SNOMED CT® A user guide for General Practice
Contents
1. can only enter a procedure at this point in the system However in some places within the patient record it could be that you want to enter a finding OR an observable entity OR a diagnosis and so you are presented with a full list of terms from more than one hierarchy in this case it is important you know you are selecting the right type of term Data translation In order to assist in the transition from Read codes to SNOMED CT cross maps between the terminologies have been created and quality assured Cross maps provide the mappings from Read v2 to SNOMED CT and CTV3 to SNOMED CT These cross maps can be used to support data migration such as when moving terms from either Read v2 or CTV3 to SNOMED CT Examples of use include GP2GP transfer and when providing data to the summary care record from a non SNOMED CT based system As Crown Copyright 2012 www nhscfh nhs uk uktc 15 increasingly data is being requested in SNOMED CT format as it is the terminology of the NHS England a system that uses SNOMED CT rather than maps to SNOMED CT is advantageous The cross maps are released at the same time as the SNOMED CT six monthly release and additionally if there is a release of any of the classifications outside of this Support The UKTC provide a help desk for support in all aspects of SNOMED CT Queries raised with the help desk will be responded to quickly with a full response by email or phone if it is felt more appropriate or it2. create a report from a query where you individually select the terms you need sometimes known as cherry picking d disease Ed diabetic complication g abnormal metabolic state in diabetes mellitus s anaemia of diabetes Pidabetes mellitus with unspecified complication fact hand syndrome s diabetic neuropathic arthropathy s diabetic oculopathy a diabetic renal disease s diabetic skin ulcer sl diarrhoea in diabetes a disorder associated with type 2 diabetes mellitus ac g pini associated with type diabetes mellitus i infection of foot associated with diabetes A lipoatrophic diabetes E neurologic disorder associated with diabetes mellitus si peripheral circulatory disorder associated with diabetes mellitus a soft tissue complication of diabetes mellitus TETT In the above the diabetic complications relating to the foot have been selected your report would need to specify exactly the terms required Combination of using relationships and specifying terms There are also occasions when a combination of relationships and specific terms are required for a report for example you may want to search for a term and its children but exclude specific terms Crown Copyright 2012 UK Terminology Centre www nhscfh nhs uk uktc 13 s disorder of appendix d of large intestine pp d amoebic appendicitis s appendicitis unqualified s atypical appendic
3. in SNOMED CT INTERNATIONAL EDITION SNOMED CT has concepts that are common to every country s edition the International Edition is the part of SNOMED CT that is shared internationally This refers to the same general content without specifying a particular release date INTERNATIONAL RELEASE SNOMED CT has concepts that are common to every country s edition the International Release is the part of SNOMED CT that is shared internationally and released on a specified date Crown Copyright 2012 www nhscfh nhs uk uktc 18 PREFERRED TERM The DESCRIPTION that is deemed to be the most clinically appropriate way of expressing a CONCEPT in a clinical record In the UK Edition these are expressed in UK English Example The preferred term for the Concept 22298006 is Myocardial Infarction QUALIFIER Qualifiers are ATTRIBUTES which are optional relationships that may be applied to a CONCEPT to further refine its meaning in a clinical record In other words adding a qualifier does not change the underlying clinical meaning of the CONCEPT but provides additional detail to the record Example Lower back pain can be qualified with the attribute SEVERITY to indicate how serious the condition is severe lower back pain READ v2 Also known as Read 5 byte Currently this is most commonly used in NHS Primary Care It isa clinical coding scheme attributed to Dr James Read RELATIONSHIP An association between two CONCEPTS Relations
4. is an open ended question The help desk can be contacted via datastandards nhs net Training Numerous education materials are available via the UKTC website For example Brochures eLearning Training Live and pre recorded Webinars Case studies http www connectingforhealth nhs uk snomed trainin For individuals who require more technical information both the UKTC and the IHTSDO provide technical documentation and additional products within the release of SNOMED CT or via their websites The UKTC run a forum for those implementing SNOMED CT details of this can be obtained by emailing datastandards nhs net The UKTC also host an NHS Networks site for SNOMED CT This has a number of resources as well as a discussion forum http www networks nhs uk nhs networks snomed ct about us Produced by the UK Terminology Centre Department of Health Informatics Directorate Version 1 April 2012 Crown Copyright 2012 www nhscfh nhs uk uktc 16 Appendix 1 SNOMED CT Glossary ATTRIBUTE The specific characteristics of a CONCEPT that can be used to express RELATIONSHIPs between it and other CONCEPTS Example The attribute FINDING SITE indicates where in the body a disease is located Pneumonia has Finding Site equal to Lung Structure BROWSER A software tool that enables searching and exploring of SNOMED CT displaying the results in an easy to understand and usable form CLASSIFICATION A syst
