Transcript Context and Benefits

SNOMED Standards Development
Organisation
College of American Pathologists
National Health Service
Connecting for Health
The SNOMED Standards
Development Organization
• Presentation 1: Content {suggested by CEN}
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What is this about?
Why a terminology?
Why SNOMED CT?
What will SNOMED NOT do?
• Presentation 2: Organisation & Governance
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What exactly is being proposed?
What are the finances?
What are the governance arrangements?
Why this arrangement
MORE DETAIL ON CD & IN PACK
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Presentation 1: Content
• Special Thanks
– Kevin Donnnelly and colleagues
– Kent Spackman
– Ian Arrowsmith
– Mike Cooke
– Grant Kelly
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The SNOMED SDO:
What is this about?
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Data exchange / messaging
Terminology standards
Document standards
Information Model / EHR standards
– Architecture standards
– Application standards
ABOUT ONE OF THE KEY STANDARDS TO
SUPPORT INTEROPERABILITY OF EHR’S
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The SNOMED SDO:
What is this about?
• An international effort to produce and
enhance a global clinical terminology
standard
• An organization supporting that effort
• A set of products and services produced
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The SNOMED SDO:
What is this about?
• Scope of SNOMED CT UK Release [Core plus
UK {local} extension]
• Size (as of Jan 2005 UK Edition)
–414,808 health care concepts
–1,084,972 descriptions
–1,465,255 semantic relationships
• English, German and Spanish language editions
• Cross mappings (ICD-10, OPCS 4.2)
• Extensions (UK Admin, UK Drugs)
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The SNOMED SDO:
What is this about?
• FROM
– Proprietary [CAP]
owned
– Single enterprise
– USA placed
– License based
– Not for profit
• Business Model
• TO
– Publicly owned
– Globally and locally
responsive
– Swiss placed
– ‘Fair share’
subscription based
– Not for profit
• Business Model
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The SNOMED SDO:
Why a terminology?
Classifications
Back office {populations}
ICD, OPCS (NIC)
Group similar conditions
Exclusion categories
Statistical analysis
Policy and strategy driven
Codes
Hierarchies
Slow change [years]
Terminologies
Front office {citizens/patients}
Read codes, SNOMED
Individual conditions
Exclusion categories “avoided”
Records and communication
Care and safety driven
Codes
Hierarchies
Rapid change [days to weeks]
Maps to classifications
CLASSIFICATIONS AND TERMINOLOGIES HAVE
DIFFERENT PURPOSES
Why a terminology? Precision
K50
K51
K52
Crohns disease
Ulcerative colitis
Other non-infective gastroenteritis & colitis
K52.0
Gastroenteritis and colitis due to radiation
K52.1
Toxic gastroenteritis and colitis
K52.2
Allergic & dietetic gastroenteritis and colitis
K52.8
Other specified non-infective gastroenteritis and colitis
K52.9
Non-infective gastroenteritis and colitis unspecified
Excludes:
Colitis, diarrhoea, enteritis, gastroenteritis
Unspecified in countries where the condition can be
assumed to be of infectious origin
Functional diarrhoea
Neonatal diarrhoea
Psychogenic diarrhoea
Why a terminology? Accuracy
K50
K51
K52
Crohns disease
Ulcerative colitis
Other non-infective gastroenteritis & colitis
K52.0
Gastroenteritis and colitis due to radiation
K52.1
Toxic gastroenteritis and colitis
K52.2
Allergic & dietetic gastroenteritis and colitis
K52.8
Other specified non-infective gastroenteritis and colitis
K52.9
Non-infective gastroenteritis and colitis unspecified
Excludes:
Colitis, diarrhoea, enteritis, gastroenteritis
Unspecified in countries where the condition can be
assumed to be of infectious origin
Functional diarrhoea
Neonatal diarrhoea
Psychogenic diarrhoea
Why a terminology?
Myocardial infarction
Heart attack
Coronary thrombosis
MI
Myocardial infarct
Why a terminology?
