Useful Applications forcampus.ahima.org/audio/2007/RB030807.pdf · and terms can completely serve...

© Copyright 2007 American Health Information Management Association. All rights reserved.

Useful Applications for SNOMED CT®

Audio Seminar/Webinar March 8, 2007

Practical Tools for Seminar Learning

Disclaimer

AHIMA 2007 Audio Seminar Series i

The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. As a provider of continuing education, the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience:

1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation;

2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and

3) if the presentation will include discussion of investigational or unlabeled uses of a product.

The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments.

Faculty

AHIMA 2007 Audio Seminar Series ii

James Richard Campbell, MD is Professor of Internal Medicine at the University of Nebraska Medical Center. He received a Bachelor of Science Degree in Physics from the University of Rochester, and his Medical Degree from the University of Nebraska College of Medicine. Dr. Campbell further completed an internship, residency and fellowship in Internal Medicine at the University of Nebraska and is boarded in Internal Medicine.

Dr. Campbell has postgraduate training in computer science and has developed and implemented clinical information systems for over 25 years. He is Chief Medical Information Officer for the Nebraska Medical Center.

He has authored and co-authored numerous articles, book chapters and abstracts. He lectures frequently on a national and international level. He currently participates in standards organizations including HL7 and is a member of the SNOMED Editorial Board.

Debra Konicek RN, MSN, BC, is the Director, Clinical Standards Initiatives for SNOMED International. In her role, she coordinates all aspects of SNOMED's standards efforts to ensure that SNOMED CT content correlates with current national and global standards initiatives. She develops relationships with key stakeholders and decision makers to ensure that SNOMED CT content effectively supports customer requirements and quality patient care. Previously as the Terminology Manager for Nursing, she was responsible for the integration of nursing terminology as well as liaisons with nursing informatics and terminology experts.

Table of Contents

AHIMA 2007 Audio Seminar Series

Disclaimer ..................................................................................................................... i Faculty .........................................................................................................................ii Seminar Outline ............................................................................................................. 1 Terminology History and Emergence of SNOMED CT ......................................................... 1 Importance of Composition ............................................................................................. 3

Definitions ......................................................................................................... 3 SNOMED Facts............................................................................................................... 5

January 2007 Release......................................................................................... 5 Content and Relative Size.................................................................................... 6 Step-by-Step...................................................................................................... 7 Subsets and Maps .............................................................................................. 7

Problem List Case Study ........................................................................................................ 8 Post-coordination .............................................................................................. 8 How does problem list work ................................................................................ 9 Problem Capture ...............................................................................................10 Problem Record.................................................................................................11 Clinical Findings are Specific ...............................................................................12 “Right carotid stenosis” ......................................................................................12 Maintaining Precise Clinical Data.........................................................................13 Extension Concept Creation… .............................................................................13 Multi-use Clinical Data........................................................................................14 Nebraska Lexicon ..............................................................................................15

SNOMED CT and Guidelines ...........................................................................................15 Guidelines Studied.............................................................................................16 Results .............................................................................................................16 Guideline Vocabulary Analysis.............................................................................17 Hierarchical Relationships...................................................................................17 Guidelines and Real Databases ...........................................................................18 Guidelines and Nebraska Records .......................................................................18 Conclusions

Clinical Scenario............................................................................................................19 How does problem list work?..............................................................................20 Problem Capture ...............................................................................................20 Primary Use Case for SNOMED CT Used in Nursing Practice ..................................22 Integration of Nursing Terminologies ..................................................................22 What SNOMED CT Hierarchies are Used in Nursing Domain...................................23 SNOMED CT Data Query ....................................................................................23 Getting back to our patient.................................................................................24 Guidelines Studied.............................................................................................24 Plan of Care Based on Problem List .....................................................................25 Hierarchical Relationships...................................................................................25 Specific Diet Education: Diabetes .......................................................................26 What can a SNOMED CT provider do for nurses?..................................................26

Conclusions ..................................................................................................................27 Resources ....................................................................................................................28 Appendix ..................................................................................................................31


AHIMA 2007 Audio Seminar Series 1

Notes/Comments/Questions

Outline

Why SNOMED CT?• History• Design features and implementation

SNOMED CT facts SNOMED CT for problem list: how to…Clinical scenario and benefitsSNOMED CT and multi-disciplinary care

1

Terminology History and Emergence of SNOMED CT

Exploratory studies demonstrate that administrative classifications function poorly for recording clinical events1995: Medical concept model: Galen and Pen&Pad• “Compositional employment of Galen promising but

ambiguity and under-specification become issues”

1997: CPRI study of clinical vocabularies• “No system comprehensive or ideal; SNOMED 3.1 and

Read v3 most complete; SNOMED composition unclear”

1997: NLM Large Scale Vocabulary Test• “Only SNOMED 3.1 and Read v3 had more than 50% of

concepts”2





“No pre-coordinated set of concepts and terms can completely serve clinical recording needs over time”

Elkin PL, Brown SH, Husser CS, Bauer BA, Wahner-Roedler D, Rosenbloom ST, Speroff T. Evaluation of the content coverage of SNOMED CT: ability of SNOMED clinical terms to represent clinical problem lists. Mayo Clin Proc. 2006 Jun;81(6):741-8.

