Statement
of the
College of American Pathologists
to the
National Committee on Vital and Health Statistics
Workgroup on Computer-based Patient Records
Presented by
Kent A. Spackman, MD, PhD, FCAP
May 17, 1999

Introduction

I am Kent Spackman, MD, PhD, Associate Professor of Pathology and Medical Informatics at the Oregon Health Sciences University. Today I am here representing the College of American Pathologists (CAP) where I serve as the Scientific Director of the SNOMED International. On behalf of the CAP, I thank you for the opportunity to appear before the National Committee on Vital and Health Statistics’ Workgroup on Computer-based Patient Records.

Since my appearance before you last year, the CAP has embarked upon several initiatives aimed at advancing the role of SNOMED® as a national reference terminology for patient health information:

• First, the CAP continues to expand the functionality of SNOMED and has begun beta testing of the next generation reference terminology, SNOMED RT.
• Second, the CAP is pushing ahead on its vision of a global terminology. To that end we have entered into an agreement with the National Health Service of the United Kingdom to merge SNOMED and the READ Codes.
• Third, the CAP has further opened up the SNOMED governance and editorial processes to reflect broader stakeholder participation.
• Finally, the CAP has begun the process to become recognized as an ANSI accredited standard.

We believe these actions, taken together, represent significant advancement of SNOMED as the reference terminology to support the patient medical record, worldwide. At a later point in my comments I will elaborate on each of these initiatives.

I offer the following comments in response to the specific questions presented to us for your consideration today.

Patient Medical Record Information

In the current health care environment, characterized by evidence-based medicine, there is an increasing need for patient medical record information that fulfills several key requirements: accessibility and therefore electronic; lifelong, integrating information from a variety of caregivers over time; shareable, while retaining meaning across providers and researchers worldwide; and of sufficient clinical detail in order to document care, assess the quality of services provided to patients and evaluate the outcomes associated with specific medical interventions.

Given the information need of the current healthcare environment, it is essential that Patient Medical Record Information (PMRI) contain sufficient clinical detail to provide a complete and accurate description of a patient’s entire health care history over the life of the patient. PMRI should also be flexible enough to address research questions of varying levels of detail. The patient medical record structure, therefore, should consist of: demographic information (race, age, sex, occupation); family history; social history; past medical history; medications history; history of current illnesses; and documentation of encounters (e.g. chief complaints, subjective findings such as signs and symptoms, objective findings such as lab tests and x-rays, assessment, treatment plan).

The ability to use the information contained in the patient medical record to make appropriate clinical interventions is solely dependent on the accuracy and comparability of the information and the detail of the information included. Comparable and accurate PMRI has implications for both individual patient care and epidemiological studies/research on groups of patients. In terms of individual patients, comparable and accurate PMRI allows multiple and interdisciplinary providers to communicate in a consistent manner about a patient’s health care process. Ideally, improved information sharing among providers will facilitate improved patient outcomes and contribute to improved continuity of patient care. For groups of patients, comparable and accurate PMRI facilitates research applications by allowing for population-based epidemiological studies that provide the foundation for future healthcare decisions, treatments and regimens.

The patient medical record has tremendous potential to serve as an effective tool for case management, clinical decision support, evidence-based medicine and research. In order to achieve these results, however, there needs to be in place a uniform acceptable reference terminology that accurately represents PMRI, allowing for timely access to and retrieval of information.

A reference terminology provides a shared understanding across all healthcare providers and all healthcare settings. Standardized reference terminologies remain central to our ability to gather clinical information consistently for patient care, to retrieve information for disease management or research, as well as to conduct outcomes analysis for quality improvement.

Overview of SNOMED and Its Role in Representing the PMRI

SNOMED, the Systematized Nomenclature of Medicine, is a comprehensive, multiaxial nomenclature created for the indexing of the entire medical record, including clinical findings, etiologies and interventions. As a reference terminology, SNOMED allows for consistent gathering and transmitting of detailed clinical information, retrieval of information for disease management or research and performance of outcome analysis for quality improvement.

The compositional nature of SNOMED and its hierarchical systematized structure transforms the notion of coded vocabulary into a powerful tool for applications such as telemedicine, outcomes analysis, cost-effectiveness studies, and practice guidelines. Its unique design will allow for the full integration of all medical information in the electronic medical record into a single data structure. Independent studies have demonstrated SNOMED to be the most complete reference terminologies in existence today for the clinical environment.1,2

The CAP’s over 30 year commitment to the development and maintenance of SNOMED has resulted in a rich reference terminology that extends well beyond pathology. SNOMED is intended to facilitate access to clinical information wherever it is needed across the globe, whenever it is needed (day or night), by whomever has legitimate need and authorization to use patient medical record information. We believe that SNOMED enables providers of various specialties, researchers and even patients themselves to have a common understanding of a patient’s condition and health care process across sites of care. Therefore, SNOMED is appropriate for all healthcare settings.

