BLOG - THE JOURNEY

Stage 2 - What is SNOMED?

Posted by: Darla at 9:56 am on March 14th, 2014

What is SNOMED and Why is it Important for Stage 2 Meaningful Use?

snomed.jpgEarly last week I was discussing some modifications to a health history screen with a physician. As we were talking I mentioned that our changes would need to be compliant with SNOMED, since SNOMED is required for meaningful use stage 2. The provider asked,” what did you say Darla? Snowman? What in the world is Snowman?”  It HAS been a rough winter here in the Midwest.

As I pulled my sweater around me to get warm, the snowman joke did shine a spot light on the bigger issue. We are 3 months into 2014 and many practices are confused about topics that are affecting their electronic health records and possibly their ability to attest.

What is SNOMED?

SNOMED-CT is an acronym for Systematized Nomenclature of Medicine – Clinical Terminology, SNOMED for short. SNOMED is a number that represents a concept. SNOMED is recognized throughout the US and internationally, and it is available at no cost through the National Library of Medicine.  Using SNOMED enables providers and electronic medical records to communicate in a common language, thus increasing the quality of patient care across many different provider specialties. Today, SNOMED is available in US English, UK English, Spanish, Danish and Swedish. Translations into French, Lithuanian, and several other languages are currently taking place. SNOMED contains more than 311,000 active concepts with unique meanings and formal logic-based definitions organized into hierarchies.

These hierarchies include multiple levels of granularity. The broad coverage of topics included can be illustrated using the following examples (partial list):

Clinical finding/disorder
Procedure/intervention
Observable entity
Body structure
Organism
Substance
Pharmaceutical/biologic product
Event
Environment or geographical location
Social context

Stage 2 meaningful use requires SNOMED in 3 areas:

(1) Problem lists
(2) Smoking status
(3) Family health history
 

Problem Lists (Core Measure)

Stage 1 meaningful use allowed providers to codify a patient problem list using ICD-9 terminology. The change for Stage 2 requires SNOMED codes. These are the codes that are embedded in the CDA (clinical document architecture) sent to other providers, IHEs and patients.  Many EHR vendors are utilizing “maps” between ICD-10 and SNOMED. This mapping may enable providers to choose an appropriate ICD-10 code and the EHR will then choose and send the corresponding SNOMED code. 

Smoking Status (Core Measure)

Stage 1 required smoking status as a text. Stage 2 requires one of the following codes:

(1) Current every day smoker. 449868002
(2) Current some day smoker. 428041000124106
(3) Former smoker. 8517006
(4) Never smoker. 266919005
(5) Smoker, current status unknown. 77176002
(6) Unknown if ever smoked. 266927001
(7) Heavy tobacco smoker. 428071000124103
(8) Light tobacco smoker. 428061000124105


Family Health History (Menu Set Measure) 

Family health history is new for 2014 and is an available menu set measure. You’ll need to choose 3 from a list of 6 possible menu set measures and this should be one of the easier ones to achieve.  The measure requires more than 20 percent of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first-degree relatives. This structured data must be matched to a SNOMED code or as an alternative the HL-7 pedigree code. 

What Steps Should You Take?

The good news is that your 2014 Certified EHR would have tested these measures and their ability to map and exchange SNOMED codes. Most will provide at a minimum codes that are required for these 3 areas of the patient record. If your system allows for custom templates and you have created templates that include problem list, family history or smoking status, then review these with your vendor to ensure your compliance. Education will be the key to success as it is with so many new concepts. Educate your staff about documentation.  It’s important to stress that systems won’t be able to recognize free text. Important information could be excluded from the patient CDA if not documented appropriately.

Lastly, celebrate Spring!  You deserve some sunshine!

Darla

Learn more about SNOMED:

http://www.ihtsdo.org/snomed-ct/

 

SNOMED Lookup:

http://www.snomedbrowser.com/

 

 

Copyright 2014 Destinations Consulting