3


2003: UCLA study of SNOMED CT for problem list functionality• “88.4% of concepts present; 98.5% of concepts

covered with SNOMED CT”

2006: Mayo clinic evaluation of SNOMED CT for problem list• used as compositional terminology, 92.3% of

terms exactly represented

Wasserman H, Wang J. An applied evaluation of SNOMED CT as a clinical vocabulary for the computerized diagnosis and problem list. AMIA Annu Symp Proc. 2003;:699-703.

4




Importance of Composition

The need for concept composition:• Arises to manage “combinatorial explosion” of

codes required for clinical records

• Implies that post-coordination will be requiredin clinical use of vocabulary

Extends the value of the vocabulary:• Defining relationships become essential

features which enhance data organization for retrieval, display management and decision support software

5

DefinitionsComposition: a concept is created by the coding system through the assembly of component elements of meaning which then form a complete and unique definitionPre-coordination: SNOMED International creates the complete definition and coding for a concept with associated terms and publishes these in standard releases Post-coordination: the vendor software supports the interactive definition of a new concept not found in the pre-coordinated release, and maintains (and shares) that code within a community of users 6




Importance of Composition

The need for concept composition:• Arises to manage “combinatorial explosion” of

codes required for clinical records

• Implies that post-coordination will be requiredin clinical use of vocabulary

Extends the value of the vocabulary:• Defining relationships become essential

features which enhance data organization for retrieval, display management and decision support software

7

Composition: example of post-coordination

“Pneumococcal pneumonia of right lower lobe”• Is_a

“Pneumococcal lobar pneumonia”266350000

• Finding site “Right lower lobe structure” 2660005

8




SNOMED FactsName: Systematized Nomenclature of Human and Veterinary MedicineOrganization: College of American PathologistsCode versions: • SNOP• SNOMED III (International)• SNOMED-RT• SNOMED-CT

Information: http://www.snomed.org/9

SNOMED CT ®January 2007 Release Features

SNOMED Core Content• Concepts

• More than 308,000 active concepts

• Descriptions• 777,000 active English language

descriptions• Relationships

• 924,000 defining relationships10




SNOMED CT ®January 2007 Release

Clinical findingProcedure Observable entity Body structure Organism Substance Pharmaceutical/biologic product Specimen Qualifier value Record artifact

Physical object Physical force Events Environments/geographical locations Social context Situation with explicit content Staging and scalesLinkage conceptSpecial concept (Inactive concept)

Formal logic-based definitions are organized into the following top-level hierarchies

11

SNOMED Content and Relative Size of other Terminologies

100,000

150,000

200,000

250,000

50,000

Body Structure

Organism

SubstancePharmaceutical/Biological Product

Qualifier ValueObservable EntityContext-DependentSocial Context

Other:Physical objectStaging and ScalesEnvironments and geographical locationsAttributeSpecimenPhysical ForceEvents

Procedure

Disease

Finding

0

CPT

NU

RSI

NG

ICD

-9-C

M

ICD

-O

S N O M E D C T ®

Other

Physical Object

Staging and Scales

Environments and geographical locations

Attribute

Specimen

Physical Force

Events

12




SNOMED CT: Step-by-StepHow to implement a problem list

Inventory concepts and terms for use caseEncode clinical meaning with SNOMED CTAdd maps from concepts as necessary for workflow and data sharingCreate the user interface from subset of terms relevant to use case Check to see if someone has done it for you…

The SNOMED community offers a collection of subsets for user interface implementation and maps to support translation from SNOMED CT to other coding systems

13

SNOMED CT Subsets and Maps

Subsets:Problem listAllergensCancer check listsUS Drugs

Languages:US EnglishUK EnglishSpanishGerman

Maps:ICD-9-CMICD-10ICD-O3OPCS-4NANDA-InternationalNIC, NOC, Omaha, HHCC, PNDSLOINC

14




Problem List Case Study: University of Nebraska

700 bed hospital; 24,000 admissions/year; 1200 medical staff, both academic and private practice; 250 house staff500,000 outpatient visits; two dozen outpatient sites across broad geographic areaComputerized patient records since 1982GE Centricity Enterprise for inpatient and outpatient care… 15

Problem List Post-coordination: GE Healthcare (Centricity)

1997: Installation coded problem list • SNOMED 3.1 clinical coding, now SNOMED CT 2006B• ICD-9-CM map for administrative translation and coding• Problem maintenance information layer

User interface:• Navigational (now rapid keyword search)• “Just-in-time” post-coordination from user terms

Warren JJ, Collins J, Sorrentino C, Campbell JR. Just-in-time coding of the problem list in a clinical environment. Proc AMIA Symp. 1998;:280-4.