SNOMED Market Acceptance

SNOMED is used both domestically and internationally for a variety of applications by a diverse group of users. SNOMED’s uses are numerous and include: mapping technologies, standardization of clinical terminologies, standardization of clinical reports, encoding of medical concepts, transmission of normalized data, infectious disease reporting, coding of emergency room encounters, article search and retrieval, outcomes assessment and coding of adverse drug reactions in clinical trials. SNOMED licenses include information systems developers, managed care organizations, community hospitals, mulit-hospital systems, payer provider hospital systems, medical libraries, insurance companies, research entities and government agencies (e.g. Department of Veteran’s Health Administration and Centers for Disease Control and Prevention).

For example, SNOMED is used by all Columbia HCA’s anatomic pathology laboratories as the core vocabulary for coding tissue samples, test results and cancer reports. In addition, Kaiser Permanente, the nation’s largest non-profit health maintenance organization, has chosen SNOMED as the core clinical reference terminology for its National Computerized Information System (NCIS), a project to enable the various Kaiser systems in different regions to communicate. Even in the U.K. SNOMED is used almost exclusively to encode the pathology record.

Each day brings inquiries of new uses of SNOMED. For instance, we are starting to see interests by radiologists in using SNOMED for encoding radiological images to facilitate retrieval.

SNOMED has also obtained widespread international recognition. It is currently used in nearly 40 countries (Appendix A).

SNOMED Initiatives

The CAP is committed to the continuing development of a worldwide clinical reference terminology. To this end, we are pleased to announce several initiatives aimed at enhancing SNOMED’s structure, used and acceptance.

Improved Functionality: SNOMED RT

A new generation of SNOMED, SNOMED RT, is currently undergoing rigorous beta testing by thirty institutions and vendors including Mayo Clinic, 3M Health Information Systems and Oceania. SNOMED RT combines the granularity and comprehensiveness of SNOMED terms and term codes with improved clarity of meaning and analytic power (Appendix B). SNOMED RT’s enhancements include:

• Over 110,000 concepts linked to clinical knowledge;
• More than 180,000 terms, each with unique computer readable codes, reflecting contemporary clinical practices; and
• An excess of 260,000 explicit relationships between terms that enables one to retrieve a case based on any of a variety of criteria (e.g. disease hierarchy, anatomic relationships).

During the testing phase, SNOMED RT will be applied to a wide variety of applications including clinical documentation and decision support, HEDIS reporting, cancer research, data warehousing and disease management. SNOMED RT is expected to be released in Fall 1999.

We believe that SNOMED RT’s multiple hierarchies and explicit semantic definitions will enable providers and researchers to retrieve and aggregate data more completely and consistently and therefore benefit more directly from complete, accessible information.

A Global Vision: CAP/NHS Agreement

The CAP has recently entered into a collaboration with the United Kingdom’s Secretary for Health on behalf of the National Health Service Executive (NHS) to combine SNOMED RT and Version 3 of the Read Codes, the NHS thesaurus of health care terms (Appendix C). The agreement will create a new international approach for computerizing scientific terms that physicians, nurses, and other health professionals use for the effective management of patient records and medical communication. The new work will combine the strengths of the two existing terminologies: the robust strength of SNOMED RT in specialty medicine, including pathology, and the richness of Read Codes Version 3 (also known as Clinical Terms V3) in primary care.

SNOMED RT and Clinical Terms V3 will continue to exist separately until the new work is well established. The CAP and the NHS will work closely with physicians, system suppliers, government agencies, and end-users to make a smooth transition from their current vocabularies to the new work, which is scheduled for availability by the end of 2001.

The merger of the two works will decrease duplication of effort, while at the same time, create the most comprehensive language of health and provide an essential building block for a common computerized medical language for use around the world.

Greater Stakeholder Input: Expansion of SNOMED Governance and Editorial Processes

It is important to note that within the CAP a separate division, SNOMED International, oversees the daily administration and maintenance of SNOMED. The intent is that SNOMED will reflect the ongoing needs of contemporary clinical practice across specialties.

The maintenance of SNOMED occurs through an open process allowing for broad input of all stakeholders. In the CAP’s continuing effort to increase broad-based input into the development and maintenance of SNOMED, the SNOMED Editorial Board has recently been expanded to include representatives from the NHS. Also, at our request the Department of Veteran’s Health Administration and the Department of Health and Human Services have agreed to send liaisons to serve on the SNOMED Editorial Board. The SNOMED Authority, the governance body within the CAP for SNOMED, has also been expanded to include representatives with experience in enterprise wide implementation of clinical systems, the needs of the global market and international standards setting activities.

