Robyn Kuropatwa & Kathy Giannangelo Describe the adoption methodology of SNOMED CT as reusable clinical content Explain the development process of SNOMED CT clinical diagnosis physician specialty subsets Describe the challenges encountered and lessons learned List the next steps 2 Introduction Approaches Status Challenges & Lessons Learned Next Steps Questions 3 Background Purpose Targeted Clinical Specialties 4 Nova Scotia Project Goals To modernize insured services by implementing a framework to accurately define clinical diagnoses and services that reflect physician practices To update policies and processes to support physician, organization and accountability needs with improved data capture and reuse To determine which SNOMED CT concepts and descriptions to include in the physician specialty subsets in order to accurately define clinical diagnoses that reflect physician practices 5 Use of SNOMED CT Enables physicians to use standardised terms Development of Physician Specialty Subsets Concept subsets Ensure clinically relevant content is included Description subsets Ensure only relevant descriptions are displayed to physicians 6 1. Anaesthesia* 2. Cardiology 3. Clinical Immunology & Allergy 4. Community Medicine* 5. Dermatology 6. Diagnostic Imaging* 7. Emergency Medicine 8. Endocrinology & Metabolism 9. Gastroenterology 10. General Practitioner 11. General Surgery 12. Genetics 13. Geriatric Medicine 14. Haematology 15. Infectious Diseases 16. Internal Medicine 17. Medical Microbiology* 18. Medical Oncology 19. Nephrology 20. Neurology 21. Neurosurgery 22. Obstetrics & Gynaecology 23. Ophthalmology 24. Orthopaedic Surgery 25. Otolaryngology 26. Paediatrics 27. Pathology 28. Physical Medicine & Rehabilitation 29. Plastic Surgery 30. Psychiatry 31. Radiation Oncology 32. Respiratory Medicine 33. Rheumatology 34. Surgery 35. Urology * Denotes unique clinical characteristics 7 Adopt or Adapt Description Subsets Cycles/Tooling/Documentation Data Quality Checks/Documentation 8 9 Not all synonyms for each concept are applicable in Nova Scotia Concept: |Spina bifida occulta (disorder)| |Cryptomerorachischisis| |SBO - Spina bifida occulta| |Spina bifida occulta| Same descriptions can cause confusion Term: Inflamed Gallbladder |Cholecystitis (disorder)| |Acute cholecystitis (disorder)|* * The description from this concept was inactivated in the July 31, 2015 release but we started out in the July 31, 2013 release 10 Cycle 1: Map Development Map historically used diagnoses to SNOMED CT Map review by at least one physician from each specialty Identify historically used diagnoses by specialty as the baseline for subset development Cycle 2: Subset Development Physicians select SNOMED CT concepts and descriptions for inclusion in subsets Selection by at least two physicians from each specialty Cycle 3: Subset Refinement Use comparative subsets to add additional concepts to improve the coverage of terms Review by at least two physicians from each specialty 11 #Specialty ICD-9-CM Diagnoses SNOMED CT Concepts 1.Cardiology1, Dermatology Emergency Medicine2,0471,778 4.Gastroenterology General Practitioner9,8758,747 6.Haematology Nephrology Obstetrics & Gynaecology2,1801,730 9.Ophthalmology1,6091, Orthopaedic Surgery1,7521,390 12 13 14 Inclusion Criterion Include if at least one reviewing physician wants to include the concept/description Exclusion Criterion Exclude if all reviewing physicians want to exclude the concept/description 15 Total: 1,188 Term is nonspecific - too vague to include all subtypes |Autoimmune disease (disorder)| |Closed fracture of bone (disorder)| Term is nonspecific - no subtypes defined in SNOMED CT |Affective psychosis (disorder)| |Muscle, ligament and fascia disorders (disorder)| Term suggested does not adhere to editorial guidelines |Abdominal pain (finding)| Comment: Add NYD |Clostridium difficile infection (disorder)| Comment: C diff Term to be added as extension concept or description See next slide 17 Concepts Abscess of small intestine Abortion with complication Hematoma of joint Description |Open intertrochanteric fracture (disorder)| |Open intertrochanteric fracture| Open intertrochanteric fracture of femur 18 Comparative Subsets Canada Health Infoway (CA), Kaiser Permanente (US), NEHTA (AU), NHS (UK) Analyses Extensions Inactive concepts Identify active replacement concepts Overlap Exclusive Relationship (supertype, subtype, unrelated) Excluded 19 Data Quality Checks Acceptable hierarchies Clinical Finding Event Flag high-level concepts Only active concepts and descriptions No same description throughout all subsets Full Documentation 20 Physician Participation Subset Development 21 Physician participation 35 physician specialties 180 physicians involved ~1,000 physician hours ~4,000 comments 22 Initial physician specialty subsets 21 completed Cycle 2 Subsets range from 96 to 1,704 concepts 178 to 3,595 descriptions 12 very close to completion expect by November 4 on hold (unique clinical characteristics) 23 Obstetrics/Gynaecology Example KP: 1,318* concepts | NS: 1,665 concepts 24 * Includes active replacement concepts 25 Difficult to display and explain content to physicians Same descriptions for different concepts Lack of granularity and synonyms need for extensions Different regional context (e.g., legal abortion without complication) Incorrect synonyms (e.g., Xanthoma and Xanthelasma of eyelid is not the same) Outdated language (e.g., complicated senile dementia) Incorrect classification of syndrome (e.g., tuberous sclerosis syndrome) Incorrect classification of disorder (e.g., Abnormal weight gain in pregnancy (disorder)) Inactive concepts require feedback to physicians 26 Lack of comparative subsets Physician selection of terms Different uses of clinical diagnoses in specialties Tracking and reminders 27 Explicit, documented methodologies are needed for consistency and uniformity of the output Physician involvement required to establish subset clinical relevance ownership Building the initial subset from previously used clinical terms is a valuable starting point Building description subsets are important to better reflect clinical terms used in practice Not all descriptions in SNOMED CT are required 28 Existing well-documented external subsets are valuable resources which could be adopted or adapted for subset enhancement Advantages to building a comprehensive subset with many potential uses rather than several separate sets for specific use cases Project success depends on physician friendly tools that can present complex information in a understandable manner 29 30 Complete Cycle 3 Subset Refinement Refinement to reflect sub-specialties clinical diagnoses Expand physician participation to 500 Clinical working group to validate potential extensions Export subsets to simple refsets Complete documentation Develop subset lifecycle refinement and maintenance policies and processes Implement across province (2,500 physicians) 31 Robyn Kuropatwa Kathy Giannangelo 32