Revolution draws near for electronic medical records
The new agreement to make SNOMED CT available nationwide should
improve the quality of patient care and accelerate the move toward
an electronic medical record, but the next steps won’t be
a July 1 conference on the national health care information infrastructure,
Health and Human Services secretary Tommy G. Thompson announced
the $32.4 million, five-year contract with the CAP to license SNOMED
CT as the vocabulary for the exchange of medical information. Starting
in January 2004, any health care facility can license SNOMED CT
through the National Library of Medicine, or NLM, which will administer
the contract. Thompson also said the department had commissioned
the Institute of Medicine to design a standardized model of an electronic
record, to be available next year.
technologies will be available at no cost because we want you to
use them,” Thompson said. “We want to build a standardized
platform on which physicians’ offices, insurance companies,
hospitals, and others can all communicate electronically, which
will improve patient care while reducing the medical errors and
the high costs plaguing our health care system.”
The NLM contract
“is a recognition that SNOMED provides a very important advance
in terminology technology,” says Franklin R. Elevitch, MD,
chair of the SNOMED International Authority and chair of Health
Care Engineering, Palo Alto, Calif. “The journey of a thousand
miles begins with a single step. This was an important step toward
initiative of licensing SNOMED International and recommending terminology
standards will pave the way for people to have the confidence to
invest in EMR technology,” adds Kent A. Spackman, MD, chair
of the SNOMED Editorial Board and professor of pathology and medical
informatics at Oregon Health Sciences University, Portland.
But even with
the weight of HHS behind the initiative to accelerate development
of a universal EMR, barriers remain. Health care institutions, only
about 10 percent of which have EMRs, must devote the resources necessary
to overhaul their information technology systems and adhere to the
standards HHS has laid out.
though the cost of the license [for SNOMED] is a fraction of the
overall cost of an EMR, it had been perceived as the barrier,”
says Dr. Elevitch. “With that removed, people are realizing
that the real costs are time and resources.”
There are cultural
impediments too. “To systematize the way physicians do their
writing and reporting, which has been highly individualized, will
be difficult,” Dr. Elevitch warns. “They’re going
to find as many excuses as possible not to do that.”
Still, experts agree that HHS’ endorsement of SNOMED as a
national health care language and its promise to produce a model
EMR will be catalysts in pushing the health care industry toward
a universal EMR.
“is absolutely essential in creating a universal EMR,”
says John Mattison, MD, assistant medical director of clinical systems
at Kaiser Permanente in Southern California and a consultant to
the SNOMED International Authority. “Currently, all the various
medical record companies use different proprietary technologies,”
making it difficult to aggregate data “without enormous translation
overhead.” With SNOMED, he adds, everyone would have the same
terminology, and transfer of information “will be vastly simplified.”
forecasts that HHS’ support of SNOMED and an EMR “is
a watershed event for the American public” in terms of quality
health care. These technologies will reduce medical errors and result
in higher quality, more cost-effective care by making it easier
for health care systems to discover and implement best practices,
my belief that five years from now, there will be two very different
types of health care organizations: those that embrace SNOMED today
and strategically manage their clinical information to improve care
delivery, and those that don’t,” Dr. Mattison says.
“In 10 years, those that don’t will be out of business.”
he adds, provides two advantages to health care organizations. “One
is being able to analyze your own outcomes and know what works and
what doesn’t,” he says. “The second is being able
to implement decision support that enhances the ability to deliver
and a common EMR, he notes, “it’s very difficult to
apply decision support across data systems that use different terms
and definitions.” This inhibits efforts to improve quality
of care by offering better information about diagnoses and treatment
A recent study
from the Rand think tank concluded that appropriate health care
is delivered only about 55 percent of the time. “Ten years
from now, we need to get that above 80 percent,” Dr. Mattison
says. That will require vastly improved decision-support systems
that guide caregivers to needed interventions.
today most systems have “very primitive alerts and messages”
that tell a physician to check the diabetes patient’s hemoglobin
A1C and find out when the person last had a foot exam.
“Physicians are habituated to this and they’re getting
alert fatigue,” Dr. Mattison says. An EMR could provide a
more sophisticated clinical context for that patient that would
encompass all aspects of care. Kaiser Permanente is committed to
developing an EMR, he says, and is using a turnkey solution from
Epic Systems that intends to incorporate SNOMED.
In five years,
predicts Dr. Mattison, 30 to 40 percent of health care systems will
have EMRs. The reason it will take so long: “Doctors are stretched
thin and don’t have a lot of enthusiasm for taking on a major
new initiative. It’s doable, but it’s tough,”
believes EMR penetration will approach 50 percent in five years.