5. pneumonia Bacterial infectious disease Bacterial pneumonia Subsets As discussed previously SNOMED CT is by necessity very large this is because it is so comprehensive However a mechanism exists called a subset that can greatly reduce this complexity by allowing definition of a selection of terms from SNOMED CT that supports a particular requirement Crown Copyright 2012 www nhscfh nhs uk uktc 9 Subsets can contain any number of concepts e g a short pick list used to identify types of male infertility 8 to a list of all clinical diagnoses 70 000 These subsets can then be used in systems to support for example data entry and provide only terms appropriate at that place in the patient record A number of the professional bodies and associations are developing subsets that contain the terms relevant to their needs Crown Copyright 2012 www nhscfh nhs uk uktc 10 Using SNOMED CT some fundamentals Recording in SNOMED CT SNOMED CT aims to minimise ambiguity that can come from reading clinical notes recorded by a different person by providing standardised terms Every concept in SNOMED CT carries a soft default context which means that unless stated otherwise within the concept description the term should be interpreted as follows e For a clinical finding that o the finding has actually occurred vs being absent or not found o itis occurring to the subject of the record the patient o i
6. the characters used in SNOMED CT is not important Hierarchical searching If your application allows it you can search for terms within hierarchies This allows you to start with a more general term and drill down to more detailed terms below this or vice versa e g a search for diabetes mellitus could be used to display all the children of diabetes mellitus all the different types of diabetes mellitus to enable you to select the most appropriate term to record The example below illustrates a search for diabetes mellitus showing its parents and some of its children Hierarchy Subtype hierarchy Parents of diabetes mellitus s disorder of endocrine pancreas sd disorder of glucose metabolism Search for Fidiabetes mellitus d s X Other specified diabetes mellitus diabetes s X Pre existing diabetes mellitus unspecified mellitus s Unspecified diabetes mellitus with renal complications s diabetes mellitus AND insipidus with optic atrophy AND deafness fal diabetes mellitus associated with genetic syndrome d diabetes mellitus due to structurally abnormal insulin fal diabetes mellitus during pregnancy childbirth and the puerperium s diabetes mellitus NOS with no mention of complication f diabetes mellitus type 1 s diabetes mellitus type 2 M diabetes mellitus with multiple complications s diabetes mellitus with no mention of complication s diabetes mellitus with other specified manifestati
7. D CT will ensure that synonymous terms selected by colleagues or more detailed terms can be identifed in a search Searching SNOMED CT Term searching As with Read codes the preferred way of searching does not require you to know any codes in fact in SNOMED CT it is highly unlikely that the actual codes will be seen by the user SNOMED CT s use of multiple descriptions for the same concept means that finding an exact match is more likely The method by which you search is likely to be different from system to system but many allow a search by entering the first few letters of the key word s within the clinical phrase required It is generally not necessary to enter the full word the first few characters 3 or 4 of the word are often sufficient As related words can often have different endings such as diabetes and Crown Copyright 2012 www nhscfh nhs uk uktc 11 diabetic this approach ensures all relevant clinical terms are retrieved If you include the last few characters of the word you may exclude important choices As with internet searching it is important to search on the key words you are looking for you should avoid using words such as acute which will return a significant number of codes Think carefully about the search words you use so that your returned list is manageable As you become more familiar with SNOMED CT you will quickly know which search tokens to enter to achieve fast data entry Note The case of
8. SNOMED CT A user guide for General Practice Crown Copyright 2012 UK Terminology Centre www nhscfh nhs uk uktc Contents PUNDOSE OF this guilde irem etos EE E EEEE TEE EE OEE obsess AE EE SERERE 4 MNtrodUCtON in a a a a a H X 4 Whatis SNOMED CI P vacssccvsitestcesstsstayiunesuyeassaniiedee E E E a E PEU E aa aA ia EET 5 Why Use SNOMED ICT 2isscctcacscucatiess 5 Benefits of Using SNOMED CT x ccc erri eh E En FR E e RYE XA RR V YE rn NY YE ERR RV E ee ARE REA RR YE ER RV n 6 Who develops and supports SNOMED CT ccsscsccccecsssesenssseceeecesseseaeeeeeeecessesesaeaeeeeeseseeseaeaeeeesens 7 New SNOMED CT requests and updates ccccssssccccecessesensececeescesseseaaececeessessesasaeeeesesseesaaeaeeeeeens 7 es EesNI trcee ER 8 How is SNOMED CT Structured esssseseseseseeeeenee enne enne nennen nennen en tene innen enne nnns en nennen 8 CONCEDES PEE 8 Relationships eene eerte en NP ELE IL e E MEME I 9 Ic E inedee aepigeeae 9 Using SNOMED CT some fundamentals cccsscccccecsssessnseceeececesseseeaeceeeessesseuaeeeeeesseesesenaees 11 Recording in SNOMED CT onosaia ch ena ut ae ton eo odes REA Cre edu nC uoa dex koe ne MEOS 11 Searching SNOMED GT enceinte d oett aeneo d eaten da depressa Rod dog EEEa RR deant 11 Reporting from SNOMED CT coded iteMs ccssccccccecessesesaecececeees
9. T CONTEXT D EEE E EE TE EE R R 18 DESCRIPTION e D 18 Crown Copyright 2012 www nhscfh nhs uk uktc 2 DESCRIPTION ps rnae a EEE OET EEE OANE 18 FULLY SPECIFIED NAME FSN yer eheu repone eve eve e veut ae ne hende tese 18 HIERARCHY serein M 18 INTERNATIONAL EDITIQN 5 222 orones er tne ori ne eee ea eer tani Pr nenne ease depend 18 INTERNATIONAL RELEASE sssssseeseees eene nennen nennen nnne tnnt tnnt inserite E rese testes nnns 18 diddsbibuo E 19 QUALIFIER arnei A ioca e d ds 19 READ V2 EEA 19 RELATIONSHIP e 19 SUBSE Taman ea iustius tutus tdtu sedet ta E aet E 19 SY NONY 19 TERM paries 19 ud a EEN E N AE M 19 TERMINOLOGY e 20 TOP LEVEL CONCEPT EE 20 UK EDITION mE 20 NeiJimd eae eaaa aR Aet 20 ADDendix Zaer e E E T 21 SNOMED CT hierarchies titt a eiae aiae e pose cerra pn 21 a Regularly used in clinical records without further elaboration seseseeeeeesees 21 b Used in clinical records but usually require additional context ueessessss 22 c