Safety
Myocardial infarction
Heart attack
Coronary thrombosis
MI
Myocardial infarct
Mitral incompetence
Medial incisal
Medical language =
ambiguous
Why a terminology?
Reduce ambiguity
PSpinal cord
compression
SCord compression
P Umbilical cord
compression
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Why a terminology?
Reduce ambiguity
PSpinal cord compression
SCord compression
P Umbilical cord compression
SCord compression
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Why a terminology?
Record keeping
– To aid their memory
– To legally document what they saw & did (and
sometimes why)
– To communicate to other members of a team
– To satisfy requirements of protocols & systems
[secondary uses]
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Research protocols
To support and justify reimbursement
Minimum data sets
Professional guidelines
Why do clinicians record patient data?
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Why a terminology?
Record keeping
• Secondary uses of clinical data are any uses other
than the primary purpose [“direct patient care”] for
which the data is recorded
– ICD-9-CM coding for reimbursement can be derived from the
dictated discharge summary, where the primary purpose
may be documentation +/- communication, (not
reimbursement).
– Communicable disease reports to the health department can
be derived from routine lab culture reports, where the
primary purpose is communication to the ordering physician,
(not epidemic detection).
• Currently secondary uses largely involves human
translation from patient record to secondary use data
set
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Why a terminology?
Record keeping
• THE IDEAL
• Record clinical data once
– with fidelity to the clinical situation
• Allow systems to derive needed data from
that single instance of recording
Potential for financial savings and increased
data accuracy
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Why a terminology?
Record keeping
• THE REALITY
• Clinicians find themselves entering the same
basic clinical facts multiple times from slightly
different perspectives for different purposes
• Reimbursement coding skews clinical data
– The level of detail is tuned to optimize
reimbursement
– Sometimes the clinical reality is obscured by
lack of fidelity in the coding options available
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Why a terminology?
Record keeping
• Terminology enables the ideal
• Microbiology laboratories
– positive Salmonella culture
• Reports go to the physician(s) caring for the
patient
• Reports also go to local/state reportable disease
registries
Increasing data accuracy for policy and strategy as
well as individual patient care
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Why a terminology?
Improving clinical care
• Major driver for clinicians
• Example; changing specific patients from one
type of therapy to another
• Search out all patients with Hypertension and/or
cardiac failure who are on high sodium content
antacids
• Convert to low concentration antacid or
alternative therapy
Can only be done with EHR’s with a
terminology and end user query tools
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Why a terminology?
Safety
• Currently data transcribed repeatedly as it
flows through the patient journey
• The Joy Project
– 10 out of 31 patients, 32% underlined a part of their record
as incorrect. The origin of data error was investigated
– 3 out of the 10 errors, 30% were attributed to:
– i) manual data transcription error
– 2 out of the 10 errors, 20% were attributed to:
– ii) poor data entry
– 1 out of the 10 errors, 10% could have been attributed to
either i) manual data transcription or ii) poor data entry.
– 4 out of the 10 errors, 40% were attributed to other factors.
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Why a terminology?
Clinical Innovation
• Safety and Efficacy Register of New
Interventional Procedures {SERNIP}
• New interventions registered with
professional body who ask for SNOMED
concept
• Enables the efficacy, effectiveness, of new
procedures to be monitored and
educational components addressed by
professional bodies
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Why a terminology?
Link to knowledge services
• Knowledge bases can be tagged with a standard
terminology through:
– Automatic tagging software and/or
– Manual highlighting of concepts
• Through appropriate software the clinician can
then access appropriate knowledge for the
precise clinical problem
• It also is a potentially valuable tool for patients
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Why a terminology?
Link to ‘grey literature’ services
• SNOMED enables Reuters to categorise
medical stories and provide information
specific to Client’s interests
• Tagging a story takes ‘less than two
minutes’
• Improved citizen access and clinician
awareness to world health news
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Why a terminology?
Rapid clinical responses
• Health records encoded with a standard
terminology mean that when drug safety
alerts are issued the GP can search out all
their patients on drug x and take
appropriate action
• No unnecessary delays or resource
wastage on hand searching through
records or awaiting patient reactions
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Why a terminology?
