College of American Pathologists
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  President’s Desk Column


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SNOMED CT and the Tower of Babel

July 2003
Paul A. Raslavicus, MD

It was in 1963 that as a pathology resident I first used SNOP topography and morphology axes to code a surgical pathology specimen. Forty years later to the day on June 30, 2003 I proudly signed on behalf of the College an agreement with the National Library of Medicine (an agency of the National Institutes of Health) to make SNOMED CT freely available to all who labor in health care in the United States. With this act we honor the many physician colleagues and staff who have worked for four decades to build the Systematized Nomenclature of Medicine to world eminence. Their outstanding contribution, the agreement with the U.S. government, and our working relationship with the National Health Service of the United Kingdom bring down the Tower of Babel that heretofore has characterized health care codification attempts to build a robust computerized patient record.

With this stroke of the pen, a seismic shift has occurred in the way medical information will flow henceforth. SNOMED CT is now positioned to be the universally acknowledged terminology standard that permits easy computer interoperability and exchange of medical information. SNOMED CT, considered by many to be the most comprehensive multilingual clinical reference terminology in the world, is about to become embedded in the culture of health care delivery in this country, eclipsing most other codification schemes. The power of our creation is such that we can stop thinking about how to collect information and start thinking about interpreting and applying it. Many speeches have been made and many papers have been written on health care quality and patient empowerment, on accuracy over time and safety first, but I offer here this evidence-based assessment: We are positioned for change, and SNOMED CT is the engine that will
drive it.

The five-year government contract makes the English and Spanish editions of the SNOMED Clinical Terms available free through the National Library of Medicine’s Unified Medical Language System Metathesaurus. Any public or private entity in the U.S. will have access to it for health care delivery, research, public health, education, and statistical reporting. In announcing the signing of the contract, Department of Health and Human Services secretary Tommy Thompson called it a “wonderful groundbreaking agreement” that will “prove invaluable in the automated exchange of clinical information needed to protect patient safety, detect emerging public health threats, better coordinate patient care, and compile research data for patients in clinical trials.”

SNOMED CT will also be available from the College. We will continue to maintain it and retain ownership, and we’ll direct our attention to developing products and services to support its effective use.

What began as a simple morphology-topography code for pathologists has grown to incorporate terminologies defining all of medicine. Our collaboration with the UK’s National Health Service produced the current SNOMED CT, which combines our strengths in inpatient care with the NHS’ knowledge of outpatient needs. This terminology makes it possible to capture, share, and aggregate health data across specialties and sites of care with precision
and consistency.

SNOMED CT easily encodes the entire patient-physician interaction process from symptomatology to objective findings, to diagnoses, to drug therapy, iatrogenic events, and so forth. The terminology is detailed, specific, comprehensive, diverse, controlled, and interconnected. Its structure is hierarchical and relational, facilitating data extraction for epidemiologic and research studies. SNOMED is a powerful tool for standardizing reports to cancer registries and public health authorities, for telemedicine, outcomes analysis, practice guidelines, clinical benchmarking, and genetic databases. All this translates to enhanced patient safety, improved care delivery, and demonstrable savings in the cost of care.

And there is more.

To support encoding of the entire patient encounter, SNOMED CT offers 344,000 concepts with unique meanings and formal, logic-based definitions organized into hierarchies. It incorporates 913,000 English-language descriptions or synonyms providing flexibility in expressing clinical concepts, and 1.3 million semantic relationships to ensure consistent data retrieval. SNOMED CT cross-maps to ICD-9-CM and is compatible with all major messaging standards (for example, HL7, DICOM, XML, ISO). It incorporates LOINC (Logical Observation Identifiers Names and Codes), the database many of us use to share lab results.

Government entities and health care organizations in more than 30 countries have adopted SNOMED CT. This nomenclature eliminates language barriers, offering a sustainable, scientifically validated communication tool that speeds understanding among diverse health care systems.

Although SNOMED CT is used worldwide by integrated delivery networks, health care provider organizations, medical research organizations, government entities, content providers, pharmaceutical manufacturers, biotech firms, and veterinary practices, many pathologists are still using SNOP or older versions of SNOMED. As health care enterprises adopt SNOMED CT more broadly, pathology data will have to be encoded in SNOMED CT as well so it stays synchronized to the electronic patient record. The NLM contract should ease that transition. While the College provides software bridges for pathologists to protect legacy data, increasing numbers of laboratory information system vendors already incorporate SNOMED CT into their products.

SNOMED CT will help researchers understand how caregivers think when they structure patient care and how they apply logic to disease processes. We are truly not far from the time when patients will carry their medical records on secure, updatable cards, cards that will guarantee that the same data are brought to each clinical encounter. As primary care physicians, researchers, public health officials, and quality gurus see the many ways that electronic health records will serve patients and the science of medicine, we can expect that total health care electronic encoding will evolve into the accepted standard.

These imperatives will drive the use of electronic records in the direct care of patients, now already visible in the avant-garde hospitals in our country. Computers in most institutions are still used only for financial record keeping and within the laboratories. Computerized recording of patient encounter information and order entry for laboratory tests, prescriptions, and radiologic exams, for example, are virtually untapped areas. Our challenge now is to advocate for quality and encourage a cultural change within medicine to bring electronic records into every patient encounter.

When the Committee on Nomenclature and Classification of Disease began its work on SNOP in the early ’50s, and as we since then invested intellectual and financial capital in SNOMED, we did not know that the pieces would fall into place in the summer of 2003. Our reward was not wholly predictable, but now we stand proud of having developed SNOMED CT for the health care needs of the world. We know we cannot hope to recoup our past investments, and the government contract is not likely to cover the entire cost of maintaining the program. But we always must remember our calling as physicians dedicated to patient service. We must be secure in knowing that as a learned profession we must give our knowledge and our work to those who follow us, just as those who have preceded us gave knowledge to us.