10. Used in clinical records to provide context to other terMS ccccccccccsssscecessssceeeesseeeeeees 23 d May be in historical records but not recommended for clinical data entry 23 Crown Copyright 2012 www nhscfh nhs uk uktc 3 Purpose of this guide Electronic data flow across the different provider healthcare systems including primary and secondary care is improved when essential clinical data in the patient record is recorded in a consistent coding system for the NHS that coding system is SNOMED CT This guide has been produced to provide GPs with basic information on SNOMED CT to support its effective use in General Practice It is assumed that the reader is already familiar with the Read codes structured records and the practice of coding aspects of the patient record The guide is generic in that it is intended to provide the fundamentals that support use with any general practice computer system that is licensed to use SNOMED CT The reader should therefore bear in mind that the way SNOMED CT terms are for example actually selected will vary from system to system This document is distributed under the Open Government License Introduction Each medical record should have a complete list of all the patient s problems including both clearly established diagnoses and all other unexplained findings that are not yet clear manifestations of a specific diagnosis such as abnormal physical f
11. dergo a change Includes motion friction electricity sound radiation thermal forces and air pressure Other categories are directed at categorizing mechanisms of injury An identifiable place Includes all types of environments as well as named locations such as countries counties and regions Assessment scales Includes naming assessment scales and tumour staging systems Used to indicate the scale used A word or phrase that along with a linkage concept adds detail to the term Contains terms such as left and right that add further detail to a concept eg fracture of neck of femur witha laterality of left left being the qualifier value laterality the linkage concept A word or phrase that along witha qualifier value adds detail to the term e g Heart attack severity acute Leg laterality left Note used with qualifier values or other terms such as body structure s but not i 10t recommenc Description This has three sub hierarchies containing concepts which have been set aside from the other hierarchies Reports and forms associated with the administrative delivery of healthcare Used by applications rather than the user Crown Copyright 2012 www nhscfh nhs uk uktc Examples dod ae 1ed I Friction Fire Gravity Pressure change Cornwall Intensive Care Unit NHS day treatment facility Cancer hospital Glasgow coma scale assessment scale Alcohol u
12. e SNOMED CT is used in clinical notation to describe in detail CONCEPTs related to an individual a service an information source etc TOP LEVEL CONCEPT Are the most general and recognisable CONCEPTs available their only parent IS_A relationship being SNOMED CT These CONCEPTSs provide the hierarchies under which everything else sits In the UK edition there are 19 top level concepts For example Clinical Finding contains all clinical disorders and examination findings e g Pneumonia or Swelling of arm Procedure contains all the activities performed in the provision of healthcare e g Biopsy of lung Organism contains animals fungi bacteria and plants necessary for public health reporting and used in evidence based infectious disease protocols e g Hepatitis C virus e g Streptococcus pyogenes e g Acer rubrum Red maple e g Felis silvestris Cat Body Structure contains both normal and abnormal anatomical structures Abnormal structures are represented in a sub hierarchy as morphologic abnormalities e g BODY STRUCTURE Entire liver e g MORPHOLOGIC ABNORMALITY Neoplasm UK EDITION The version of SNOMED CT that is designed for use in the UK It contains content from the International Edition as well as content that is specifically for UK use only without specifying a particular release date UK RELEASE The version of SNOMED CT that is designed for use in the UK and provided on a specified
13. ed terminology would be more comprehensive and desirable and so SNOMED CT was born The international collaboration provides international effort and resource to develop and maintain the terminology CTV3 contributing over half of the original content for SNOMED CT An international market for products using a common terminology is long term more likely to improve the quality of EHR systems Crown Copyright 2012 www nhscfh nhs uk uktc 5 The Information Standards Board for Health and Social Care ISB has approved SNOMED CT as the terminology for use within clinical computer systems in England It is expected that SNOMED CT will eventually replace the Read codes SNOMED CT contains many of the healthcare coding schemes currently in use such as the Glasgow coma scale and work is ongoing with different professional specialities to ensure their needs are met within SNOMED CT Benefits of Using SNOMED CT In primary care where uptake of structured electronic records is already advanced much of the benefit of using SNOMED CT within the patient record will be seen through improved sharing of information across care settings the ability to receive electronic data such as discharge summaries in a coded format and the ability to aggregate data across care settings to support for example quality outcomes analysis Some of the benefits that can be achieved through SNOMED CT include SNOMED CT content is applicable to all healthcare professi
14. ematic arrangement of like entries based on differing characteristics e g ICD 10 This is generally a method of aggregating information for statistical purposes for populations not individuals Example ICD 10 code 121 9 Acute Myocardial Infarction unspecified CONCEPT A single unit of thought or idea with a distinct clinical meaning to which a unique CONCEPTID has been assigned Example Myocardial Infarction disorder CONCEPTID The code that uniquely identifies a CONCEPT within SNOMED CT Example For the clinical meaning of Myocardial Infarction disorder the Conceptld is 22298006 CROSS MAP A link from a single CONCEPT in SNOMED CT to its equivalent s in another CLASSIFICATION or TERMINOLOGY A concept may have a single cross map or a set of alternative cross maps Example The Concept 22298006 Myocardial Infarction cross maps to the ICD 10 target code 121 9 Acute Myocardial Infarction unspecified Additionally the cross map includes alternative target codes from ICD 10 categories 121 acute myocardial infarction and 122 subsequent myocardial infarction CTV3 Clinical Terms Version 3 CTV3 is a terminology developed by the NHS in the late 1990 s which subsequently became the main source of clinical data in SNOMED CT CTV3ID A five character code allocated to a CONCEPT in CTV3 Equivalent to the CONCEPTID in SNOMED CT Example Myocardial Infarction corresponds to the CTV3 code X200E Crown Copyr