Decision support
• Reminder and recall service for cervical
screening and immunisation
• Drug-drug interaction
• Drug- clinical condition interaction
• Investigation- clinical condition interaction
eg pacemaker in situ and Magnetic
Resonance Image scans
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Why a terminology?
Clinical Audit
• Part of professional practice to maintain
registration in UK
• Is the reality of practice meeting current
levels of knowledge
• Example: Have all the patients taking the
drug Amiodarone had their Thyroid
function measured?
Use of terminologies in EHR’s greatly
enables clinical audit
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Why a terminology?
Payment on clinical outcomes
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General Practitioners in England currently paid
on the quality of their care through 21 rule sets
Basis is Read Codes plus published evidence
eg National Institute of Excellence {NICE}
Example: Indicator ASTHMA 8: The
percentage of patients aged eight and over
diagnosed as having asthma from 1st April
2006 with measures of variability or
reversibility.
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Why a terminology?
Sharing the record with the patient
Headline: 'Hospital that forgot to tell nurse she had cancer'
Sub-headline '£100, 000 for woman who thought she had
escaped illness'
'Doctors failed to tell a nurse they suspected she had breast
cancer for two years.
Jayne Muir 50 discovered their suspicions only from reading
about it in her medical notes.
A mammogram had shown she could have cancer.......by the
time she was diagnosed the cancer had spread dramatically'
Page 23; 29th October 2005: Daily Mail Julie Weldon Science Correspondent
Sharing records is easier with EHR’s encoded
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with a terminology; Two new UK projects
Why SNOMED CT?
• Directly supports
– Representation & queries based on
meaning
– Computable tracking of historical
relationships of retired codes
• Indirectly supports
– Specification of user interface
– Definition of minimum data sets, checklists,
and data collection standards
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Why SNOMED CT?
• Provides a common representation
• Independent of how the data was recorded:
– natural language
• e.g. English, French, Spanish, ...
– terms
• e.g. craniopharyngioma, Erdheim tumor, pituitary adamantinoma,
Rathke's pouch tumor
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data sets
information system interface
implementation details
type of site
type of user
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Why SNOMED CT?
• First rule of coding: Yesterday’s data should be
usable tomorrow
• Non-Hodgkin’s lymphoma histologic type
– Classification has been changing
– More than 25 different classifications have been
published since 1925
– Major classifications in past 30 yrs:
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Rappaport
Working Formulation
Kiel
REAL
WHO
SNOMED CT Manages Obsolescence
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Acute lymphoblastic leukemia
ICD-O-2
Acute lymphoblastic leukemia
L1
M-98213
M-98283
L2
M-98263
L3
ICD-O-3
Acute lymphoblastic leukemia
Precursor B cell leukemia M-98363
Burkitt cell leukemia
M-98263
SNOMED history table contains two rows:
M-98213 REPLACED-BY M-98363
M-98283 REPLACED-BY M-98363
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Why SNOMED CT?
Subsets
• A collection of terminology, selected and grouped
for a particular purpose
• May be composed of anything from a single
component to the entire set of concepts,
descriptions or relationships
• Commonly needed for:
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–
–
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Data quality improvement
Message field validation
Simplified data entry and retrieval
Elimination of ‘noise’
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Why SNOMED CT?
Subsets
• Subsets are an integral part of SNOMED CT
– SNOMED CT is a large, rich and complex resource
• The subset mechanism provides a consistent way to
make this rich content manageable
• Subsets assist implementation of appropriate, usable, and
consistent interfaces through which users can access relevant
concepts
• Subsets allow clear and concise expression of value-set
constraints for data entry and communication specifications
• The SNOMED CT subset mechanism provides a published
common form for representation of subsets
• This allows
– A vendor neutral distribution format for subsets
– Opportunities for alternative collaborative tooling to create
and manipulate subset to meet global, national and local
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needs
Why SNOMED CT?
