Convergence of U.S. and U.K. medical terminologies nears
By BETTY GASCH
Healthcare InfoTech Contributing Writer
As Saturday’s opening session of the TEPR ’99 (Toward an Electronic Patient Record) conference in Orlando nears, news releases already sent out indicate that TEPR will be an important gathering for many. Just last week, the College of American Pathologists (CAP) announced an agreement that calls for the development of a new work that combines CAP’s SnoMed RT nomenclature with Version 3 of the Read Codes. The Read Codes are the United Kingdom’s National Health Service (NHS) nomenclature of healthcare terms and the most comprehensive terminology used throughout the U.K. SnoMed is the most inclusive terminology nomenclature used in the U.S.
Kent Spackman, MD, scientific director for SnoMed (Northfield, IL), said 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." Spackman added that such terminology "supports a convergence of meaning that spans languages and national borders."
This agreement is a major step in the movement toward a common international computerized medical language for use worldwide. The new effort will continue to have broad-based clinical input as it combines the robust nature of SnoMed RT and its emphasis on specialty medicine with the richness of the Read Codes for primary care. SnoMed RT and the Read Codes will continue to exist separately until the new work is well-established. The initial efforts of the joint development have begun and the project is expected to be completed by the end of 2001.
SnoMed RT and the Read Codes are defined as multi-dimensional, structured clinical terminology for electronically coding the medical record. The structure of clinical terminology standardizes clinical terms, which allows the easy transmission of patient-related data across diverse and incompatible information systems. The purpose of standardization is to enable healthcare practitioners and professionals as well as institutions to collect and analyze data, to compare the quality of healthcare being practiced, to develop treatment guidelines and to conduct outcomes research. The fine granularity of these back-end vocabularies make them ideal for coding the computer-based patient record (CPR). SnoMed has focused on specialty medicine, while the Read Codes have emphasized primary medicine.
SnoMed RT, the current version of SnoMed, is the fruit of a collaborative effort between the College of American Pathologists and Kaiser Permanente’s (Oakland, CA) Convergent Medical Terminology (CMT) Project, as well as other major medical associations. SnoMed RT’s current strategic alliances include the American Veterinary Medical Association, the American Dental Association, the American College of Radiology, the American Medical Association, the Logical Observation Identifier Names and Codes, the National Library of Medicine, the National Center for Health Statistics and the American Academy of Ophthalmology. As of February, SnoMed was in the negotiating stages of associating with the European Society of Gastrointestinal Endoscopy, the American Dietetic Association and the American Nurses Association.
SnoMed stands for the Systematized Nomenclature of Medicine. Version 3.5 was released to the marketplace in August of 1998 and contains 156,965 terms and codes. SnoMed RT is an international relational terminology and knowledge base that is currently out in beta version. It contains 11 distinctive modules or axes. The unique features of SnoMed RT are the non-ambiguity of the meaning of terms, which was made possible because of the incorporation of multiple hierarchies, semantic definitions and compositional syntax.
Practically speaking, all of this means that SnoMed RT is able to map medical terms across multiple axes and also to synthesize medical terms using specific vocabulary. The example used in the handout provided by the CAP is the coding of tuberculosis of the pleura. The diagnosis is assigned a code number in the infectious diseases axis, but is cross-referenced to the topography (a compilation of anatomic terms) hierarchy and receives a code number there as well. It is given a third code number to denote the mycobacterium tuberculosis hominis organism (and mapped to the axis containing "organisms"). The depth and usefulness of this fine granularity coding becomes apparent when a clinical researcher wants to know the number of disease conditions of the pleura or how many cases of tuberculosis have been diagnosed in the past year, for example.
The robustness of the vocabulary is useful for eliminating synonymous terminology in coding. For example, the synonymous meanings and mapping of the terms "increased body temperature" and "fever, pyrexia, hyperthermia and febrile." Any of these terms would be retrieved if a clinician requested, for example, the number of febrile cases following any surgical procedure within the past six months. The ease of retrieval for quality control as well as for research should be apparent. The focus of SnoMed has primarily been specialty/acute care medicine.
SnoMed is a not-for-profit division of the College of American Pathologists. CAP is the largest medical society composed exclusively of pathologists. SnoMed is being used in more than 25 countries and version 3.5, which was released in August 1998, contains 156,965 terms and term codes.
The Read Codes, the U.K. comprehensive, hierarchically arranged, nomenclature of terms had their origins in primary care in the early 1980s. At that time, Dr. James Read, then a full-time general practitioner, developed a set of simple codes for his first computer in order to record conditions that presented frequently in his practice. In 1990, the Read Codes were purchased by the U.K.’s National Health Service and have since become the national standard. They have been primary care and physician focused and are cross-referenced to the ICD-9-CM and OPCS-4 diagnostic and procedural codes (used in the U.K.).
Informal surveys have shown that anywhere from 5% to 90% of primary care physicians use computers in the U.K.. The discrepancy is the result of the definition of the term "computerization." It is likely that 90% of all U.K. physicians have a computer in their office and use the same for accounts and scheduling, but do not use the computer for much else. In all probability, the 5% of the physicians represented in the survey are the number who take the computer beyond the basics to the research and quality control levels. It is this 5% who will be interested in the convergence of SnoMed and the Read Codes. Physicians in England, Wales, Scotland and Northern Ireland have adopted the Read Codes, and New Zealand has obtained a national license for the use of Read Codes across all healthcare sectors.
The Read Codes cover such axes as occupations, signs and symptoms, investigation diagnoses, treatments and therapies, drugs and appliances operative and non-operative procedures, prospective care, lab and radiology procedures and administration.
The significance of this movement toward a common international computerized nomenclature is that it brings all of the different clinical information in a computerized system together and allows clinicians to communicate in a language that makes sense. This is true within national borders and among clinicians who speak the same language. The possibilities grow enormously when the scope of thinking expands to include a number of nations and practitioners who speak varying languages. Think of the potential for the containment of diseases such as the HIV virus, tuberculosis and other common problems of humanity coded in a universal nomenclature and set of codes. While it is true that especially the international medical community has a long way to go before the application of any code is used for prevention or control of disease, it is essential that the initial steps be taken. The convergence of SnoMed and the Read Codes is an important early stride.
The degree to which the various vendors realize this and see the benefit of buying into this work rather than continuing to create incomplete subsets of it in their products, reflects their commitment to open systems. It is simply too expensive for every vendor to duplicate this work and in fact, they cannot do so. Therefore, those who adopt this nomenclature coding on the back end will offer superior products to those who continue to promote their own proprietary solutions.
Companies that have adopted a front-end, interface nomenclature such as Oceania’s (Palo Alto, CA) Notes or Medicomp’s (Chantilly, VA) Medcin will have an excellent foundation in which to incorporate this new SnoMed/Read back-end nomenclature when it becomes available.
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