15. fault context So for example about another family member is absent has happened in the past Note See glossary for DEFAULT CONTEXT A drug or other substance that is used to treat a patient This hierarchy is separate from the substance hierarchy in order to clearly distinguish drug products products from the chemical constituents substances of drug products Crown Copyright 2012 www nhscfh nhs uk uktc Examples Swelling of arm finding Pneumonia disease Biopsy of lung Diagnostic endoscopy Chest x ray Flash flood Motor vehicle accident Exposure to measles virus Body weight Tumour size Date of admission Range of hip abduction Family history of stroke No nausea Blood transfusion declined Aspiration pneumonia resulting from a procedure Has infirm partner Tamoxifen product Tramadol product Multivitamin tablet product Sex hormone product 21 Hierarchy Social Context b Used in clinical records but usually require additional Hierarchy Description Normal and abnormal anatomical body structure Body Structure Abnormal structures are represented Organism Physical Object Substance Specimen Description Non clinical demographic information Contains social conditions and circumstances significant to healthcare Includes family and economic status ethnic and religious heritage and life style and occupations in a sub hierarchy as morphologic abnormalities An
16. h concept always has at least two descriptions associated with it the fully specified name and the preferred term A concept can also have further descriptions associated with it known as synonyms which allow for different expressions with the same clinical meaning The Concept with the fully specified name of Heart disease disorder Preferred Term Heart Disease Heart disease s isorde r Synonym Cardiopathy Synonym Disorder of Hea 56265001 Synonym Morbus Cordis N Synonym Cardiac Disorder Synonym Cardiac Diseases Relationships Synonym Heart Diseases cardiac finding heart disorder structure of mediastinum disorder of cardiovascular system In the above example the fully specified name is the unique human readable form with the unique Concept ID of 56265001 The preferred term is the one that most clinicians use for this disorder and underneath is a list of synonyms which are the different ways that clinicians express the same term Crown Copyright 2012 UK Terminology Centre www nhscfh nhs uk uktc 8 We can also see that we are provided with more information about this disorder through its relationships We can see that it is a cardiac finding and it is a disorder of the cardiovascular system In addition we can see that it occurs in the heart structure and that we can determine its severity Relationships A concept is identified by its code and descriptions but it also has relationships which def
17. hips define the structure of SNOMED CT SUBSET A group of SNOMED CT components normally a list of CONCEPTs that share a specified common characteristic or use case Grouping CONCEPTs like this makes user selection easier by restricting what is available Example a list of all procedures carried out in a podiatry clinic SYNONYM An acceptable alternative to the PREFERRED TERM as a way of expressing a CONCEPT Synonyms are an alternative to the preferred term but with the same meaning Although the same word s may be associated with different concepts their clinical meaning is different Example 1 Dressing within SNOMED CT this synonym has three meanings The act of putting on clothes the procedure carried out on a wound and the physical object that is placed ona wound to protect it Example 2 Heart Attack Infarction of Heart and Cardiac Infarction are all Synonyms of the Concept Myocardial Infarction TERM The CTV3 and READ2 equivalent to the DESCRIPTION in SNOMED CT Note the words DESCRIPTION and TERM are often used interchangeably TERMID A five character code in CTV3 or two character code in READ2 allocated to a TERM Equivalent to the DESCRIPTIONID in SNOMED CT Crown Copyright 2012 www nhscfh nhs uk uktc 19 TERMINOLOGY A structured collection of terms A terminology is a collection of names words or phrases used to name things in a particular discipline in this case healthcare A terminology lik
18. ight 2012 www nhscfh nhs uk uktc 17 DEFAULT CONTEXT Unless stated specifically in the DESCRIPTION the situation associated with a SNOMED CT CONCEPT For a clinical finding that e the finding has actually occurred vs being absent or not found e itis occurring to the subject of the record the patient e itis occurring currently or at a stated past time For a procedure that e the procedure was completed e it was performed on the subject of the record the patient e it was done in the present time or at a stated past time DESCRIPTION A human readable phrase or TERM associated with a SNOMED CT CONCEPT Note the words DESCRIPTION and TERM are often used interchangeably There are different types of descriptions used in SNOMED CT such as FULLY SPECIFIED NAME PREFERRED TERM and SYNONYM DESCRIPTIONID The code that uniquely identifies a DESCRIPTION within SNOMED CT Example Myocardial Infarction has a Descriptionld of 37436014 FULLY SPECIFIED NAME FSN A description that unambiguously portrays a CONCEPT It is not normally used in a clinical record and is always expressed in American English Example The FSN for the Concept 22298006 is Myocardial Infarction disorder HIERARCHY An ordered organisation of CONCEPTS linked together by RELATIONSHIPs More general CONCEPTS appear higher in the hierarchy with increasing levels of specialisation or granularity detail below them There are 19 different hierarchies
