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  President’s Desk Column

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May 2004
Mary E. Kass, MD

Modern health care is fragmented; it’s the nature of the beast. So we depend on patients to relate their medical histories, but not all can give reliable accounts. Medical records are helpful, but they don’t always travel well. Many are illegible and most reflect a multiplicity of medical dialects. We all speak health care, but institutional, occupational, and cultural influences muddy the message.

Paper-based hospital communications systems are cumbersome. Inpatients should not undergo redundant procedures because one shift doesn’t know what the other shift is doing, but that’s what happens. They should not make one trip to x-ray in the morning and another to ultrasound after lunch. They should not undergo multiple blood draws the same day. These inefficiencies drain the patient’s energy, tax the staff, and cost money.

We know that automation offers solutions, but health care is in many ways a latecomer to the electronic age. The big challenges are financial and cultural. On the administrative end, business types understand that when digital systems eliminate miscommunication, lost orders, and redundant procedures, patient days go down and so do costs. And they can appreciate the liability benefits that accrue when so much systems-based error is prevented. But the process of advocating for such a big investment brings the cultural barriers into sharp relief, and the conversation gets more complicated.

Huge changes that will disrupt hospital routines cannot be implemented without grassroots support. While we know that electronic physician order entry, record keeping, and clinical decision advisories are eminently logical, we also know the journey can be painful. I gather that gestation is the worst of it.

One of the biggest barriers has been the need for a standardized clinical terminology that functions transparently across dispersed sites of care. I chose to write about the electronic medical record this month because within the next few weeks, perhaps even before you read this, that barrier will be toppled.

Last summer, the College signed a five-year contract licensing the National Library of Medicine to provide English and Spanish language editions of SNOMED Clinical Terms (SNOMED CT) to public and private entities across the U.S. engaged in health care delivery, research, public health, education, and statistical reporting. This spring, the U.S. Department of Health and Human Services is expected to announce that SNOMED CT core content is accessible at no charge through the National Library of Medicine Unified Medical Language System Metathesaurus.

Over a period of nearly 40 years, the College has supported SNOMED and the vision of those who saw its potential. This was always a labor of love; if we’re lucky it may someday break even. But as the old saying goes, if you want to make a small fortune, take a large fortune and invest it in a vineyard. SNOMED is vintage CAP, something that speaks clearly to who we are and what we are about.

With national licensure, SNOMED CT becomes, in the truest and most gentle sense, the mother of all clinical terminologies. Inclusion in the metathesaurus will embed SNOMED CT in the fabric of universal medical communication. The College has developed the world’s premier medical nomenclature, a system with the power to encode everything in the physician-patient interaction, to note signs, symptoms, findings, diagnoses, procedures, and drug therapy in a detailed, specific, and interconnected language. SNOMED CT is an incredibly powerful tool for epidemiology, research, education, statistical analysis, and public health applications.

SNOMED CT is a comprehensive clinical terminology that will enable researchers to relate and manipulate clinical findings, design more effective treatment guidelines, and evaluate quality and cost of care. It can interface with all the major messaging standards and cross-map to and link relevant information from the basic sciences and the medical literature. SNOMED CT features more than 344,000 unique terms organized into multiple hierarchies, 913,000 descriptions, and 1.3 million semantic relationships. Codes are available to describe 17,000 organisms and all reportable infectious diseases. Because it eliminates language barriers, SNOMED CT is used in more than 30 countries.

Once SNOMED is embedded in the electronic record, instantaneous communication, data analysis, public health screens, and data mining for research will be exponentially simpler. But we have to get there first. Now that SNOMED is well positioned and refined, we need to persuade our colleagues, both physicians and administrators, to invest the time, energy, money, and political capital to establish electronic data systems in our hospitals.

What can you do as a staff pathologist? You can form a medical and nursing staff advisory committee to help the informaticists at your hospital ensure that the system is clinician-friendly. You can prepare the medical staff, making regular reports on the work of your committee and telling people just what to expect. You can take pains to ensure that the power of SNOMED CT is predominant in the minds of those who care about patient safety. You can do what SNOMED does: Help us communicate more effectively with one another.

SNOMED CT is a robust and flexible instrument that can dramatically improve the quality of care in our institutions. In time, I have no doubt that it will facilitate applications that most of us would never have thought possible. The story needs to be told, early and often. It is time that medicine joined the digital electronic age. SNOMED is our language. Let’s speak up for it.

Dr. Kass welcomes communication from members. Send your letters to her at president@cap.org