SNOMED - 5-Step Briefing

1) Introduction

SNOMED CT:

Is the most comprehensive, multilingual clinical healthcare terminology in the world
Is a resource with comprehensive, scientifically validated clinical content
Enables consistent representation of clinical content in electronic health records
Is mapped to other international standards
Is in use in more than eighty countries

The SNOMED CT clinical terminology has unmatched depth, enabling clinicians to record data with enhanced accuracy and consistency. SNOMED CT remains a growing and evolving product made better by the Community of Practice.

SNOMED CT supports the development of comprehensive high-quality clinical content in electronic health records. It provides a standardized way to represent clinical phrases captured by the clinician and enables automatic interpretation of these.

Clinical breadth of SNOMED CT

SNOMED CT it is not just a coding system of diagnosis. It also covers other types of clinical findings like signs and symptoms. It includes tens of thousands of surgical, therapeutic and diagnostic procedures. It includes observables (for example heart rate), and also includes concepts representing body structures, organisms, substances, pharmaceutical products, physical objects, physical forces, specimens and many other types of information that may need to be recorded in or around the health record.

The comprehensive scope of SNOMED CT reduces the need to support multiple incompatible or overlapping code systems in the same health record system. This means SNOMED CT can become the common terminology for consistent communication, retrieval and processing across clinical specialties and between health care facilities at local, national and international levels.

2) Benefits

SNOMED CT based clinical information benefits individual patients and clinicians as well as populations while supporting evidence-based care.

The use of an electronic health record improves communication and increases the availability of relevant information. If clinical information is stored in ways that allow meaning-based retrieval, the benefits are greatly increased.

The added benefits range from increased opportunities for real time decision support to more accurate retrospective reporting for research and management.

Benefits to individuals

SNOMED CT enabled clinical health records benefit individuals by:

Enabling clinical information to be recorded consistently
Enabling support systems to check the record and provide real-time advice
Supporting the sharing of appropriate information with others involved in delivering care, allowing the understanding of the information in a common way by all providers
Allowing accurate and comprehensive analysis that identifies patients who require follow-up or changes of treatment
Removing language barriers – SNOMED CT enables multilingual use

Benefits to populations

SNOMED CT enabled clinical health records benefit populations by:

Facilitating early identification of emerging health issues, monitoring of population health and responses to changing clinical practices.
Enabling accurate and targeted access to relevant information, reducing costly duplications and errors.
Enabling the delivery of relevant data to support clinical research and contribute evidence for future improvements in treatment.
Enhancing audits of care delivery with options for detailed analysis of clinical records to investigate outliers and exceptions.

Supporting evidence-based healthcare

SNOMED CT enabled clinical health records support evidence-based care by:

Enabling links between clinical records and enhanced clinical guidelines and protocols.
Enhancing the quality of care experienced by individuals.
Reducing costs of inappropriate and duplicative testing and treatment, limiting the frequency and impact of adverse healthcare events.
Raising the cost-effectiveness and quality of care delivered to populations.

3) How does SNOMED CT work?

The SNOMED CT logical model defines the way in which each type of SNOMED CT component and derivative is related and represented.

The core component types in SNOMED CT are concepts, descriptions and relationships.
Our model specifies how the components can be managed in an implementation setting to meet a variety of primary and secondary uses.

Concepts

Every concept represents a unique clinical meaning, which is referenced using a unique, numeric and machine readable SNOMED CT identifier. The identifier provides an unambiguous unique reference to each concept and does not have any ascribed human interpretable meaning.

Descriptions

Two types of description are used to represent every concept – Fully Specified Name (FSN) and Synonym. The FSN represents a unique, unambiguous description of a concept's meaning. This is particularly useful when different concepts are referred to by the same commonly used word or phrase. Each concept can have only one FSN in each language or dialect.

A synonym represents a term that can be used to display or select a concept. A concept may have several synonyms. This allows users of SNOMED CT to use the terms they prefer to refer to a specific clinical meaning.

Relationships

A relationship represents an association between two concepts. Relationships are used to logically define the meaning of a concept in a way that can be processed by a computer. A third concept, called a relationship type (or attribute), is used to represent the meaning of the association between the source and destination concepts. There are different types of relationships available within SNOMED CT.

4) How is SNOMED CT used?

SNOMED CT itself is only a part of the solution to addressing the requirements for effective electronic health records. A terminology on its own 'does nothing'. To benefit from use of a clinical terminology, it must be implemented and used as part of an application.

The design of the software application in which it is used, and the objectives and motivation of its users, are key factors in determining success.

SNOMED CT is critical for clinical documentation, as it supports the representation of detailed clinical information in a way that can be processed automatically.

Realization of the capability of SNOMED CT to support clinical information and meaning based retrieval requires careful consideration of the actual setting, in terms of scope of use, record structure, data entry, data retrieval and communication.