19. indings or symptoms Lawrence Weed NEJM 1968 278 597 599 Today we also expect that record to contain medications allergies adverse reactions certain aspects of family history procedures undertaken etc Recording data within the electronic patient record in a standard way across the NHS and internationally provides clear unambiguous and consistent records It can assist data entry and is critical to support national reporting It allows systems to use that codified data to for example retrieve patient records pass data in a safe way from one healthcare system to an6other provide additional features such as drug alerts based on say allergies adverse reactions and co morbidities as well as provide for effective data analysis for example for clinical audit and service provision The type of information that is most useful if coded includes diagnoses symptoms observations drugs and procedures Understanding what local regional national use is made of that data can help users in understanding which is the most appropriate clinical term to select when offered a number of options that may all seem to be acceptable There may also be local policies in place on what to record within the electronic record often this is to support local monitoring and analysis Systemized Nomenclature of Medicine Clinical Terms is managed by the IHTSDO www ihtsdo org Crown Copyright 2012 www nhscfh nhs uk uktc 4 What is SNOMED CT The Sys
20. ine what kind of concept it is e g clinical finding procedure as well as additional information such as finding site Every concept has at least one relationship to another many have more than one and it is these relationships that further define the concept for example the concept pneumonia is a disease of the lung has a finding site of lung structure and can have a severity with options such as mild or severe Unlike Read codes the terms in SNOMED CT can have multiple relationships thus alleviating the need for terms to appear twice as they have to in Read codes e g bacterial meningitis and meningitis bacterial In Read codes this happens because bacterial meningitis is both an inflammatory disease of the central nervous system and a bacterial disease which are two separate hierarchies in Read codes whereas in SNOMED CT it exists once but has two parents bacterial infection of central nervous system and infective meningitis Relationships are a very powerful mechanism which allow not only grouping of closely related concepts but also machine processing of the information in SNOMED CT It is designed to enable aggregation of clinical information for secondary uses without any loss of the detail required for primary clinical use An example of is a relationships in SNOMED CT SNOMED CT Concept Disease of respiratory system Infectious disease Disease of lung Pneumonia K Infective
21. itis s catarrhal appendicitis s chronic appendicitis complicated appendicitis E pp gd recurrent appendicitis d relapsing appendicitis In this example you may want a list of the different types of appendicitis but exclude the classifications X Other appendicitis and other appendicitis NOS select appendicitis and all its children but NOT X Other appendicitis OR other appendicitis NOS So reporting using SNOMED CT is very much about using the terms within SNOMED CT and their hierarchies and not aspects of the codes themselves Abbreviations and acronyms Abbreviations and acronyms can be ambiguous so those that are included in SNOMED CT are usually found with the expanded text following e g MI myocardial infarction Abbreviations and acronyms on their own do not generally exist in SNOMED CT though there are some exceptions for unambiguous acronyms This approach facilitates searching for terms using the abbreviation or acronym for example MI while ensuring the full description is seen to ensure the correct term is selected There are some abbreviations in use that mean different things in different clinical specialities this approach avoids misinterpretation of such abbreviations For example if you search for PID in SNOMED CT you will find PID pelvic inflammatory disease and PID Prolapsed intervertebral disc ensuring you select the correct term Note For historical reasons you will find some ambiguou
22. n which hierarchy it sits as this will change its fundamental meaning For example the term dressing has three distinct meanings in SNOMED CT e Dressing the activity of putting on clothes is an observable entity e Dressing the thing that is placed over a wound is a physical object e Dressing the act of covering a wound is a procedure The type hierarchy of a concept helps to clarify its meaning so in the above example observable entity procedure and physical object are each a different hierarchy within SNOMED CT Knowing the hierarchy will allow you to select the correct term you are looking for Different systems facilitate a user identifying this context in different ways and it useful if you know how to do this in your particular system for example the Fully Specified Name if viewable for the term selected contains the hierarchy in brackets eg application of dressing procedure other systems allow you to look at the hierarchy alongside on the screen When presented with a list of very similar terms knowing the hierarchy can help ensure you select the correct term while remembering that the provision of synonyms will at times give you lists of terms that mean the same thing Appendix 2 provides a list of all the different SNOMED CT hierarchies along with an explanation and examples of the content within that hierarchy In some systems at data entry you may only be presented with for example procedures if you
