For many years providers have been doing a good job of summarizing their patients’ current and relevant medical conditions on a “problem list”.
Typically this list is located within the first page of a patient’s chart, ideally enabling the medical provider to quickly assess the current and past medical issues of the patient. While the intent is clear, the methodology is not – many providers still using paper charts may use acronyms to express a clinical condition (e.g. MS or AA) or they may not add the date of the diagnosis and/or its resolution. For those providers who utilize EMRs (electronic medical records) the problem may be more complex due to the lack of interoperability between different EMR systems.
Enter Meaningful Use Stage 2 and SNOMED CT
Stage 2 Meaningful Use criteria expands upon the Stage 1 requirements to further improve and utilize healthcare IT and EMRs to provide consistent, collaborative care among different provider groups for any given patient. This means that these electronic systems need to talk to each other and more importantly they need to understand each other. The only way for them to reach this understanding is to speak a common language. Stage 2 of Meaningful Use has defined this language as SNOMED-CT – specifically for the problem list within a patient’s chart.
This is an acronym for Systematized Nomenclature of Medicine – Clinical Terminology. It is recognized throughout the US and internationally, and it is available at no cost through the National Library of Medicine. Using SNOMED-CT enables providers and electronic medical records to communicate in a common language, thus increasing the quality of patient care across many different provider specialties.
SNOMED-CT will also improve the accuracy of patient data analysis. Knowing that a standard medical terminology is being used across the enterprise, and within other hospitals, simplifies the query and resulting report. Users can be confident that they haven’t missed anything in their definition of a diagnosis and rely on a complete report for this patient population.
Sounds simple. Unfortunately, it is far from simple. It is structured into “hierarchies” – 19 of them -- which further define the clinical concept. These hierarchies are then broken down into increasing granularity, resulting in very specific clinical concepts to define a patient’s condition. Whew! We think the ICD-10 coding hierarchy is complex – it’s nothing compared to SNOMED-CT.
I can hear my provider colleagues screaming now. “No! We are already swamped trying to figure out ICD-10! We just want to care for our patients!” The good news is that the industry hears you, and products are available in the healthcare IT market to facilitate the translation of your problem lists into reportable, standardized SNOMED-CT codes. It will be important to ask your EMR vendors how they are handling this Meaningful Use Stage 2 requirement. Many vendors are utilizing “maps” between ICD-10-CM and SNOMED-CT to ensure this goal can be met. The mapping from the ICD-10 code to SNOMED-CT occurs behind the scenes, and is easily retrievable. However, the provider’s time is not affected and the goal for meeting this core requirement of Meaningful Use Stage 2 is ensured.
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SNOMED CT® is a registered trademark of the International Health Terminology Standards Development Organisation (IHTSDO)