Recording a structured family health history is a menu requirement in Stage 2 of Meaningful Use, both for eligible providers* and eligible hospitals**. Both specifications require that the health history of first-degree relatives be recorded, and provide the choice of recording the history either in SNOMED CT or using the HL7 Pedigree standard. One of the key issues we’ve been working with clients on is how to capture both the context (which relative is being discussed) and the condition (medical issues associated with the relative).
The HL7 Pedigree standard provides very explicit directions on expressing context (using the Family Member Value Set). To express the condition, the Pedigree standard is flexible, allowing the use of a variety of terminologies (e.g. SNOMED CT, ICD-9-CM, ICD-10-CM) to capture the conditions that each relative has. Examples of the XML format for the HL7 Pedigree standard can be generated using the US Surgeon General website My Family Health Portrait.
Although the Pedigree standard does not require the use of SNOMED CT for medical conditions, we do recommend it. SNOMED CT particularly expressive for medical terminologies and HLI has created a subset of SNOMED CT concepts that are particularly appropriate for family health history. Some EHR vendors have found this subset to be a useful, for instance, in creating pick lists of concepts in their user interface for family history.
If the Pedigree standard is not used, SNOMED CT must be employed - but the guidance from ONC and MCS does not indicate exactly how SNOMED CT is to be used. In our work with EHR vendors, we think it is clear that EHRs must be able to associate conditions with first-degree relatives. In general, it is therefore ideal for condition to be selected from the SNOMED CT Clinical finding hierarchy. The context can be specified by encoding the relative involved (perhaps either using the Family Member Value Set from the Pedigree standard, or using concepts from the SNOMED CT Social context hierarchy (e.g. brother, natural brother, half-brother). At this point, if an EHR vendor already employs a method for associating condition with context, we aren’t recommending any changes to the method. For those vendors without an existing method of associating condition with context, perhaps this may be a good time to adopt the Pedigree standard.
This raises the question of whether and when to employ pre-coordinated SNOMED CT expressions in the Situation with explicit content hierarchy that are that directly link content to context:
- There seems to be clear-cut value for including pre-coordinated expressions that make negative assertions? (Example: ‘313376005 No FH: breast carcinoma’.)
- The value of creating a pre-coordinated expression for positive assertions about family health history (Example: ‘430292006 Family history of malignant neoplasm of breast in first degree relative’) Isn’t as clear, and should probably be avoided.
We look forward to continuing to support terminology needs for capturing family health history, and will keep alert for best practices for the syntax outside of the Pedigree standard. In the meantime, we encourage clients to explore HLI’s Family History Subset when conditions are represented in SNOMED CT.