23. on fal diabetes mellitus without complication Less detailed Children of diabetes mellitus More detailed Reporting from SNOMED CT coded items Unlike Read v2 the codes for each of the SNOMED CT terms are meaningless so it is not possible to ask for all patients with the coded items that begin say C10 However the fact that Read v2 is full in some hierarchies and that it is a single hierarchy system means that some of the terms required may be elsewhere within the Read hierarchies This is not the case in SNOMED CT as a term can be categorised in more than one way i e it can be in more than one hierarchy In SNOMED CT a common way of reporting is to search for a term and all its children e g diabetes mellitus and all its children would provide all the different entries that relate to types of diabetes Below is a screen shot from a browser showing diabetes mellitus and all its children This is a representation of the terms your search would identify in the patient record when searching for all the different types of diabetes mellitus by searching for the code for diabetes mellitus and all its children Crown Copyright 2012 www nhscfh nhs uk uktc 12 betes mellitus Hf x Other specified diabetes mellitus HIE Pre existing diabetes mellitus unspecified Di te HIE X Unspecified diabetes mellitus with renal complications abe a Ha diabetes mellitus AND insipidus with optic atroph
24. ons in all healthcare settings and all clinical specialities e The Read codes do not and cannot be extended to support all healthcare needs e Sharing data can reduce the need to repeat health history at each new encounter with a healthcare professional it also means the clinician does not have to rely on the accuracy of the patient s knowledge e Data can flow electronically across healthcare without the need to re enter data or try to find equivalent codes for essential clinical terms from a different coding scheme SNOMED CT provides improved expressivity and reduced ambiguity e SNOMED CT can record clinical information at greater levels of specificity than provided by Read v2 and therefore provide the terms required for different clinical specialties e SNOMED CT contains content that is not and cannot be provided with the Read codes for example the extensive array of imaging procedures now in use and histopathology to name just two examples e Read codes evolved from earlier classifications and some are ambiguous in their meaning SNOMED CT provides for codes deemed ambiguous to be replaced with well specified codes SNOMED CT is international e The ongoing development of SNOMED CT is an international collaborative effort The benefits of this being o Costs of the terminology are shared across more than one nation o Data can flow across national and international boundaries o Asingle international terminology facilitates a com
25. or profit organisation based in Denmark and owns the intellectual property rights for SNOMED CT More information about the IHTSDO can be found at http www ihtsdo org In the UK the UK Terminology Centre UKTC is responsible for the UK Edition of SNOMED CT and as the national release centre it distributes both the international and UK Edition of SNOMED CT National and international arrangements have been established to ensure there is adequate and relevant governance of SNOMED CT and its content to ensure it meets the needs of healthcare in the respective jurisdictions The UK Edition contains terms that are specific to the UK but not internationally relevant and so ensures we meet UK healthcare requirements More information about the UKTC can be found at http www nhscfh nhs uk uktc New SNOMED CT requests and updates Requests for new content that is of national relevance can be made by any user within the UK The UKTC pro actively engages with Professional Bodies and new developments for national reporting to ensure as much as possible that required codes are available when needed We recommend that an individual user s request for change is made via their system supplier or system user group This will allow suppliers to manage the changes and to provide temporary codes where necessary while the new content is being authored If it is necessary to make requests for change directly the process and details can be found at h
26. organism of significance in human medicine such as animal bacteria fungus or plant A tangible and visible object Includes natural and man made objects focusing on those associated with healthcare Non living and chemical materials Includes foods nutrients allergens and materials Used to record the active chemical constituents of all drug products A specimen for observation study testing or evaluation Represents entities that are obtained for examination or analysis usually from a patient Crown Copyright 2012 www nhscfh nhs uk uktc Examples e Economic status social concept e Asian ethnic group e Clerical supervisor occupation e Donor person e Thief life style e Judaism religion philosophy context Examples e Structure of thyroid body structure e Neoplasm morphologic abnormality e Mycobacterium tuberculosis e Streptococcus pyogenes e Acer rubrum Red maple e Felis silvestris Cat e Suture needle e Artificial organ e Vena cava filter e Colostomy bag e Dust e Oestrogen e Haemoglobin antibody e Methane e Codeine phosphate e Nail specimen e Pus specimen e Clean catch urine e Specimen from patient e Calculus specimen 22 Hierarchy Physical Force Environment or Geographical Location Staging and Scales Qualifier Value Linkage Concept Hierarchy Special Concept Record Artifact Description The influence that causes an object to un
27. petitive international market for software systems and functionality o Healthcare systems provided by international suppliers will reduce overall software development costs by using a single international terminology See http www isb nhs uk documents isb 0034 amd 26 2006 Crown Copyright 2012 www nhscfh nhs uk uktc 6 SNOMED CT supports analysis of patient data e SNOMED CT addresses the current hierarchy restrictions with Read so that reports can correctly identify required patient records without having to cope with the various exceptions e SNOMED CT supports better expressivity there are some clinical terms such as data on allergies and adverse reactions that the Read codes do not support well Increased data recording facilitates improved data analysis Today s technology SNOMED CT is an evolution from previous terminologies e SNOMED CT addresses the issues of previous terminologies providing a dynamic terminology that can meet the changing requirements of healthcare for example Read v2 contains codes that are no longer required or are medically incorrect as knowledge has advanced but there is no method to remove these in Read v2 e SNOMED CT better supports today s technology and systems adopting SNOMED CT and utilising its features can provide improved functionality over time Who develops and supports SNOMED CT The International Health Terminology Standards Development Organization IHTSDO is an international not f