Database:• Extension identifiers stored in user record; SNOMED CT

and NMC extension maintained in GE Concept Dictionary files

16




Problem List Post-coordination: GE Healthcare (Centricity)

17

Clinical Scenario: How does problem list work?

Dr. C does initial outpatient exam on 69 y/o male who presents with a blood sugar of 245 mg/dl, blood pressure of 170/100Examination remarkable for bruit in right neck, heart murmur, loss of sensation in both feet with open sore on great toeLaboratory confirms diabetes and stage II kidney diseaseDr C records diagnoses on problem list…

18




Problem Capture

19

Problem Capture

20




Problem Capture

21

Problem Record

22




Clinical Findings are Specific

Dr C orders testing of carotid circulation to assess bruit detected on examination

23

“Right carotid stenosis”

24




Case Study: Maintaining Precise Clinical Data

Just-in-time post-coordination supports dynamic clinical coding dictionaries with clinical precision:• Clinicians employ the specific concepts

they need• AHIMA certified coding staff manages

new clinical concepts as they are recorded

• SNOMED post-coordination is done as necessary and mapping is employed within Centricity behind the scenes

25

Extension Concept Creation…

26




Case Study: Maintaining Precise Clinical Data

27

Case Study: Multi-use Clinical Data

Order entryService recognition

28




Nebraska Lexicon©:GE Healthcare Problem List

Initially implemented with 11,200 descriptions

Multi-disciplinary problem list supports all departments in primary and referral-based care

Now 14,600 descriptions employing 11,000 concepts

Distributed and maintained on behalf of 21 healthcare enterprises in US

Coding updates with each release of SNOMED CT and ICD-9-CM

Physician and one full time certified coding staff maintain user interface and manage updates; GE distributes resource to other customers

29

SNOMED CT and GuidelinesSystematically select and process publications from www.guideline.govEmploy standardized procedures for guideline analysis and codingAnalyze vocabulary needs studyingSNOMED CT with and without post-coordination, UMLS, ICD-9-CMVocabulary coding reviewed and graded: Exact, Broad, Narrow, MissingAssess for systematic strengths, deficiencies and suggestions of editorial priorities 30




Guidelines Studied

Institute For Clinical Systems Improvement (ICSI). Major depression in adults for mental health care providers. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2002 May. 43 p.

Major depression in adults for mental health providers

Royal College of Nursing. Pressure ulcer risk assessment and prevention. London: Royal College of Nursing; 2001 Apr. 36 p.

Pressure ulcer risk assessment and prevention

American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002 Jan;25(Suppl 1):S33-S49.

Standards of care for patients with diabetes

Institute For Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute For Clinical Systems Improvement(ICSI);2002 Jun. 49p.

Immunizations

31

Results: SNOMED CT coding completeness by guideline

0

6%

3%

0

Narrower

2%3%92%Diabetes

N=90

8%1%85%Depression

N=93

15%15%70%Pressure sores

N=71

2%098%Immunizations

N=127

MissingBroaderExact match

32




Guideline Vocabulary AnalysisICD captured only 22% of clinical concepts; only SNOMED CT approached 100%Analysis of concept requirements is one critical element of the utility of a reference terminologyHowever, our experience clearly dictates that decision logic function depends upon other terminology features….

33

SNOMED CT Hierarchical Relationships

Guideline goal:

“If patient has diabetes mellitus,

Then administer a

flu shot”

34




SNOMED CT Relationships: Guidelines and Real Databases

SNOMED “Is_a” relationships support decision logic identification of all instances of concepts for logical completeness

In the guidelines studied:• Average 8.9 SNOMED children per

concept (0-161)

• Average 224 SNOMED descendant concepts (0-17227)

35

SNOMED CT Relationships: Guidelines and Nebraska Records

We analyzed problem list data for 1.4 million records (252,000 patients) in the Nebraska Centricity® databaseWe counted whether the descendant concepts from our guideline analysis occurred anywhere in actual clinical recordsAverage use of related concepts per guideline concept invoked in Nebraska coded records was 22 (0-1606)E.g.: Query asks for “diabetes” but “Complicated type I diabetes” is in problem list 36




Conclusions

For support of clinical problem list, SNOMED CT:• Is more clinically exact• Can be implemented within a user interface• Can be implemented to effectively support

multiple data recipients and use cases • Provides better decision support features

What about other clinical record users?

