SNOMED and the administrative future of medicine...

Editorial time, it has been awhile. A story about a stick and a carrot. And how they will affect the practice of medicine in the US.

Let me start by introducing SNOMED. SNOMED, by it's own description, is "the most comprehensive, multilingual clinical healthcare terminology in the world."

In layperson's terms, SNOMED is a structured clinical language designed to describe the details of a visit in a consistent, discrete fashion. It's an effort to codify every scrap of data that you put into your EHR and turn everything from your free text notes (eventually) to your lab results into data that can be organized, exchanged, and reviewed.

This also means that the days of scribbling "OM left" or simply picking a generic ICD-9 code for billing and moving on to the next patient are coming to an end. It's one of the little time bombs packed into the Stage 2 MU requirements (more below).

Your shorthand - while invaluable while your patient is in front of you - makes everything from data exchange to population management effectively impossible. What makes your single patient visit efficient today causes tomorrow to be inefficient.

How does this affect pediatricians? Right now, you generate two primary chunks of data at the end of every visit: your chart notes (which can be in 1001 different formats, depending on your EHR...or handwriting), and CPT/ICD-9 codes. The former, which is rarely able to exchanged directly outside your office, is for clinical purposes. The latter combination exists, ostensibly, for billing purposes but has been co-opted for all kinds of clinical use (PCC does it all the time - we help you use ICD-9 and CPT codes for everything from patient recall to immunization tracking and more). SNOMED is the effort to have a chart note that is both readable and shareable...and make the billing process simpler and more consistent.

Ask anyone in the business of quality measurement: ICD-9s and CPT codes make poor measuring sticks. We need to separate the billing and clinical experiences. Enter SNOMED. No real challenge there.

So, why the talk about the stick and the carrot? Let's look at the stick, first.

The Stick

The stick is very easy to understand: Meaningful Use. For Stage 2 certification, an EHR must use SNOMED terminology in a number of places. Here's one example:

170.314(a)(5) Problem list. Enable a user to electronically record, change, and access a patient’s active problem list:

(i) Ambulatory setting. Over multiple encounters in accordance with, at a minimum, the version of the standard specified in §170.207(a)(3)

Of course, the standard specified above includes SNOMED.

If it's not clear, this means that your Problem List, long the domain of ICD-9 codes, will now be recorded using SNOMED. I chose this example because it's where PCC decided to introduce the concept to our clients (more on that later).

In the scramble to get certified, EHR vendors (including PCC) are feeling forced to cram in these changes without a lot of time to prepare and manage the process. Even if you don't wish to participate in MU - or, for many pediatricians, you CAN'T - your vendors (again, including PCC) are forced to make these changes anyway. Without Stage 2 certification, many or most of our third party relationships - such as every lab connection, eRX, your state HIE, your state immunization registry - will simply refuse to work with us.

It's not just the government, either. PCMH recognition bumps into SNOMED. Payer-level quality measures reference SNOMED. SNOMED is replacing ICD codes in many (most?) CQM/NQF reports.

In other words, using SNOMED is effectively required if you want to work with a viable EHR. Or even if you don't. And there's the stick.

The Carrot

What's the carrot? The future.

We all know how the design of EHRs is crippled by the need to make records for billing (and not records of _care_). ICD-9 and, soon, ICD-10 will become your billing effort while other standards (SNOMED, LOINC) will take over as your clinical descriptors. With the evolution towards a more clinically oriented note, you should start to glimpse a future where your EHR supports your clinical process and not just your billing process.

Perhaps the biggest complaint I've heard about MU is that it didn't accomplish or even focus on the biggest problem we have in the EHR world: the interchange of data. Doctors want to choose the EHR that suits them best, not the EHR that suits their ACO/MSO/hospital overlords. And if they could just pick that EHR and share their data, what a marvelous world that would be. The first step towards that marvelous world is getting disparate systems to speak the same, useful language. SNOMED is that answer.

I have more to say about this subject, including how PCC is implementing SNOMED and why we've made the choices we've made, but I'm looking for some feedback from anyone first. Anyone reading here use SNOMED?