Is SNOMED CT a Practical Usable Clinical Terminology Today?

In a recent posting at the E-Health Insider web-site it is reported that the Royal College of Physicians is urging a “universal and rapid SNOMED deployment” to be undertaken by the UK Connecting for Health IT Program.

The article can be found here:

http://www.ehiprimarycare.com/news/item.cfm?ID=2338

More interesting than the article is an anonymous response to the suggestion found at the bottom of the article. This is worth quoting in full as it goes to make some points and provide some useful resources for those interested in the area of practical, clinically useful SNOMED CT implementation.

“12 Dec 06 12:29

SNOMED: caveat emptor

Readers of this article (and the RCGP) are advised to check the detail before rushing into demands for immediate SNOMED implementation.

Major suppliers, would be implementers and academics are on public record stating SNOMED has manifest and significant quality control and implementation issues.

http://hl7-watch.blogspot.com/

http://www.shopcreator.com/mall/infopageviewer.cfm/Abiescouk/SCT06download

On a purely pragmatic level, clinical code sets supporting QOF/QMAS on the DoH website (URL changes almost daily :-( ) for SNOMED have not been updated since 2005 release (unlike those for the Read Codes which are up to date). This latter alone is unlikely to encourage jobbing GPs to queue up as guinea pigs for the 'imminent' releases of SNOMED enabled systems from EMIS, In Practice and others.

It just isn't as simple as whip the system suppliers I'm afraid.”

A review of the material found on these pages certainly raises some interesting and very complex questions and I would suggest anyone with an interest in the area review these two sites and the links / downloads provided carefully.

The messages I came away from all this material with were as follows:

1. If David Markwell’s presentation from March 2006 is to be believed the work of encapsulating the complexity for SNOMED CT behind a useable clinically friendly interface has yet to be completed. Without well engineered seamless interfaces to the use of SNOMED CT adoption and use of the terminology will be very slow indeed

2. The Kaiser Permanente implementation of SNOMED CT within its EPIC software implements a narrow subset of the full contents of SNOMED to make clinical coding and billing easier.

3. Professor Alan Rector (a global terminology guru if there is one) from Manchester University has recently said in a presentation that “Unless we can formalise the mutual constraints ... HL7 v3 + SNOMED = Chaos'. 'The documentation is beyond human capacity ... to write or to understand'.”

4. Other groups appear to be really struggling to deploy usable clinician friendly systems.

5. There are some significant academic linguists and ontologists who have very significant concerns about the underlying data model on which SNOMED CT is based.

6. The emergence of supporting terminologies in areas where localisation to a specific country is needed (e.g. in the local formulary) has been slower that might have been expected.

7. There is at least some concern regarding the overall data quality of the material already contained in SNOMED CT.

8. There also seem to some harmonisation issues between HL7 V3.0, CEN/ISO Standards and OpenEHR with Archetypes which indirectly impinge to some extent of terminology use.

What does all this mean practically?

I think that it is at least possible that large scale deployment of clinician friendly SNOMED CT may be more delayed than is anticipated at present – i.e. out to beyond 2010 and there is even the possibility that it may all prove ‘too hard’ and some simpler better designed approach – based on the lessons learnt from SNOMED CT – may need to be engineered.

Whatever happens it seems clear all those interested in the area should spend some time getting familiar with the current state of play so they can formulate, for themselves, informed estimates of just when systems which fulfil the promise of SNOMED CT are likely to be available.

I for one will not be holding my breath. Just as HL7 V3.0 and openEHR have taken over a decade to be developed and are not yet quite ready for ‘prime time’ as far as I know I suspect history will repeat with SNOMED CT.

I hope I am wrong!

David.