In that time, “you’ll see significant numbers of hospitals
in the U.S. using a real EMR with SNOMED as the terminology,”
he says. Early adopters will move to the EMR within two to four
As for pathologists
themselves, many departments are still taking a primitive approach
to coding, Dr. Spackman reports. “They code topography and
morphology and detach that for indexing,” he says. “The
main thing that does is to identify a case or two for teaching purposes.”
That function may not even require SNOMED.
of SNOMED CT, Dr. Spackman adds, is that “it will allow people
to start simple and then migrate to more elaborate or technical
solutions.” For example, beyond topography and morphology,
“you may want to know some of the intermediate findings. You
may want to go beyond simple case finding to analyzing an experience
across all cases and multiple departments.” Health systems
may want to improve quality assurance, such as making sure that
all Pap tests with a certain level of dysplasia have appropriate
followup. For these types of sophisticated uses, “you really
need a sophisticated coding system, and that’s where SNOMED
CT shines,” he says.
Like Dr. Spackman,
Dr. Elevitch believes physicians and health care systems will gradually
become convinced of the advantages of moving to SNOMED CT on its
own terms, not just because it can be licensed free from the NLM.
“For pathologists, CT is the next step in digital technology
because it allows them to produce digitized reports incorporating
images and other information,” Dr. Elevitch says. For cancer
centers in particular, this will be important.
1, 2004, the essential data elements of the CAP’s cancer protocols
will become required parts of pathology reports on cancer specimens
at all cancer programs accredited by the American College of Surgeons
Commission on Cancer. The CAP protocols can be implemented more
easily with SNOMED CT, Dr. Elevitch notes.
CT, you have the ability to improve quality through peer review,
including tracking, by linking with clinical outcomes databases,”
he says. SNOMED CT thus “becomes a model for extending surgical
pathology reports in general.”
CT across an institution could reduce the number of unnecessary
tests, improve the quality of care, and save money, Dr. Elevitch
adds. For example, Dr. Elevitch previously worked at El Camino Hospital
in Palo Alto, where “we did peer review using pathology information.”
The information can be tracked much more easily if it’s coded
electronically. “In the daily operation of pathology labs,
CT allows you to access all the records, digital images, and medical
literature in one search,” he says.
and clinicians will have to be educated about the benefits, such
as faster on-line ordering and fewer errors in results reporting.
“The revolution will take time,” Dr. Elevitch says.
“SNOMED CT becomes a tool for sharing information. There really
are silos in the health care organization that technology like CT
can help break down.”
Boston’s Beth Israel Deaconess Medical Center, which is affiliated
with Harvard Medical School and is one of the nation’s premier
teaching hospitals, exemplifies some of the obstacles that the HHS
a general perspective, [the agreement] is a good thing,” says
Bruce Beckwith, MD, director of the critical care lab at Beth Israel.
One deterrent, however, could be that the SNOMED contract lasts
only five years. “If I were going to build a new system, I’d
want to know what assurance I have that this will be around long-term,”
he says. (See the section “Negotiating with the NLM,”
page 8, for the NLM’s response.)
Like many institutions,
Beth Israel is using an older version of the technology, SNOMED
II. “We had looked into upgrading but didn’t have the
money in our budget,” Dr. Beckwith says. For an individual
laboratory, moving to SNOMED CT is not urgent. “What most
people do with SNOMED is code their cases for faster retrieval later
on,” he says, “but you can also do a text-based search
that’s almost as effective.”
SNOMED CT becomes
more compelling, however, if an institution plans to exchange information
with peers. “Once you go to send your reports to someone else,
having SNOMED CT becomes more important,” Dr. Beckwith says.
“If both places are coding with SNOMED, the exchange is much
easier.” Thus, as health care institutions continue to consolidate,
he expects SNOMED CT to gain popularity.
SNOMED CT is
also a great tool for institutions that share information for research
purposes, Dr. Beckwith says. For instance, Beth Israel participates
in a cancer research-sharing cooperative called the Shared Pathology
Informatics Network, or SPIN, funded by the National Cancer Institute.
SPIN intends to get pathology departments in academic centers to
de-identify their cancer tissue reports and make them available
wants to develop a Web-based system where cancer researchers have
access to a large database of pathology information,” he says.
If someone is doing a study on a rare tumor, “they’ll
be able to find cases through the SPIN database.”
that reports be coded in such a way that they all speak the same
language. “SNOMED,” says Dr. Beckwith, “was the
choice of all the pathologists on the project,” which includes
cancer research consortia affiliated with Harvard, the University
of California-Los Angeles, Indiana University, and the University
of Pittsburgh. But the sticking point with SNOMED was the cost and
Under the NLM
agreement, SPIN can obtain SNOMED at no cost and make it available
to anyone who wants to use the cancer database, Dr. Beckwith says.
