Historically, a doctor recorded a patient’s medical issues on a problem list included as part of the patient’s paper chart.
Chronic illnesses and major medical issues were included on the list. Such paper records faced severe limitations, however. The chart was housed in one physical location, restricting accessibility. Each healthcare provider organization working with the patient would maintain its own records -- including problem lists -- leading to a highly fragmented view of the patient. Caregivers moving towards a more collaborative care delivery model would soon find paper records an undesirable and insecure way to share patient data. In addition, these paper-based problem lists were not always consistently maintained.
But problem lists have finally arrived in the digital world. Clinician observations on a patient’s current and relevant conditions can now be documented within the patient’s electronic health record (EHR) using the SNOMED CT® terminology code set as a common language.
EHR systems that support the SNOMED CT standard are able to communicate patient problems with each other. This interaction, in turn, enables collaborative, consistent patient care among different provider groups.
Stage 2 of the federal government’s Meaningful Use program now requires SNOMED CT for documenting problem lists. Providers must adopt the standard in order to qualify for the financial incentives offered under the Meaningful Use initiative, which provides individual physicians and hospitals incentives for installing EHR systems.
But providers aren’t the only ones who stand to gain from SNOMED CT compliance. Patients benefit as well. Here’s how:
Clear and consistent documentation
We as physicians strive to compile an accurate problem list, but each provider documents patient conditions in his or her own way. For example, physicians may use different acronyms to identify a clinical condition (e.g. MS or AA). There may also be inconsistency in adding appropriate diagnosis to the problem list as well as maintaining the list. SNOMED CT compliance provides a uniform method of expressing clinical conditions, which bolsters the clarity and completeness of the problem list. Patients benefit when a new physician or specialist can readily interpret a standardized problem list.
The trend among providers to embrace collaborative care is an important aspect of the nation’s healthcare reform efforts. Care delivery models such as Accountable Care Organizations and Patient-Centered Medical Homes revolve around this collaborative care concept. Enabling technology, standardization, and interoperability is critical for enabling this collaboration. Thus, SNOMED CT compliance among providers and their IT systems will allow clinical systems to talk to and understand each other. SNOMED CT bridges the communications gap for problems and diagnosis, while the use of other standardized terminologies such as RxNorm and LOINC normalize drugs and labs.
Longitudinal Patient Records
The longitudinal patient record has long been a healthcare industry goal, but one that has been difficult to achieve due to the fragmented nature of patient data. The ability to share data among systems, such as the information contained on problem lists, overcomes that fragmentation and will make it possible to pull together a comprehensive, longitudinal medical history. Compliance with SNOMED CT will move providers and patients one step closer to that objective.
Accurate Patient Data Analysis
SNOMED CT compliance will boost the accuracy of patient data analysis. The use of a standard clinical terminology across the enterprise and within other providers will simplify the query and resulting report. In addition, the increased specificity of SNOMED CT compared to the ICD billing code sets improves the granularity of the analysis. With the ontology structure of SNOMED CT, I can now enable more sophisticated queries such as identify all patients who have a disease of the lung, or all patients who have various types of heart disease. In a population health management context, patients benefit from more targeted and helpful interventions.
The Case for SNOMED CT
Clearer documentation, greater accessibility and easier collaboration are all reasons to adopt SNOMED CT. Meaningful Use compliance offers another incentive. But the ultimate end goal is improved patient care. When providers can capture the full patient picture on a problem list, appropriate treatment can be initiated early, improving the patient outlook.
Has your organization implemented SNOMED CT as part of your Meaningful Use Stage 2 attestation process? If not, what obstacles are you encountering? Leave your comments below.