The expansion of the SNOMED governance and editorial processes attest to the CAP’s commitment to develop a clinical reference terminology useful for a multiplicity of users across various sites.

Furthermore, SNOMED International will maintain its not-for-profit status but will eventually become self-sufficient. The CAP is committed to widespread availability and access to SNOMED with minimal cost and restrictions.

ANSI Accreditation

We are in the process of submitting SNOMED for ANSI accreditation by the canvass method. The application reinforces the CAP’s commitment to the open, multidisciplinary approach used to make enhancements to the reference terminology.

For example, as outlined in our application, working groups of the SNOMED Editorial Board, such as the Convergent Terminology Group for Nursing. The purpose of the SNOMED Convergent Terminology Groups is to advise the SNOMED Editorial Board regarding scope of coverage, creation of hierarchies and semantic terminology definitions, and scientific accuracy of concepts and terms.

Another issue addressed in our ANSI application is the creation of a web site that will enable users to make on-line requests and suggestions for term additions with feedback guaranteed within a specific time frame. The CAP is also in the process of developing a set of well-defined editorial principles and policies for working with professional specialty organizations.

We believe that ANSI accreditation of SNOMED will further encourage the broader adoption of SNOMED worldwide.

SNOMED’s Relationship to Other Medical Terminologies and Healthcare Message Format Standards

SNOMED is the core reference terminology that links with other medical terminologies. SNOMED is currently mapped to ICD-9-CM codes to facilitate health reporting and statistical analysis. This mapping has provided one point of reference for the coding of disease categories. A mapping of SNOMED terms to CPT-4 has begun in collaboration with the American Medical Association and the National Library of Medicine. SNOMED also contains a set of concepts and codes that fully support compatibility with MEDDRA, the Medical Dictionary for Drug Regulatory Affairs.

The CAP is a member of the Health Level Seven (HL7) and actively contributes to the coordination of HL7 messaging standards and SNOMED content. The HL7 vocabulary committee has voted to recommend SNOMED as one of the approved vocabularies for use in HL7 messages.

The Digital Imaging and Communications in Medicine (DICOM) Standard is a complete specification of all the elements required to achieve interoperability between biomedical images, imaging systems and the associated text, measurements, and waveforms to be exchanged electronically from one site to another. In 1996, the CAP’s alliance with DICOM fostered the formation of the SNOMED DICOM Microglossary (SDM). Developed at the request of the American College of Radiology, using SNOMED as the foundation, the SDM provides a context-sensitive controlled terminology for the clinical specialties that perform or depend upon diagnostic imaging procedures.

Medical Terminology Issues Requiring Government Intervention

Both in the U.S. and abroad there is growing recognition and support for standards related to medical terminologies. In the absence of such standards, terminologies having limited scope and direction have been developed to address emerging issues. The government can play a critical role in testing and improving medical terminologies as well as in fostering collaboration among developers.

First, the government could use its role as a provider of health care services to adopt and require standardization in their own health care initiatives for clinical decision making and support systems in federally funded healthcare initiatives. An example of such an initiative is the Government Computer-based Patient Record (GCPR) framework, where a common reference terminology can be applied across the DOD, VA and Indian Health Service. Other examples of government healthcare initiatives include public health cancer and chronic disease reporting by CDC or NIH, adverse event reporting to the FDA, Medicare risk adjustment data and Medicare managed care reporting of HEDIS measures.

Second, the government can help to facilitate the coordination between the various interlocking medical terminologies and facilitate the interface between the end users, developers of the software systems and the developers of the terminologies. Such was proposed at the recent CPRI Terminology II conference regarding the interface between SNOMED, the drug database vendors and HL7 messaging. Collaboration among developers is essential in order to decrease redundancy across different systems and users in order to increase resource efficiency.

Finally, the government might consider providing financial incentives to providers for submitting government requested public health data in electronic form. This would help ally the individual practitioner’s interest with that of the interests of the national health.

Issues Related to Comparability of PMRI and Government Intervention

In most information systems today, the data gathered for and entered into the patient medical record is not comparable, thereby minimizing the ability to share patient information, conduct appropriate patient monitoring and make appropriate quality assessment determinations. Furthermore, because most information systems rely on paper-based clinical encounter data, retrieving patient information can become a very inefficient costly and time consuming process not in keeping with the needs of today’s healthcare environment. This creates a problem in the ability to use PMRI for there is no one common, agreed upon terminology used to represent all of the information.

The government can facilitate comparable patient medical record information by adopting standardized clinical reference terminogies for the computer-based patient record to allow a common representation of patient medical record information. We believe that providing a recommendation along these lines to Secretary Shalala is well within the purview of the NCVHS.

