Provides an overview of how using SNOMED CT in EHR can increase the usefulness of the clinical data contained in them

1. SNOMED CT
– THE LANGUAGE FOR
EHR
Dr SB Bhattacharyya
MBBS, MBA, FCGP
Member, National EHR Standardisation Committee, MoH&FW, GoI
Member, Health Informatics Sectional Committee, MHD 17, BIS
Hony. State Secretary (2015), IMA Haryana
President (2010 – 2011), IAMI

2. Electronic Health Record
■ A longitudinal record of the health of an individual sequentially
arranged from the very first medical record to the very latest
■ Consists of all health-related records like
– Medical Records – treatment and discharge summaries
– Immunisation Records
– Investigations (Laboratory & Imaging) Results & Reports
– Prescriptions
– Physician Notes
– Health Worker Notes
2Dr SB Bhattacharyya©

3. Records – why keep them?
■ For reuse
– As a source of historical data & information
– Information exchange among providers
– To anticipate future health problems
– As a record standard preventive measures
– To identify deviations from the expected
– As basis for clinical research – trials and observational
■ As legal evidence
3Dr SB Bhattacharyya©

4. Semantic Interoperability
■ Patient is having active tuberculosis
■ Patient had tuberculosis in the past that has since been successfully treated
■ The two statements above are significantly different as is the treatment to be
administered
Dr SB Bhattacharyya© 4

5. Case summary
During early spring, a 45 year old male presented with complaints of fever
accompanied by a runny nose, cough without expectoration along with feeling of
malaise and generalised body ache for the past one day. There were no other
complaints although the patient kept on insisting that he had “cold”.
The patient had a past history of infection with Koch’s bacilli for which he
successfully underwent ATT. In family history, both his parents and his two siblings
– elder brother and sister – all suffer from NIDDM.
On examination he was found to have an oral temperature of 38°C, bilaterally
clear chest, normal heart sounds, doughy feel of abdomen, liver and spleen not
enlarged, and plantar reflex negative. Based on the findings, a clinical diagnosis
of seasonal influenza was made.
Dr SB Bhattacharyya© 5

6. Case summary
He was advised CBC, RBS, CXR, Mantoux Test, and Urine RE/ME. He was
prescribed oral form of acetaminophen 500mg stat and PRN, oral form of
diphenhydramine hydrochloride 25mg 8 hourly for three days, plenty of fluids
orally and bed rest.
He reported back with his test reports the next day stating that he was feeling
better. All investigation results and reports were unremarkable, except his RBS
was 200 mg/dL. He was advised to consult a diabetologist without delay,
complete his medications and report back only if fresh problems arose.
There were no further follow-ups by the patient for this particular episode.
Dr SB Bhattacharyya© 6

7. Pertinent Questions
■ When the patient said he had “cold”, what exactly was he trying to say?
■ What is infection with “Koch’s bacilli”?
■ How accurate was the clinical diagnosis? How likely was this diagnosis to have
turned out to be a laboratory diagnosis should the appropriate tests based on
evidence based medicine have been run?
■ Did the patient require to undergo all the tests as advised, particularly given the
fact that most were “unremarkable”, or could some of them been safely avoided
without risking the patient?
■ Were any investigation or further examination missed?
■ Based on his previous history of Koch’s infection and concomitant strong family
history of NIDDM, did he merit more aggressive treatment with antibiotics?
Dr SB Bhattacharyya© 7

8. Pertinent Questions
■ Was there any delay in referring the patient to a diabetologist, particularly in view of the
fact that he had such a strong family history of NIDDM and that he was already 45 years old?
Was it also alright to test him only for RBS or should Fasting Blood Sugar, Postprandial Blood
Sugar and Test for Glycosylated Haemoglobin tests should additionally have been carried out
before referring?
■ What do these acronyms ATT, CBC, RBS, CXR, RE/ME, and NIDDM actually mean?
■ Was the treatment plan the right one for the patient or could it have been designed better
and that too just for him?
■ Could the answers to the questions above been made available while the patient was sitting
in front of the doctor?
■ Was it wise to have suggested to the patient that he did not need any further follow-ups for
this complaint unless any fresh problems arose?
■ What if this clinical summary needs to subsequently be read in Spanish by someone who
does not know a word of English? Can this be done without any loss in meaning?
Dr SB Bhattacharyya© 8