Subsets
• Devolved responsibility
• National control
• Provide effective tools:
– Simple to use and individually configurable to allow subsets to
be created/edited with the minimum of effort (including
tutorials)
– Ability to set permissions/rights to allow viewing and/or editing
rights
– Workflow elements
– The tool must support multiple synchronous users
– To support the distributed working environment it must
be possible to undertake all of the above processes over
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the www
Why SNOMED CT?
Team Based Care {UK view}
4 Byte set
Version 2
CTV3
SNOMED CT
primary care
clinical summary
acute sector
clinical summary
all sectors
specialist & generalist
full clinical record
all sectors
specialist & generalist
full clinical record
multi-national
Why SNOMED CT?
• Most comprehensive terminology
– Humphreys BL et al JAMIA 1997;4:484-500
• Scores higher than alternatives on independent
multidimensional evaluation
– Ref provided in pack
• Dynamic twice yearly releases
• Multiple hierarchies for consistent retrieval and
analysis
• Cross referenced to multiple classifications
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What will SNOMED NOT
do?
• How far does a SNOMED CT take us
towards being able to use secondary
data?
– Permits common reference points for
meaning
– With appropriate history mechanism, sustains
the value of previously recorded data
– Does not (independently) solve the problem of
data collection / data entry
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What will SNOMED NOT
do?
• It will not on its own solve the professional
data input challenges of accuracy
• Who is responsible for defining professional
standards of data quality?
– Will professional specialty organizations step up to
the challenge?
• What clinical data is essential?
– Who decides so that clinicians are not overburdened?
• How can support and incentives be provided to
clinicians?
SNOMED CT can act as a support tool to
these bodies
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What will SNOMED NOT do?
• It will not solve your legacy data and
legacy system problems BUT will offer
some help through mappings
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What will SNOMED NOT do?
• It will not on its own solve the secondary
use dilemma
– The value of secondary data accrues (mainly)
to parties other than those who collect it
– The value of secondary data depends on its
quality, while the quality of data is directly
proportional to the care with which it is
collected
SNOMED CT does enable the dilemma to be
mitigated
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This is the problem?
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In conclusion….
• SNOMED CT (in the NHS) will facilitate the sharing of
electronic patient records to provide clinical support
across all care settings
• SNOMED CT is part of the solution,
not part of the problem…..
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Presentation 2
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The SNOMED Standards
Development Organization
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•
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•
•
The Value Proposition
Context and Benefits
Governance and Structure
SSDO Financial Model
Technology Environment
Code of Conduct and Benefit Summary
Process for Moving Forward
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The Value Proposition
What is the
SNOMED Terminology?
• Documents describing the SNOMED CT
standards and specifications
• The terminology database consisting of
– Concepts, Descriptions, Relationships
• Technical tools to support development
and request processing
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What is the
SNOMED Terminology?
• SNOMED allied standards
– Enabling SNOMED CT to effectively
interoperate with other international
information standards
• Implementation standards for the
successful use of SNOMED CT, including
– Translations
– Reference implementation instructions
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Why a Clinical Terminology?
Costs
• Terminology use benefits the entire
healthcare system
– Save as much as 5% of total healthcare costs*
– Up to €84 Billion per year in US
* Source - Walker J et al., Market Watch 2005:19th January;10-18
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Why the SNOMED Terminology?
• Validated Product
• Leading Global Terminology
• Ready for Local Implementation
• €84 million already invested in SNOMED CT
SNOMED CT should become the
Global Clinical Terminology
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Why Adopt SNOMED CT?
High cost and delays to develop alternatives
• Estimated cost to create an alternative:
– €21 to €46 million to develop a terminology
– €7 to €8 million per year to maintain and support
– End-user costs increase as software vendors must
support two competing terminology standards
• Development would take up to five years,
delaying national EHR adoption
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Why Adopt SNOMED CT?
Avoid the costs of delaying data migration
• Safe data migration to SNOMED CT will cost
– Data Conversion
– Clinician Re-Training
• Total cost for the UK:
~ €375 per citizen
~ € 24 per citizen
~ €24,000 million
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Why Adopt SNOMED CT?