“One of the points of the project is to use readily available
tools whenever possible,” he adds. “We also wanted to
have minimally restrictive terms on what we use.”
however, that even though the license for SNOMED is free, “it’s
not free to implement because there will be programming costs.”
That may be one deterrent to widespread, immediate adoption. Beth
Israel will probably wait until it upgrades its laboratory information
system before adopting SNOMED CT. “We don’t have any
current plans to do it because of operating limitations in our particular
environment,” Dr. Beckwith says.
As for an electronic
medical record, Beth Israel already has a customized solution. Dr.
Beckwith predicts the hospital will wait to see what HHS produces
as the model before committing to moving in that direction. “License
fees are only one small part of changing technology,” he notes.
Overcoming structural barriers is a much bigger problem.
can jump in
Under the SNOMED agreement, “solution providers now have a
standard around which to mold or reinvigorate their solutions,”
says Jeff Rose, MD, chief medical officer for Cerner Corp., Kansas
City, Mo. The controlled medical terminology that SNOMED provides
“will allow us to use clinical decision support, compare data,
share data sets that have meaning across health plans, all to the
benefit of public and individual health.”
the missing links,” Dr. Rose adds, “has been standard
terminology. The progressive solution providers had to develop their
own.” Now, with SNOMED, “we don’t have to flounder
any more. We have a target. There are incentives to migrate to this
Dr. Rose, who
notes that Cerner has been using SNOMED in its products for years,
says he’s “thrilled” by the HHS decision because
it will make it possible to compare results produced by technologies
from different vendors. “Even within institutions, that has
been difficult,” he says.
Dr. Rose also
welcomes HHS’ endorsement of the HL7 standard and its determination
to release a model for an EMR. “What the government tends
to do is provide the minimum that you should do,” he says,
leaving vendors with room to add on. “The next step is for
the solution providers and institutions to figure out how to use
current agreement extends only to the United States, Dr. Rose believes
other countries will establish SNOMED as the vocabulary for EMRs.
(The United Kingdom has already done so.) “It’s got
a shot at becoming a global standard,” he says.
with the NLM
The NLM, which is part of the National Institutes of Health, had
studied various vocabularies for about a decade, according to Betsy
Humphreys, who, as associate director for library operations at
the NLM, negotiated the contract with the CAP. The NLM and others
had by the mid-1990s identified two candidates—SNOMED and
Great Britain’s Read Codes, she says. Then came the welcome
announcement that the two would be merged. “When they announced
the combined product, that became an obvious candidate for a U.S.-wide
license,” Humphreys says.
The NLM had
already convinced other federal health care agencies, including
the Centers for Disease Control and Prevention, Department of Veterans
Affairs, and Department of Defense, that national licensing of clinical
vocabularies made sense but that it couldn’t stop with the
federal government. “There’s a lot of interaction between
government agencies and private institutions,” such as DoD
contracts with private health care providers. So licensing something
solely for government use would be too limiting, Humphreys explains.
to negotiate for SNOMED was passage of the Health Insurance Portability
and Accountability Act of 1996, which, among other things, recommended
investigating what role the federal government should take in promoting
clinical standards for an EMR.
the CDC had an initiative to share lab data on reportable conditions
using the LOINC (Logical Observation Identifiers Names and Codes)
vocabulary, which is complementary to SNOMED. The NLM licensed LOINC
in September 1999, establishing a pattern for joint federal support
of clinical terminologies.
the CAP in 2000 to initiate the negotiation for SNOMED. “It
took us a long time to reach agreement,” she says, in part
because sole-source negotiations don’t have the built-in deadlines
of competitive ones.
has asked an Institute of Medicine study committee to provide advice
on the EMR, which would serve as a basis for a recommended model
incorporating the technical standard HL7. “This is to move
along having a standard specification for the core of an EMR,”
While the NLM
will provide training in how to use its UMLS (Unified Medical Language
System)Metathesaurus, into which SNOMED will be incorporated by
early 2004, the CAP will continue to offer separate specialty SNOMED
content, tools, and implementation services not covered by the license.
licensees can continue to receive uninterrupted service from the
CAPor move to the NLM version. While the CAP will make SNOMED files
available free under the NLM agreement, “there won’t
be any free support,” Dr. Spackman says. The payments from
the NLM include a one-time upfront license fee and ongoing fees
After the five-year
contract with the CAP is up, the NLM intends to negotiate follow-on
contracts. The current agreement, Humphreys notes, allows the NLM
to use whatever is delivered in the next five years. Even in the
“unlikely event that we didn’t reach agreement with
the CAP for further use,” she says, the NLM and its licensees
would have the right to continue to use SNOMED, though not the annual
updates from the CAP.
Karen Southwick is a writer in San Francisco.