9. To effectively address these…
■ Semantically interoperable standardised clinical vocabulary
needs to be used
■ Currently (2016), SNOMED CT fits the bill best
■ So, what is SNOMED CT?
■ Since April 2014 India is a member of IHTSDO
■ This entitles any one in India – EHR/EMR vendors and their users –
to access and use SNOMED CT for free within the country
Dr SB Bhattacharyya© 9

10. SNOMED CT
■ SNOMED CT stands for Systematized Nomenclature of Medicine –
Clinical Terms
■ SNOMED is now an acronym
■ Owned, maintained and distributed by IHTSDO
■ IHTSDO stands for International Health Terminology Standards
Development Organization
10Dr SB Bhattacharyya©

11. SNOMED CT
■ Based on the concept-based approach, SNOMED CT considers
every clinical term to relate to a clinical concept like fever,
which
– is a body temperature above reference range, and
– interprets body temperature
■ SNOMED CT is a semantically interoperable polyhierarchical
subtype multi-lexical clinical terminology system that is able to
deliver robust benefits to the health care services
11Dr SB Bhattacharyya©

12. SNOMED CT
■ It is the richest vocabulary currently available to describe clinical
findings, diseases, procedures, etc.
■ Contains more than 300,000 concepts, more than 1 million
descriptions and more than 900,000 relationships (July 2014
International Release).
■ SNOMED-CT aims at transmitting all concepts that have been
expressed throughout history in the healthcare domain,
unambiguously.
12Dr SB Bhattacharyya©

13. SNOMED CT
■ Provides clinical content and expressivity for clinical
documentation and reporting.
■ Used to code, retrieve, and analyze clinical data.
■ The terminology is comprised of concepts, terms and
relationships with the objective of precisely representing
clinical information across the entire spectrum of health care.
13Dr SB Bhattacharyya©

14. SNOMED CT
■ Concepts are defined using the meronomic “IS-A” sub-type
relationships
■ Concepts are also additionally defined using the “HAS-A”
attribute type relationships
■ Example: Fracture of tarsal bone (disorder)
– | IS A | Fracture of foot (disorder)
– “has a” FINDING SITE of Bone structure of tarsus (body
structure)
– “has a”(n) ASSOCIATED MORPHOLOGY of Fracture
(morphologic abnormality)
14Dr SB Bhattacharyya©

15. Myocardial Ischemia is fully defined
as…
■ | IS A | myocardial necrosis
■ | IS A | ischemic heart disease
■ | IS A | myocardial disease
■ | IS A | necrosis of anatomical site
■ | HAS A |
– associated morphology = infarct “AND”
– finding site = myocardium structure
15Dr SB Bhattacharyya©

16. Supports Synonyms Aplenty
■ Myocardial infarction
■ Cardiac infarction
■ MI – Myocardial infarction
■ Heart attack
■ Infarction of heart
■ Myocardial infarct
16Dr SB Bhattacharyya©

17. Few more SNOMED CT Examples…
■ Disease
– Diabetes mellitus
■ | is a | disorder of endocrine system
■ | is a | disorder of glucose metabolism
■ Procedure
– Percutaneous transluminal angioplasty (procedure)
■ | is a | Transluminal angioplasty
■ | is a | Catheter procedure
■ | is a | surgical repair procedure by device
17Dr SB Bhattacharyya©

18. 18
Cellulitis of Foot
Is a
Disorder of foot
Cellulitis of lower limb
Has a
Associated morphology
=
Cellulitis
Finding site
=
Lower limb structure
Dr SB Bhattacharyya©

