Transcript ISD Terminology Service - University of Edinburgh

Harnessing Clinical
Terminologies and
Classifications for Healthcare
Improvement
Janice Watson
Terminology Services Manager
11th April 2013
Why do we need terminologies
and classifications in healthcare?
• Clinical coding underpins the analyses for creating
Scottish national healthcare intelligence reporting – it
facilitates aggregation and comparison – you can
count it
• Without accurate clinical coding our analyses would
be flawed
• Without accurate analyses we cannot support
effective decision making to improve patient care
The Information Process
Acute Care – the Scottish Morbidity
Record (SMR)
SMR records are SUMMARY records of hospital encounters
• Patient admitted - procedures performed & diagnosis made
• Clinician writes up case notes and discharge summary
• Clinical coders translate clinical text into coded information using
coding rules and SMR definitions
• Coded information is entered into hospital’s Patient Administration
System by coders, extracted into SMR format, validated and
transferred to national data warehouse
• Information analysed – national reporting
• Information used for policy making, performance management,
healthcare planning and costing, research and epidemiology in
order to improve Scotland’s health and healthcare
Which systems do we use?
Classifications
• ICD10 (WHO owned) ~12,000 codes – used to record morbidity and
mortality. International use
• OPCS4 (UK) for recording clinical interventions – from assessment to
transplants ~ 8,000 codes
Both of the above are used to describe in-patient activity
Terminologies
• Read Terminology (V2 UK based) ~ 80,000 terms
Used in Primary Care systems
• SNOMED CT – international -not widely used in Scotland yet ~ 400,000
terms
Not used widely in Scotland yet but expected to be used in future
Benefits to patients
• Shared clinical meaning can help to improve continuity of
care e.g. facilitating safe transfer of clinical information
between primary and secondary care
• Services can be compared and contrasted and
benchmarked against national standards to promote
better patient care
• Patients with given conditions and risk factors can easily
be identified for proactive anticipatory care – e.g.
currently developing extensions to ICD10 coding system
to improve identification of patients with specific types of
myocardial infarction and heart failure; SPARRA tool can
be used to identify patients at risk of readmission
Problems and Issues
Classifications
•
•
•
•
Structured with rules – easier to compare and analyse
Not good at incorporating up-to-date clinical language
Not designed to record routine clinical care
Require an understanding of coding rules and dependent on getting
the right information from the patient record
• Perception that secondary use information not a clinical priority
Terminologies
• Good at incorporating up-to-date clinical language
• Could be used to record routine clinical care in fine detail
• Electronic based – can embed in systems and record at point of care
by clinicians
• Too many choices and no rules – hard to compare
• Systems not sufficiently developed to constrain choices
• Difficult to aggregate and analyse
Cross maps help but require clinical verification
Future Developments
• New services for research purposes – secure area and
validation processes to allow researchers access to
anonymised national data for research purposes and a
new support service for researchers (eDRIS)
• Integration of health and social care data and expansion
of analytical services to support other public bodies
• New GP extraction service to utilise national primary care
information
• Our name is changing – amalgamation of ISD with Health
Protection Scotland to form the Public Health and
Information Services Strategic Business Unit (part of
National Services NHS Scotland)
Terminology Services
• Terminology and classification training, advice and support
to coders, analysts, clinicians etc
• Terminology and classification maintenance (e.g.
developing terms for new national vaccination programme
and managing ICD10 update nationally)
• Communications and publications (e.g. publication of
Scottish Clinical Coding Standards to promote more
consistent coding practice)
http://www.isdscotland.org/terminology
Clinical Coding helpdesk operates Tues-Thursday 9am-5pm
Tel 0131-275-7283 or email [email protected]