37

Return to our clinical scenario…

Based upon clinical findings of neuropathy and foot ulcer, Dr C refers patient to wound care nurse specialist for shared management…

38




Clinical Scenario: How does problem list work?

Nurse K does initial new patient assessment on 69 y/o male who has been identified by his physician to need diabetic management specifically in terms of current neuropathy and great toe lesionAssessment interview reveals that patient is at risk for further skin breakdown due to his diabetes, associated neuropathy, and existing lesion on great toe.Further history taking also identifies that this patient has minimal knowledge regarding his diabetesNurse K records diagnoses on problem list… 39

Problem Capture

40




Problem Capture

41

Problem Capture

42




Primary Use Case for SNOMED CT Used in Nursing Practice

SNOMED CTRecommended as core nursing terminology choice by the NCVHS

and required by the Federal Consolidated Healthcare

Informatics Initiative

43

Integration of Nursing Terminologies

SNOMED CT Nursing is providing an integrated resource where the various nursing terminologies are available for electronic interoperability applications. Examples:

The American Nursing Association (ANA) recognized nursing terminologies A variety of patient safety and nursing quality resources

44




What SNOMED CT Hierarchies are Used in the Nursing Domain?

Nursing diagnoses: clinical findings (problem list, assessments, plan of care, subsets, nursing notes, flow sheets)

Signs and symptoms: clinical findings(assessments, plan of care)

Interventions and actions: procedures(order sets, plan of care, education plan, nursing notes)

Outcomes: observables(plan of care, nursing notes)

45

SNOMED CT Data Query

SNOMED CT provides the ability to query the data based upon the defined organizational inclusion criteria.

The data extracted will collect all concepts based on the SNOMED CT relational defining relationships.

This is what makes SNOMED CT unique from other standardized nursing terminologies

46




Clinical Scenario:Getting back to our patient….

Nurse K does initial new patient assessment on 69 y/o male who has been identified by his physician to need diabetic management specifically in terms of current neuropathy and great toe lesion

Assessment interview reveals that patient is at risk for further skin breakdown due to his diabetes, associated neuropathy, and existing lesion on great toe.

Further history taking also identifies that this patient has minimal knowledge regarding his diabetes

Nurse K records diagnoses on problem list… 47

Guidelines Studied

Institute For Clinical Systems Improvement (ICSI). Major depression in adults for mental health care providers. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2002 May. 43 p.

Major depression in adults for mental health providers

Royal College of Nursing. Pressure ulcer risk assessment and prevention. London: Royal College of Nursing; 2001 Apr. 36 p.

Pressure ulcer risk assessment and prevention

American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002 Jan;25(Suppl 1):S33-S49.

Standards of care for patients with diabetes

Institute For Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute For Clinical Systems Improvement(ICSI);2002 Jun. 49p.

Immunizations

48




Plan of Care Based on Problem List

Guideline goal:“If patient has knowledge deficit:diabetesProvide specific disease related education”

49

SNOMED CT Hierarchical Relationships

Diet Education querywill find all

child concepts and related concepts

based on the “definition”of Diet education

50




Specific Diet Education: Diabetes

51

What can a SNOMED CT provider do for nurses?

Collect comprehensive data in a convenient and consistent manner

Manage data in electronic format

Enable data analysis

Compare data within and across settings

• Data truly comparable

Evaluate clinical practice and its effectiveness

Validate the contributions of nursing and allied health

52




Conclusions

For support of clinical problem list, SNOMED CT:• Is more clinically exact

• Can be implemented within a user interface

• Can be implemented to effectively support multiple data recipients and use cases

• Provides better decision support features

• Can effectively support a multidisciplinary team approach to diagnosis and decision making……

53

Questions ???




Resources

Website: SNOMED CThttp://www.snomed.org/

Online learning:Clinical Vocabularies: A Technology for the CPR http://campus.ahima.org/campus/course_info/CSS/CSS_info.htm

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AHIMA Audio Seminars

Visit our Web site http://campus.AHIMA.orgfor information on the 2007 seminar schedule. While online, you can also register for seminars or order CDs and pre-recorded Webcasts of past seminars.

Upcoming Audio Seminars

Information Integrity in EHRsMarch 13, 2007

Coding Kidney Disease and TreatmentMarch 15, 2007

New Date:Understanding and Using ICD-10-PCS

April 10, 2007




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