19. Pain in upper limb
Is a
Finding of sensation of upper
limb
Pain in limb
Has a
Finding site
=
upper limb structure
19Dr SB Bhattacharyya©

20. Electronic Encounter Record
HISTORY: Present Illness
Add Another Investigations Diagnosis Treatment
CloseCancel Clear Redo Save Draft
St. Somewhere Clinic
Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 01 (New)
Unique ID: 9991 2345 6789 Allergies: No Known Allergies (NKA) Primary Physician: Dr X Y Zed
Chief Complaint Search for chief complaints
Accompanied By Search for conditions
Followed By Search for conditions
And By Search for conditions
Relieved By Search for interventions
Accompanied By Search for interventions
20Dr SB Bhattacharyya©

21. Electronic Encounter Record
Investigations TreatmentHistory
Diagnosis Type DiagnosisSearch for diagnosis types Search for diagnosis
Primary Diagnosis
CloseCancel Clear Redo Save Draft
St. Somewhere Clinic
Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 01 (New)
Unique ID: 9991 2345 6789 Allergies: No Known Allergies (NKA) Primary Physician: Dr X Y Zed
Interpretation: Diagnosis
Diagnosis Type Search for diagnosis types
Diagnosis
Secondary Diagnosis
Search for diagnosis
21Dr SB Bhattacharyya©

22. Treatment type Treatment Route of administration
Medication Tablet Chloroquine Phosphate 250mg Oral
Medication Table Primaquine Phosphate 15 mg Oral
Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 01 (New)
Unique ID: 9991 2345 6789 Allergies: No Known Allergies (NKA) Primary Physician: Dr X Y Zed
Search for treatment
Add Another Investigations DiagnosisHistory
Electronic Encounter Record
CloseCancel Clear Redo Save Draft
St. Somewhere Clinic
Treat with
Treatment
22Dr SB Bhattacharyya©

23. Investigation Results
Investigation Result
Peripheral blood smear examination, light
microscopy
Confirmed presence of Plasmodium vivax
Plasmodium falciparum was absent
Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 03
Unique ID: 9991 2345 6789 Allergies: No Known Allergies (NKA) Primary Physician: Dr X Y Zed
History Diagnosis Treatment
Electronic Encounter Record
St. Somewhere Clinic
CloseCancel Clear Redo Save Draft
23Dr SB Bhattacharyya©

24. Investigation Results
Investigation Result
Peripheral blood smear examination, light
microscopy
Confirmed presence of Plasmodium vivax
Plasmodium falciparum was absent
Patient Name: Mr A Bee Cee Age: 25 years Gender: Male Episode: 09 Encounter: 03
Unique ID: 9991 2345 6789 Allergies: No Known Allergies (NKA) Primary Physician: Dr X Y Zed
History Diagnosis Treatment
Electronic Encounter Record
St. Somewhere Clinic
CloseCancel Clear Redo Save Draft
24Dr SB Bhattacharyya©

25. Electronic Encounter Record
HISTORY: Present Illness
CloseCancel Clear Redo Save Draft
St. Somewhere Clinic
Patient Name: Ms B Cee Dee Age: 55 years Gender: Female Episode: 39 Encounter: 01 (New)
Unique ID: 9999 8765 4321 Allergies: Allergic to Penicillin Primary Physician: Dr Em No
What is the Complaint? Search for complaints
Go
User enters “Pain” here…
25Dr SB Bhattacharyya©

26. In clinical medicine, “Pain”…
■ Is associated with an anatomical site (body structure) or it may
be generalised like a body ache
■ Has sensation quality, aka “character”, like “aching”, “burning”,
“colicky”, “dull”, etc.
■ Can have a pattern like “acute”, “chronic”, “constant”,
“diffused”, etc.
■ Can have severity like “mild”, “moderate”, “severe”, etc.
■ Can be induced (precipitated / brought on) by certain
aggravating factors that may be one to several
■ Can be relieved (made to go away) by certain methods including
administration of medication
26Dr SB Bhattacharyya©