Avoid the huge harm of not migrating data
• Without Data Migration to SNOMED CT
– Injuries
– Deaths
~ 832 / 100,000 citizens
~ 20 / 100,000 citizens
• For UK: Injuries
Deaths
~ 490,000 (3% of beds)
~ 12,089♦
♦ Source: British Medical Journal, Jul 2004; 329: 15 – 19 (prescribing harm only)
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Why Join the SNOMED SDO?
Commercial Benefits
• Costs are minimal compared to €84+ million to
implement an Electronic Patient Record system
• Fees are affordable and costs are shared among
members according to their ability to pay
• Fees will reduce as additional members join
• HIT investment risks are significantly reduced
• Protect your Healthcare IT investment now
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Why Join the SNOMED SDO?
Sustainable Governance
• Validated Product
• Sustainable Model
• Shared Ownership
• Code of Conduct
• Localization Support
• Simple Licensing
• Global Collaboration
• Vendor Engagement
• Compatible with
Other Standards
• Clear Management
Processes
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Context and Benefits
The SNOMED SDO Proposal
• Create a Governance Structure that will
– Increase international acceptability
– Provide a stable financial foundation
– Allow SNOMED CT to achieve its potential
• The Proposed Solution
– Transfer SNOMED CT to a SNOMED
Standards Development Organization, which
will be jointly controlled by its member nations
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Vision Statement
The SNOMED CT® Standard
Necessary for international interoperability,
conformance and decision support
– Managed by the SNOMED® SDO
– Encourages uptake and collaboration
– Allows local needs to be met
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New SNOMED Enterprise Model
National
SNOMED
Centre
National
SNOMED
Centre
SNOMED
SDO
National
SNOMED
Centre
Local/National
Health Entities
National
SNOMED
Centre
Shared technology environment enables collaboration
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SNOMED SDO: Principles
• Purpose
– Support clinical care of patients internationally
• Integrity
– Ensure clinical and technical integrity
• Funding
– Stable and secure governance structure
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Governance and Structure
Governance and Structure
• SSDO Membership
• SNOMED SDO Structure
• SSDO Support Organization
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Global Membership,
Global Outlook
Europe
The Americas
Africa and the Asia and Oceania
Middle East
Representation Based on Four Global Regions
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SSDO Full Members:
Charter Members
• Full Members at SSDO Formation
– Signatories to SSDO Heads of Agreement
• Benefits
– Participate in design of the final SSDO
structure and its creation
– Select initial Management Board
– Select initial committee chairs
– All benefits of Ordinary Members
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SSDO Full Members:
Ordinary Members
• Full Members after SSDO Formation
• Benefits
– Rights to distribute and use Core content and
standards within territory
– Eligibility for Board and Committee seats
– Equal voice in SSDO decision-making
– Access to SSDO technology environment
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Other Membership Types:
Affiliate Members
• Organization or Individual Membership
– Non-government and non-commercial
– Not located within a Full Member’s territory
• Benefits
– SNOMED CT licence for personal, noncommercial or research purposes only
– Participation in SSDO working groups
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Other Membership Types:
Vendor Members
• Commercial Membership
– Any commercial organization, including
healthcare providers and software vendors
• Benefits
– May license SNOMED CT for commercial use
in non-Full Member territories
– Membership in Vendor Forum
– Participation in SSDO working groups
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SNOMED SDO Structure
Harmonisation
Boards
Content
Committee
Management Board
Technical
Committee
Research &
Innovation
Committee
Vendor Forum
Finance &
Operations
Committee
Support Organisation
Working
Groups
Working
Groups
Research
Teams
Task & Finish
Groups
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Management Board
• Executive Authority of the SSDO
– Primary decision-making group
– Upholds the Vision and Principles
• Membership
– 12 members and Chair serving 3 year terms
– Only SSDO Full Members eligible
– 3 seats allocated to each of 4 global regions
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Board Committees
• Content
– Editorial Responsibility for the Core
