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Master Class on EMR/EHR Standards by Karanvir Singh

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Master Class on EMR/EHR Standards by Karanvir Singh, Chief Medical Information Officer, Indraprastha Apollo Hospitals, India

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Master Class on EMR/EHR Standards by Karanvir Singh

  1. 1. SNOMED CT Systematized Nomenclature Of Medicine – Clinical Terms ---An introduction --- Dr Karanvir Singh MBBS, MS, FRCS (Glasgow) Chief Medical Information Office Apollo Hospitals
  2. 2. Systematized Nomenclature of Pathology (SNOP) 1965 CAP Broad clinical terms included (SNOMED) 1975 CAP Logic based SNOMED-RT 2000 CAP Read codes1980s NHS UK Read codes v3 Clinical Terms v3 CTV3 1990s NHS UK SNOMED-CT2007 IHTSDO India became a member of the IHTSDO 2014 SNOMED-CT2002 CAP NHS UK US UK
  3. 3. SNOMED CT
  4. 4. SNOMED CTerminology
  5. 5. Coding system vs Terminology A 66 year old man was brought the accident and emergency department of a trauma center hospital with a history of near drowning in a boating accident. After initial resuscitation he was airlifted, from the holiday resort he was staying in, by a medical helicopter. On admission he was unconscious…
  6. 6. Coding system – ICD-10 A 66 year old man was brought the accident and emergency department of a trauma center hospital with a history of near drowning in a boating accident. After initial resuscitation he was airlifted, from the holiday resort he was staying in, by a medical helicopter. On admission he was unconscious… Boating accident 90.1 Near drowning T75.1 Unconscious R40.2
  7. 7. Terminology – SNOMED CT A 66 year old man was brought the accident and emergency department of a trauma center hospital with a history of near drowning in a boating accident. After initial resuscitation he was airlifted, from the holiday resort he was staying in, by a medical helicopter. On admission he was unconscious… Man 339947000 Boating accident 43682008 Near drowning 87970004 Holiday resort 257636005 Medical helicopter 32472009 Resuscitation 439569004 Trauma center 36125001 Accident emergency 394576009 On admission 278307001 Unconscious 418107008 • No history of diabetes • Father has cataract • Hip replacement is planned for next month
  8. 8. Natural language processing
  9. 9. Natural language processing
  10. 10. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support
  11. 11. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support
  12. 12. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support
  13. 13. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support
  14. 14. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support 14
  15. 15. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support
  16. 16. Snomed CT • Is the most comprehensive, multilingual clinical healthcare terminology in the world • Allows very granular data capture that can be viewed at any other level of granularity • Allows powerful analytics & decision support 16
  17. 17. Let us see how it is better than existing healthcare coding systems Let us compare it with ICD-10 17
  18. 18. More clinical terms
  19. 19. Codes for Ectopic Pregnancy in ICD-10 • ICD-10 has five codes (terms) only • Abdominal • Tubal • Ovarian • Others • Unspecified
  20. 20. 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
  21. 21. Multiple ‘ancestors’
  22. 22. ICD-10 classification system has a problem Look at how Pneumonia is classified
  23. 23. Pneumonia is all over the place! Section Code Title Infectious 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
  24. 24. Viral pneumonia Infectious disease of lung Lower respiratory tract infection Disorder of lung Disease Viral infection Infective pneumonia Viral respiratory infection Viral disease Infectious disease Poly-hierarchy in SNOMED CT
  25. 25. 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
  26. 26. 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
  27. 27. Snomed CT has no limits on the codes that can be used No sharing of codes by two different conditions
  28. 28. 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
  29. 29. Will SNOMED CT replace ICD-10? Yes & No • Clinical modules & analytics would benefit from SNOMED CT • The medical records departments will continue ICD-10
  30. 30. Let us look at the nuts & bolts of SNOMED CT
  31. 31. These are four different conditions (clinical ideas) 1. Ischemic heart disease 2. Angina 3. Unstable angina 4. Myocardial infarction 5. Heart attack 6. Cardiac infarction 7. MI Same clinical meaning (idea) Each clinical idea is called a concept
  32. 32. Each concept has a (near) random concept number 1. Ischemic heart disease 414545008 2. Angina 194828000 3. Unstable angina 4557003 4. Myocardial infarction 5. Heart attack 6. Cardiac infarction 7. MI Same clinical meaning (idea) 22298006
  33. 33. 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 infarction 5. Heart attack 6. Cardiac infarction 7. MI Same clinical meaning (idea) 22298006 - infarto de miocardio