27. Pain [contd.]
■ It can also be associated with the following:
– This could be the very first time ever the patient has
experienced such a sensation in the affected body part or it
could a recurrent phenomenon
– It will have a clinical course like “gradual onset”,
“cyclical”, “non-progressive”, etc.
■ Other than some clinicians who deal with pain findings either on
a regular basis or often enough, it can safely be assumed that
most will fail to note and consequently not capture all the
details associated with pain. EHR systems using SNOMED CT can
consequently help all clinicians in this regard irrespective of the
care setting, specialisation or ability and experience thereby
improving quality of care overall.
27Dr SB Bhattacharyya©

28. Electronic Encounter Record
CloseCancel Clear Redo Save Draft
Details of Pain
St. Somewhere Clinic
Patient Name: Ms B Cee Dee Age: 55 years Gender: Female Episode: 39 Encounter: 01 (New)
Unique ID: 9999 8765 4321 Allergies: Allergic to Penicillin Primary Physician: Dr Em No
Add Aggravating Factors Add Relieving Factors
Associated with Search for body structure
Sensation quality Search for pain sensation quality
Pattern Search for pattern of pain
Severity Search for severity
Occurrence Search for occurrence
Clinical Course Search for clinical course
28Dr SB Bhattacharyya©

29. Add Add Relieving Factors
Aggravating Factors
<none entered yet>
Aggravating Factor
Patient Name: Ms B Cee Dee Age: 55 years Gender: Female Episode: 39 Encounter: 01 (New)
Unique ID: 9999 8765 4321 Allergies: Allergic to Penicillin Primary Physician: Dr Em No
Electronic Encounter Record
CloseCancel Clear Redo Save Draft
Details of Aggravating Factors of the Pain
St. Somewhere Clinic
Search for aggravated by observable entity
29Dr SB Bhattacharyya©

30. Relieving Factors
<none entered yet>
Relieving Factor
Electronic Encounter Record
CloseCancel Clear Redo Save Draft
Details of Pain Relieving Factors
St. Somewhere Clinic
Patient Name: Ms B Cee Dee Age: 55 years Gender: Female Episode: 39 Encounter: 01 (New)
Unique ID: 9999 8765 4321 Allergies: Allergic to Penicillin Primary Physician: Dr Em No
Add Add Aggravating Factors
Search for pain characterised by relieving factor
30Dr SB Bhattacharyya©

31. How relationships help in data query
31Diagram courtesy IHTSDO Dr SB Bhattacharyya©

32. Benefits of Using SNOMED CT in EHR
■ Analyse every part of a record: from history to treatment
■ Support for
– Conducting outcomes research
– Evaluating the quality and cost of care
– Designing effective treatment guidelines
■ Providing more easily accessible and complete information
pertaining to the health care process (medical history, illnesses,
treatments, laboratory results, etc.), thereby resulting in
improved patient outcomes
■ No challenge in migrating from one version to another – it is
seamless and most often an automated process
32Dr SB Bhattacharyya©

33. Introduction to SNOMED CT
by Dr SB Bhattacharyya available at
■ http://www.amazon.com/Introduction-SNOMED-CT-S-B-
Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269681&sr=8-
1&keywords=introduction+to+snomed+ct – hardcopy only
■ http://www.amazon.in/Introduction-SNOMED-CT-2016-
Bhattacharyya/dp/9812878939/ref=sr_1_1?ie=UTF8&qid=1453269722&sr=8-
1&keywords=introduction+to+snomed+ct – hardcopy only
■ http://www.springer.com/gp/book/9789812878939 – ebook and hardcopy
■ http://link.springer.com/book/10.1007/978-981-287-895-3 – chapter-wise
online access only
33Dr SB Bhattacharyya©

34. sbbhattacharyya@gmail.com
34Dr SB Bhattacharyya©