• Technical
– Leads SSDO Technical Strategy
• Research and Innovation
– Develops SSDO Research Strategy
• Finance and Operations
– Monitors SSDO Operations and Activities
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Other Groups: Vendor Forum
• Representing SSDO Vendor Members
– Meets annually with Management Board with
agenda determined by Vendors
– Consults on strategic and practical issues
– Sends one representative to each Board
Committee (excluding Finance)
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Other Groups:
Harmonisation Boards
• International SDO Collaboration
– Established between the SSDO and some
other Standards Development Organization
– SSDO representatives must include the Board
Chair or Deputy and one Executive Officer
– Creates an Allied Standard for interoperability
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SSDO Support Organization
• CAP to act as SSDO Support Organization
– Leverages unique knowledge and skills
– Three-year contract with annual renewal
– Contract initially guaranteed for five years
– Budgets based on current best estimates
– Year-end reconciliation of actual costs
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SSDO Support Organization
• Handles All SSDO Operations
– Employs SSDO Executive Officers
– Develops and maintains the Core content
– Manages the shared technology environment
– Supports the Board and its Committees
– Facilitates member communications
– Provides administrative and professional
services
80
SSDO Financial Model
SSDO Estimated Costs –
Many Nation Model
Cost
• Set-Up SSDO
• Tech Infrastructure *
• Operational Cost †
Year
1
1&2
Annual
Estimate
€0.84m
€8.4m
€8.4m
Notes:
* Year 1 €6.4m, Year 2 €2.0m – majority may be deferred
† Actual cost will be based on actual membership
† Includes €0.84m ongoing capital investment
† Will be subject to small annual indexation
82
SSDO Income:
Full Member Fee Principles
• Joint and fair share responsibility for
operating expenses
• Based on ability to pay
• No advantage to delaying membership
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SSDO Income:
Full Member Fee Principles
• Fees based on World Bank metrics
• Metrics updated with World Bank figures
every three years to allow budgeting
• Additional income may reduce Full
Member fees
– e.g. Management Board may use Joining
Fees from Ordinary Members to reduce
Annual Fees
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SSDO Income:
Full Member Fee Calculation
• National wealth is best metric
• Gross National Income (GNI Atlas)
– GDP plus net flows of income from abroad
– Three-year average of exchange rates to
smooth transitory rate fluctuations
– WB favours it for comparing relative size of
economies
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SSDO Full Member
Annual Fee Calculation
• Based on USA exemplar
• €4,600,000 is current annual US CAP fee
Estimate of Country
Country GNI x €4,600,000
=
Annual Fee
US GNI
Annual Fees available in Heads of Agreement
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SSDO Full Member
Annual Fees – Myth Buster
Nation
• UK
• China
• Korea Rep.
Population
Est. Annual Fee
59m
€766,000
1,296m
€638,000
48m
€256,000
…and Annual Fees will reduce as membership
increases due to high proportion of fixed costs
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Comparing Health Economies
and Estimated Fees
Nation Health Econ.
Health IT
SSDO Fees
• UK
€118Bn*
€4.7Bn†
€0.76m
• US
€1,426Bn‡
€40Bn‡
€4.6m
SSDO fees will be 0.012% to 0.017% of Health IT
* UK NHS budget
† 4% is NHS target spend – source: Wanless Report
‡ Annals of Health Care (US)
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Technology Environment
Vision: Fundamental Principles
for Technology
• Processes Must Drive Technology
– Technology should not determine processes
– Create effective business processes
– Deploy technology to fully support processes
90
Vision: Fundamental Principles
for Technology
• Support the Entire SSDO Membership
– Eliminate or reduce barriers to access
– Accessible and useful to all SSDO members
– Encourage collaboration and cooperation
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Scope:
Requirements and Constraints
• Common Shared Workspace
• Configuration and Workflow Management
• Product Development
• System Access and Performance
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SNOMED SDO Benefits Summary
• Create the global clinical terminology
required for EHR implementation
• Reduce risk by joining committed partners
• Avoid the costs of terminology delay –
billions of dollars and thousands of lives
• Participate in democratic governance
• Share reducing costs on a fair share basis
93