Long term goals and program to achieve the goals. SNOMED CT National Release Center organisation, processes and resources within Socialstyrelsen. Ongoing implementation initiatives. Lotti Barlow, Socialstyrelsen SNOMED CT 2019 -seminaari (28.3.2019)

1. SNOMED CT in Sweden
SNOMED CT 2019
Seminar in Helsinki 28 March 2019
Lotti Barlow

2. The governing of health care and
medical care in Sweden

3. How Sweden is governed
3/26/2019
National level
• The Riksdag (Parliament)
Has the legislative power
• The Government
Enforces the decisions of the Riksdag and develops
proposals for new laws or amendments to
legislation
• Government agencies
The National Board of Health and
Welfare is one of the agencies

4. Our mission statement
The National Board of Health and Welfare
safeguards health, welfare and equal
access to good health care and social care
We work to ensure good health and social
care through guidance by rules, knowledge
and government grants, and through
follow-up and evaluation

5. How Sweden is governed
Regional level
• Sweden is divided in 21 regions
• Each region is responsible for their
health care and medical care
Activities are financed primarily
from taxes and to some extent
from fees and government grants

6. How Sweden is governed
Local level
• Sweden is divided in 290 municipalities
• Each municipality is responsible for schools,
preschools, care of the elderly and disabled
persons, individual and family services,
roads, water supply and sewage system etc.
Activities are financed primarily from
municipal taxes and partly through
government grants and fees

7. The role of the National Board of Health
and Welfare
7
• Works with both healthcare
and social services
• Works with many tools, from
regulations to guidelines,
government grants,
monitoring, evaluation and
nationwide data bases
• Provides support for both
governance and knowledge
based guidance

8. Vision for eHealth 2025
8
Areas of action in the vision:
1. Regulations
2. More consistent use of concepts
3. Standards
https://ehalsa2025.se/in-english

9. Vision for eHealth 2025
9
Areas of action in the vision:
1. Regulations
2. More consistent use of
concepts
3. Standards
https://ehalsa2025.se/in-english

10. Our tools to enable semantic
interoperability
10
• The National Information
Structure
• SNOMED CT
• Classifications from WHO and National/Nordic ones
• The Terminology Database

11. Snomed CT in Sweden

12. 12
• 2007
– Sweden joins SNOMED International (IHTSDO)
– Sub-projects: translation, mapping and
maintanence
• 2010-2011
– Bulk translation of SNOMED CT finished
• Approximately 280,000 terms translated into Swedish
– The Mappning method is published
– The maintanence organization is in place

13. Translation of the whole SNOMED CT
• The translation can keep a high
speed and quality issues can be
identified
• Continuisly building knowledge
Advantages

14. 14
• Now
– Maintenance mode
– Focus on user support
– Goal: structured EHR documentation for
efficient use of information

15. The maintanence consists of
• Two releases per year
• Addition of new concepts to the Swedish
version
• Addition of synonyms
• Influence on the international version
• Give user support - education and
implementation support

16. Information structure and
terminology

17. Where should the information be
expressed?
• An information model
needs a terminology
• SNOMED CT needs an
information model
• How do you choose
where to decide what?

18. Spectrum of strengths
Terminology What, how and why
+++ Disease, symptom, sign, procedure, body structure,
morphology, substance, drug, device, organism …
++ Refinement of concepts (e.g. laterality).
+
+
Clinical situations in a context, e.g.
Present/absent/uncertain, Family history, past history
Requested/planned/done.
++ Relationships between record entries.
Structural constraints on classes or attributes.
+++
Dates, times, durations and quantities.
Instances of people, organizations and places.
Structural
Model Who, when and where
From David Markwell

19. • SNOMED CT is best used in the patient record
• Socialstyrelsen recommend the use of
SNOMED CT
• But …
It is up to the Health Care Regions to decide if
they want to use SNOMED CT in the
documentation

20. Barriers until now
• How the health care regions are run
– Socialstyrelsen can not decide on how the documentation
looks and how it is handled in the systems
– The Health Care Regions owns this question
• Documentation systems have not been able
to handle SNOMED CT
– Low maturity grade to use a standardized terminology
– A lot of free text in the patient records

21. But…
21
Now there is hope
for a way forward

22. All regions develop or order new
systems
Cambio Cosmic (develop)

23. The Swedish National Release Center

24. The Swedish NRC
•Number of employees – 8
– Different competences – MD, terminologist, technical
engineer, pharmacist, health informatician, bio-medical
scientist and behaviour science
•Maintenance of SNOMED CT
– Translation
– Extension
– Support for implementations
– Connecting terminology to information structure

25. Ways of success
• To have SNOMED CT easily accessible in Swedish
– Through the browser
– Efficient licensing portal
• Educations
– SNOMED International
– Webbinars in Swedish
• Be accessible
– Give users support
– Some questions we can’t answer, but at least we know what
questions have been asked!
• Cooperate

