College of American Pathologists
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cap today

Revolution draws near for electronic medical records

August 2003
Karen Southwick

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 easy.

Speaking at 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.

“These 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 an EMR.”

“This 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.

“Even 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.”

Better medical care
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.

Using SNOMED “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.”

Dr. Mattison 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, he says.

“It’s 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.”

Using SNOMED, 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 optimal care.”

Without SNOMED 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 protocols.

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.

For example, 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,” he says.

Dr. Spackman 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 years.

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.

The advantage 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.

Starting Jan. 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.

“With 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.”

Using SNOMED 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.

But pathologists 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.”

Case in point
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 initiative faces.

“From 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 for research.

“The NCI 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.”

SPIN requires 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 license terms.

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.”

He cautions, 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.

Vendors 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.”

“One of 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 vocabulary.”

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 this.”

Although the 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.

Negotiating 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.

An incentive 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.

Furthermore, 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.

Humphreys approached 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.

Meanwhile, HHS 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,” Humphreys says.

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.

Current SNOMED 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 for updates.

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.