  34. 34. Independent system of classification Concept Concept ID Ischaemic Heart Disease 414545008 Angina 194828000 Unstable Angina 4557003 Myocardial Infarction 22298006 Heart Attack 22298006 Cardiac Infarction 22298006 MI 22298006
  35. 35. In independent system of classification Concept Concept ID Ischaemic Heart Disease 414545008 Angina 194828000 Unstable Angina 4557003 Myocardial Infarction 22298006 Heart Attack 22298006 Cardiac Infarction 22298006 MI 22298006 Myocardial disease Myocardial necrosis Necrosis of an anatomical site
  36. 36. 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
  37. 37. How do multiple relationships help? Cellulitis of foot Disorder of foot Cellulitis of lower limb Is a child of…Is a Understanding the logic part of SNOMED CT Very powerful analytics
  38. 38. Multiple types of relationships Cellulitis of foot Disorder of foot Cellulitis of lower limb CellulitisFoot structure Is aIs a Associated morphologyFinding site
  39. 39. Cellulitis of foot Disorder of foot Cellulitis of lower limb CellulitisFoot structure Is aIs a Associated morphologyFinding site Cellulitis of toe Cellulitis of heel Is a Is a
  40. 40. Cellulitis of foot Disorder of foot Cellulitis of lower limb CellulitisFoot structure Is aIs a Associated morphologyFinding site Cellulitis of toe Cellulitis of heel Is a Is a Toe structure Finding site Cellulitis Associated morphology Is a
  41. 41. Cellulitis of foot Disorder of foot Cellulitis of lower limb CellulitisFoot structure Is aIs a Associated morphologyFinding site Cellulitis of toe Cellulitis of heel Is a Is a Toe structure Finding site Heel structure Finding site Cellulitis Associated morphology Cellulitis Associated morphology Is a Is a
  42. 42. Cellulitis of foot Disorder of foot Cellulitis of lower limb CellulitisFoot structure Is aIs a Associated morphologyFinding site Cellulitis of toe Cellulitis of heel Is a Is a Toe structure Finding site Heel structure Finding site Cellulitis Associated morphology Cellulitis Associated morphology List me all foot problems Is a Is a
  43. 43. Cellulitis of foot Disorder of foot Cellulitis of lower limb CellulitisFoot structure Is aIs a Associated morphologyFinding site Cellulitis of toe Cellulitis of heel Is a Is a Toe structure Finding site Heel structure Finding site Cellulitis Associated morphology Cellulitis Associated morphology List me all patients with cellulitis Is a Is a
  44. 44. Associated morphology = Cellulitis* Cellulitis of foot Cellulitis of foot excluding toe Cellulitis of forearm Cellulitis of forehead Cellulitis of gingiva Cellulitis of groin Cellulitis of hand Cellulitis of hand excluding finger Cellulitis of head Cellulitis of heel Cellulitis and abscess of lower leg Cellulitis and abscess of lower limb Cellulitis and abscess of neck Cellulitis and abscess of nose (external) Cellulitis and abscess of perineum Cellulitis and abscess of shoulder Cellulitis and abscess of submandibular region Cellulitis and abscess of temple region Conditions with the word “Cellulitis” within it *Partial data
  45. 45. Associated morphology = Cellulitis* Cellulitis of foot Cellulitis of foot excluding toe Cellulitis of forearm Cellulitis of forehead Cellulitis of gingiva Cellulitis of groin Cellulitis of hand Cellulitis of hand excluding finger Cellulitis of head Cellulitis of heel Cellulitis and abscess of lower leg Cellulitis and abscess of lower limb Cellulitis and abscess of neck Cellulitis and abscess of nose (external) Cellulitis and abscess of perineum Cellulitis and abscess of shoulder Cellulitis and abscess of submandibular region Cellulitis and abscess of temple region Beat knee Chronic recurrent streptoccocal erysipelas Cutaneous erysipeloid Disseminated cutaneous erysipeloid Erysipelas Erysipelas of lower limb Erysipeloid Facial erysipelas Localized cutaneous erysipeloid Ludwig's angina Onychia of finger Phlegmon Postpartum AND/OR puerperal erysipelas Recurrent erysipelas Seal finger Conditions with the word “Cellulitis” within it Conditions even without the word “Cellulitis” *Partial data
  46. 46. 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
  47. 47. How is it used in a hospital’s EMR?
  48. 48. The hospital’s EMR software Snomed CT Record services (EMR) Terminology services (Snomed CT) Patient Ram Lal, age 56, admitted with a diagnosis of Herni Hernia Inguinal hernia Indirect inguinal hernia Indirect inguinal hernia with obstruction
  49. 49. Leveraging relationships We can show all the SubType concepts of E in the operation list of a foot surgeon Operations on the foot
  50. 50. SubTypes (All descendants) Operations on the foot Foot joint operations Foot incision Division of muscle of foot Tenotomy of abductor hallucis muscle
  51. 51. How will clinicians benefit from it? The drawbacks of current coding system that are addressed by SNOMED CT
  52. 52. 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
  53. 53. No abbreviations in ICD-10 • The doctor may search by typing • COPD • MI • IHD
  54. 54. 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
  55. 55. 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
  56. 56. 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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