28. release date It contains content from the International Release as well as content that is specifically for UK use only Crown Copyright 2012 www nhscfh nhs uk uktc 20 Appendix 2 SNOMED CT hierarchies This appendix lists all the 19 SNOMED CT hierarchies with a brief description They are ordered by their general use with those most relevant first Some of these are not advised to be available for clinicans to enter in the record The expected use is indicated by the heading of the section a Regularly used in clinical records without further elaboration Hierarchy Clinical finding Procedure Event Observable Entity Situation with Explicit Context Phamaceutical biologic product Description What phenomena is observed Contains the sub hierarchies of Finding symptoms and Disease Important for documenting clinical disorders symptoms and examination findings What is being done Purposeful activities performed in the provision of health care What is taking place Describes the situation around the individual at a specific time which is relevant to their healthcare This does not include procedures or interventions which are in the Procedure hierarchy A quantitative observation Terms that are used to record measurements readings numerical results dates etc and always have an associated value entry Phrases that need to be recorded in the patient record but change the de
29. s abbreviations that are not expanded these are slowly being addressed and retired from SNOMED CT Concepts that should NOT be used in clinical records Although they exist in SNOMED CT codes ending in NOS or NEC or including square brackets are discouraged from being used They exist in SNOMED CT due to Read s origins from the classification ICD 9 where every episode needed to be allocated to a classification code but over time these will be retired from SNOMED CT and will not be available for selection Until all concepts of this type are detected and removed from SNOMED CT the guidance is to select the equivalent concept without the suffix prefix or to code with the concept one level up the hierarchy and use free text to add any necessary additional detail Descriptions containing any of the following are to be discouraged from use e EC elsewhere classified e OS otherwise specified e NOS not otherwise specified NEC not elsewhere classified HFQ however further classified Crown Copyright 2012 www nhscfh nhs uk uktc 14 e NOC not otherwise classifiable e specified e unspecified e otherwise e elsewhere classified e classified elsewhere other SNOMED CT hierarchies SNOMED CT concepts are organised into 19 distinct hierarchies each of which cover different aspects of healthcare So when selecting a term it is vital to understand i
30. se inventory assessment scale Dukes staging system tumour staging Bilateral Open Reduced Removal action Right Has etiology Finding site Severity Method Has reason Examples Inactive concept the supertype ancestor of all inactive concepts Navigation concept the supertype of all navigation concepts Namespace concept the supertype of all Namespace Concepts Disabled driver certificate administration Lloyd George record folder 23 This document is produced by Education and Implementation UK Terminology Centre Leeds LS1 4HY datastandards nhs net Crown Copyright 2012 www nhscfh nhs uk uktc 24
31. sesaeaeceeecesseseaeeeeeeeseseesseaeees 12 Selecting specific SNOMED CT terms ccccccccsssscceessscececssscececsessececeesececesseceesesseceeseeaeeeeseaaeess 13 Combination of using relationships and specifying terms ccsccccccsssssssseeeeeecessesssseseeeeeens 13 Abbreviations and Acronyms ccccsessssccececsssesscececececssseseaaeaeceescssseseeaeeeseeeceseesaaaeseeeesesesesseaeas 14 Concepts that should NOT be used in clinical records eeeeeeseeneeennnnn 14 SNOMED CT hierarchies itte Inr eet eret sn Eee pee Pee eP e ae ERR EXER Fe en eee aR Ev npe nnt 15 Data translation z rr deett e as eto Eu iie eee lot didus 15 ede 16 Eccle 16 Produced by the UK Terminology Centre Department of Health Informatics Directorate 16 VEFSION TD ADEHEL2012 tet i o ic eben e tede eel iei tedster E pedo onse bdo ed 16 Appendix 1 SNOMED CT Glossary ccceceseesssececececssseeeaeceeeceseesesaaaeseceesssesuaaaaeceesessseseaaeaeeeeeens 17 PTET iis d E 17 BROWSER sarimie mna E EE E EE E E EEEE TE 17 CLASSIFICATION m toners 17 CONCEP Tersier toute a a a a e i aeia Ea a detest sguetestwessdele RE 17 een sq 17 CROSS MAP 17 DE EE 17 OI Ep S 17 DEFAUL
32. tematized Nomenclature of Medicine Clinical Terms is commonly referred to as SNOMED CT It is a structured collection of clinical terms specifically for use by clinicians in the day to day recording of patient care In addition SNOMED CT contains information that can be used by systems to support activities such as clinical alerts decision support and the triggering of additional functions such as links to clinical pathways and knowledge resources SNOMED CT enables elements of a patient s electronic health record to be coded in a clear unambiguous way that is consistent across all of healthcare It covers areas such as diseases symptoms operations treatments devices and drugs Systems that accurately record healthcare encounters in a way that can be reliably communicated and exchanged across different systems will reduce the requirement of additional manual input and thus reduce data entry errors as well as provide business efficiencies The coding of clinical content within the electronic patient record also allows analysis of patient episodes over a period of time both to identify health trends that enable decisions on services and to investigate approaches for improved patient outcomes such as reducing re presentation by particular patient types groups in emergency departments SNOMED CT is being incorporated into electronic healthcare applications across the whole of healthcare including secondary primary community and mental health and