26. SNOMED CT is used in National
projects
• Alert information
• National knowledge base for reasons for prescription
• National list of prescriptions
• Reasons for encounter
• Laboratory medicine
• Cancer and pathology

27. Situation: emergency
Alert information
diagnoses
drugs
implants
transplants
treatment
limitations
contagions
violence
hyper-
sensitivities
to drugs
to food
to chemicals
to insect bites
malignant hyperthermia
adrenal insufficiency
anticoagulants
immunosuppressants
…
implantable cardioverter defibrillator
ventriculovascular shunt
…
…
kidney transplantation
transplantation of heart
…
medication refused
patient refuses hospital admission
…
not for resuscitation
MRSA
…
ESBL-CARBA
risk for violent behaviour
…
Threatened patient
Enforced single documentation Contextualised presentation
Terminology refsets catching the
data needed for each context

28. National knowledge base for
reasons for prescription
• Government commission since 2012
• About 1600 SNOMED CT coded* reasons for prescription, linked
to all drugs on the Swedish market
– Support the clinicians to get easier access to clear and structured information
about the reason for prescription of a drug treatment
• About 1200 terms for “treatment intent” (not SNOMED CT coded)
– To give the patients better information about the treatment intent
• The knowledge base is distributed to the Swedish regions and
system developers on a weekly basis from March 2019
• Reasons for prescription and treatment intents will be included in
the National drug list (under development)
* Clinical findings, disorders and procedures

29. Administration of drugs
• National drug list is planned to 2020-07-01
• For administration EDQM* is insufficient
– Mapping from SNOMED CT to EDQM-codes for administration of drugs
– Addition of new SNOMED CT-codes when needed – both to the
national and the international edition
• European Medical Agency in the EU and Medical
Products Agency in Sweden presents codes per
drug product
* European Directorate for the Quality of Medicines,
Standard Terms Database

30. Reasons for encounter
• Government commission from 2018 to develop a
national code system with reasons for encounter
• First version contains about 200 terms that are
SNOMED CT coded
– To be completed in Swedish May 2019 release
– Mainly symptoms and signs, some procedures
• Next step:
– To test the code system in a pilot (EHR system)
– To send on referral to the Swedish regions

31. Laboratory medicine
Sample
Sample type= 16221491000119104 | prov från
tömd urin |
Site =
Analysis
Type = NPU06073 Urin(specifikation)—Bakterie;
taxon(procedur) = ?
Method = 61594008 | odling av mikroorganism
|
Finding/Result
Value = 112283007 | Escherichia coli |
Finding/Results
Value = 78065002 | Enterococcus faecalis |
Reference sets

32. Focus on Microbiology
NPU SNOMED CT No. of SNOMED-CT codes
(at least)
Sampling site
/localisation)
X 66
Sample types X 83
Analyses X
Analytical
method
X 56
Organism X 3386
Results/Finding X 86

33. Structuring of pathology reports
Modified from Ellis, D.W., & Srigley. Virchows Arch (2016) 468:51–59
• Quality registers
• Clinical research
• Statistics
• Biobanks
• Health economics
• …
Level 7
Information
Interoperability
with SNOMED CT

34. Towards implementation in Sweden
the pathology profession (Level 6)
Swedish Society of Pathology (SvFP)/KVAST (quality and standardization):
– Newly formed SNOMED CT Working Group within SvFP
• Support the standardization work
• Coordinate/facilitate/harmonize the synoptic reports (in collaboration with
Scott Campbell)
Development of standardized (synoptic) pathology reports
KVAST-group Discussed Chosen tumor types Status synoptic
protocols
Skin Yes Malignant melanoma of skin Protocol completed with
SNOMED CT codes
Liver/bile ducts and
pancreas
Yes Primary cancers in liver, bile ducts,
pancreas and periampullary region
Protocols in advanced
phase
GI tract Yes Colo-rectal cancer In progress
Hematopathology Yes B-cell lymphoma Protocol completed with
SNOMED CT codes
Breast Yes Breast cancer In progress
Urology Yes Urinary bladder cancer In progress

35. International collaboration within
pathology
• SNOMED International working groups
– Cancer synoptic reporting
– Pathology and laboratory medicine
• Professional societies
– Swedish Society of Pathology
– Royal College of Pathology (UK and AU)
– College of American Pathologists
• Multilateral collaboration
– Finland and Sweden

36. Lessons learned

37. • Have the right competenses and tools within
the organization
• Make use of the international community
• Make SNOMED CT easibly accessible
• Have goals for implementations and
responsibility
• Cooperate with other actors under
the e-Health umbrella
• Show the advantages of using SNOMED CT

38. Last but not least

39. Congratulations
Finland!
•And the Winner in the
World Happiness Report!
•That waited until now!
•You will get a lot for ”free” such as:
– SNOMED International is a much more mature organization
– You can get help and advice from other members
– There are tools to support the maintanence
– There are web based educations
•We are glad to have all of the Nordic
countries within the family!

40. Questions?

41. For contact:
Lotti Barlow
lotti.barlow@socialstyrelsen.se