Conclusion

In closing, the CAP would again like to stress that in order to keep pace with the current and future healthcare information needs, detailed clinical information in the patient medical record must be available whenever it is needed, wherever it is needed, by whomever has a legitimate right to that information. Central to the ability to access patient medical record information and use it to its fullest potential for patient care monitoring and quality assessments is the need for standardized reference terminologies. SNOMED is the most complete reference terminology in use today that captures all aspects of the patient medical record in an electronic format. The government should consider the valuable contribution that it can make to the adoption of consistent reference terminologies by its own example. We believe that an electronic patient medical record will ultimately strengthen the future health information infrastructure and the health of our population in the years ahead.

Thank you.

References

1. Chute C, Cohn S, Campbell K, Oliver D, Campbell JR. The content of coverage of clinical classifications. JAMIA. 1996;3:224-33.
2. Campbell R, Carpenter P, Sneiderman C, Cohn S, Chute C, Warren J. Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions and clarity. JAMIA. 1997;4:238-51.

Appendix A

Countries Using SNOMED

Japan	Chile
Sweden	China
Switzerland	Austria
New Zealand	Ireland
France	Norway
Turkey	Poland
Argentina	Hungary
Portugal	South Korea
Israel	Iran
Spain	Singapore
Netherlands	Scotland
Malaysia	Russia
Finland	Australia
Greece	England
Germany	Wales
Belgium	South Africa
Canada	Brazil
Scotland
Taiwan

Appendix B

Appendix C

News Release:

SNOMED® RT AND READ CODES TO BE COMBINED INTO AN INTERNATIONAL TERMINOLOGY OF HEALTH

Joint development agreement by the College of American Pathologists and United Kingdom’s Secretary of State for Health

(Northfield, IL) The vision of a unified international terminology that supports the integrated electronic medical record was advanced by the announcement of a historic collaboration between the College of American Pathologists (CAP) and the United Kingdom’s Secretary of State for Health on behalf of the National Health Service Executive (NHS). The agreement calls for the development of a new work that combines SNOMED® RT, the CAP’s Systematized Nomenclature of Medicine, with Version 3 of the Read Codes, the NHS thesaurus of health care terms.

"The agreement will create a new international approach for computerizing scientific terms that physicians, nurses, and other health professionals use for the effective management of patient records and medical communication," said Kent Spackman, MD, PhD, SNOMED Scientific Director. "Such terminology supports a convergence of meaning that spans languages and national borders."

This agreement signals a major milestone for the international medical community. The CAP and the NHS both have current vocabularies that have been heralded as leaders in clinical terminology. The merging of the two works will decrease duplication of effort and create the most comprehensive language of health. When brought to fruition, the new work will provide an essential building block for a common computerized medical language for use around the world.

The new work will continue to have broad-based clinical input, physician involvement and support. It will combine the strengths of the two existing works: the robust strength of SNOMED RT in specialty medicine, including pathology, and the richness of Read Codes Version 3 (also known as Clinical Terms V3) in primary care.

SNOMED RT and Clinical Terms V3 will continue to exist separately until the new work is well established. The CAP and the NHS and will work closely with physicians, system suppliers, government agencies, and end-users to make a smooth transition from their current clinical vocabularies to the new work, which will be available by the end of 2001.

"The College recognizes the importance of terminology for the future of health care including administrative simplification, outcomes research, and telemedicine," noted CAP president Thomas P. Wood, MD. "As an advocate of high quality and cost-effective patient care, the CAP has made a firm commitment to ensure SNOMED’s continued acceptance for the encoding of the computerized patient record."

Speaking in London, Great Britain’s Minister for Health, Lady Hayman said, "To meet our commitment to providing electronic patient records for everyone in this country, our clinicians need a common, agreed language for use in creating the records. We believe that this agreement with another world leader in the field will further support our goal."

SNOMED RT is the CAP’s comprehensive, structured concept-based reference terminology supporting clinical data capture, retrieval, analysis, and electronic messaging. Used for electronic medical records, outcomes analysis, and clinical decision support in more than 25 countries, SNOMED captures, in a consistent way, the complexities of medicine across the broad spectrum of health care specialty areas.

The College of American Pathologists (CAP) is a medical society serving nearly 16,000 physician members and the laboratory community throughout the world. It is the world's largest association composed exclusively of pathologists and is widely considered the leader in laboratory quality assurance. The CAP is an advocate for high quality and cost-effective patient care.

In 1990 The National Health Service Executive established the National Health Service Center for Coding and Classification (NHS CCC) as part of the Information Management Group to develop the clinical terms. In 1996, the Center also became the United Kingdom’s Joint World Health Organization (WHO) Collaborating Center for International Classification of Diseases (ICD). It provides advice and support to the NHS on use of information to support patient care.

Contact:

For CAP in US: Gail Cowan 847-832-7439 or Shari Shane 314-552-6717

For NHS in UK: Chris Horner 001-44-113-254-5606