33. tis occurring currently or at a stated past time e For a procedure that o the procedure was completed o itwas performed on the subject of the record the patient o itwasdoneinthe present time or at a stated past time The only exceptions to this are concepts where the description actually contains a specific context e g father smokes and these are all grouped in a special hierarchy situation with explicit context explained in appendix 2 When recording in the patient record free text should only be used to add additional detail and never be used to negate or modify the meaning of the coded item For example family history of or excluded added as a free text comment to a coded entry fundamentally changes its meaning In the first case it is saying that the condition applies to someone other than the patient and in the latter that the patient definitely does not have the condition There are some negative concepts in the terminology but these are exceptions to the general rule or were inherited from Read codes for example not constipated Note SNOMED CT has evolved from the legacy terminologies of Read and over time In some areas it contains many codes when deciding which term to select use the one that is completely true and closest to what you would normally record and aim to be consistent across patients Some practices have agreed the sets of codes they will use to get consistency within the practice The relationships in SNOME
34. ttp www connectingforhealth nhs uk systemsandservices data uktc snomed change Crown Copyright 2012 www nhscfh nhs uk uktc 7 SNOMED CT releases The UK Edition of SNOMED CT is currently released every six months while the SNOMED CT UK Drug Extension is released four weekly Content continuously evolves to meet clinical need including the retirement of content that is no longer appropriate e g ambiguous terms as well as the addition of new terms This is different to the Read codes How is SNOMED CT Structured SNOMED CT is a collection of about 600 000 medical concepts associated with about 1 750 000 descriptions known as terms in Read codes and related to each other in a hierarchy also known as a taxonomy consisting of about 2 600 000 relationships NOTE These figures are totals from the UK Edition October 2011 Release Concepts A SNOMED CT concept is a unique clinical phrase which is identified by a unique numeric identifier that never changes known as the Concept ID equivalent to the codes in Read codes e g C10 Unlike Read codes Concept IDs do not contain hierarchical or implicit meaning they do not reveal any information about the nature of the concept SNOMED CT concepts are never deleted but may be retired for example if they are ambiguous Included in the SNOMED CT data files is a history file which contains details of these changes and recommended concepts that could be used in their place Eac
35. while it is not essential for everyone in the NHS to understand SNOMED CT in depth it is important to have some background understanding of SNOMED CT to maintain high levels of data quality Why Use SNOMED CT SNOMED CT is the natural successor to the current coding schemes in use Read codes version 2 Read v2 and clinical terms version 3 CTV3 and has been developed with the knowledge gained through these terminologies SNOMED CT addresses the current issues we know exist with those legacy terminologies It is the only terminology that meets the requirements of both primary and secondary care in the UK and is the most extensive international clinical terminology in existence Read v2 already presents a number of issues which cannot be resolved it has a number of terms which are no longer current some are actually incorrect or misspelt and some are problematic for example sexual orientation is categorised as a mental disorder In addition some of the hierarchies are full meaning that new terms cannot be put in the correct logical place Those responsible for writing reports have to know where the logic of Read v2 is no longer correct and compensate in the way they write their reports this is not sustainable long term and constitutes a risk that reports are currently not identifying all the required records Read v3 CTV3 was developed to address the problems with Read v2 but this experience highlighted that an internationally maintain
36. y AND deafness al diabetes mellitus associated with genetic syndrome Ha diabetes mellitus due to structurally abnormal insulin s diabetes mellitus during pregnancy childbirth and the puerperium Ha diabetes mellitus NOS with no mention of complication s diabetes mellitus type 1 s diabetes mellitus type 2 FI diabetes mellitus with multiple complications Ha diabetes mellitus with no mention of complication All the HF s diabetes mellitus with other specified manifestation Ha diabetes mellitus without complication different types of Hia Houssay s syndrome A Lfainsulin autoimmune syndrome diabetes mellitus PF glinsulin autoimmune syndrome without complication sl latent autoimmune diabetes mellitus in adult a maternal diabetes mellitus a maternally inherited diabetes mellitus s multiple complications due to diabetes mellitus a neonatal diabetes mellitus Ha other specified diabetes mellitus with coma Hia pineal hyperplasia AND diabetes mellitus syndrome a posttransplant diabetes mellitus i pre existing diabetes mellitus fel Pregestational diabetes mellitus AND OR impaired glucose tolerance modified White clase LD ronal cucia and dichatae cundranan 0 Selecting specific SNOMED CT terms There are times when a list of related terms is not sufficient for your requirements as the terms you are looking for may not be clinically related to each other In this instance it is necessary to
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