidney calculus

• Only the term Calculus in Kidney exists in ICD-10 • Such issues are present with most diagnosis

No abbreviations in ICD-10 • The doctor may search by typing• COPD• MI• IHD

ICD-10 terms are not appropriate for printing What the doctor wants to write What is available in ICD-10 tables – prints as such

Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease, Unspecified

Ureterocele Other specified disorders of kidney and ureter

Neonatal tetanus Other tetanus

Achlorhydria Other specified diseases of stomach and duodenum

Recurrent appendicitis Other appendicitis

Indirect inguinal hernia Inguinal hernia

Direct inguinal hernia Inguinal hernia

Strangulated inguinal hernia Unilateral or unspecified inguinal hernia, with obstruction, without gangrene

Hepatic encephalopathy Hepatic failure, not elsewhere classified

Bird flu (H5N1) Influenza due to certain identified influenza virus

Swine flu (H1N1). Influenza due to certain identified influenza virus

ICD-10 codes are not appropriate for printing What the doctor wants to write What is available in ICD-10 tables – prints as such

Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease, Unspecified

Ureterocele Other specified disorders of kidney and ureter

Neonatal tetanus Other tetanus

Achlorhydria Other specified diseases of stomach and duodenum

Recurrent appendicitis Other appendicitis

Indirect inguinal hernia Inguinal hernia

Direct inguinal hernia Inguinal hernia

Strangulated inguinal hernia Unilateral or unspecified inguinal hernia, with obstruction, without gangrene

Hepatic encephalopathy Hepatic failure, not elsewhere classified

Bird flu (H5N1) Influenza due to certain identified influenza virus

Swine flu (H1N1). Influenza due to certain identified influenza virus

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Summary• Snomed CT is the terminology that supports the EMR. On its own it

does nothing• It is very clinician friendly• It is multilingual• It allows very powerful data analytics• It augments decision support capabilities of an EMR

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Questions through the THIT app please

SNOMED CT

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