The Principles of Electronic Transfer of Radiology

Reports to GPs

Ian Arrowsmith

NHS Information Authority

The NHS Plan

An “NHS designed around the patient”. Stresses the need to support well co-ordinated

“seamless” services across “whole systems”. The right information available at the right place, at the

right time for the right care provider (and in a useful form)

(Why) do we need electronic clinical messaging ?

What is a clinical message ?

What is a message ?Main Entry: 1mes·sage

Pronunciation: 'me-sijFunction: nounEtymology: Middle English, from Old French, from Medieval Latin missaticum, from Latin missus, past participle of mittereDate: 14th century1 : a communication in writing, in speech, or by signals2 : a messenger's errand or function3 : an underlying theme or idea

Merriam-Webster

What is a clinical message ?

What is communication?Main Entry: com·mu·ni·ca·tion

Pronunciation: k&-"myü-n&-'kA-sh&nFunction: nounDate: 14th century1 : an act or instance of transmitting.....information.....a verbal or written message....a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior...

Merriam-Webster

What is a clinical message ?

‘Clinical information’ as defined by CEN:

Information about a patient, relevant to the health or treatment of that patient, that is recorded by or on behalf of a healthcare professional.

CEN - Commite Europeen de Normalisation; a Brussels based organisation of 18 national standards bodies in Europe. The Health Informatics Technical Committee of the European Standardization Committee is known as CEN TC251

What is a clinical message ?

A communication in writing, in speech, or by signals which contains information about a patient, relevant to the health or treatment of that patient, that is recorded by or on behalf of a healthcare professional.

A simple clinical message

Clinical messaging in the 21st Century

NHS Definition

Clinical Messaging can be defined as

“The secure electronic transmission of structured data that contains patient information, between healthcare parties."

Basic Clinical Message Types

Request/Order Report/Result Query/Update Acknowledgement

Clinical message examples

Pathology requests and reports to GPs Radiology requests and reports to GPs Discharge summaries to GPs Out of Hours messages to GPs NHS Direct messages to GPs GP to GP record transfer GP to Outpatient referrals

What do we want to achieve ?

Faster delivery of report ‘Safer’ delivery of report More timely treatment of patient Possible provision of links to images Information incorporated directly in GP

patient record

Current Practice

Pony Express Snail Mail Fax Unstructured text report emailed Structured text ‘message’ delivered Notification that a report is available for

browsing sent to GP by email

Disadvantages of current practice

Data may be unstructured -incorporation into GP record not automated

Data may be structured in different ways Inconsistency in composition of data

transferred - coding schemes Variable levels of Security/Confidentiality

Properties of a National Message Specification

The Message should be Structured The Message structure should be

Standardised The Message content should be

Standardised The Message should be transferred

securely

Structured Message

System A System B

Message

Diagnosis

Family history

Messaging standards Security/Confidentiality Infrastructure Coding Browsing

Technical aspects

Security/Confidentiality

Content Integrity Clinical domain-domain encryption Origin authentication by application Secure confirmed receipt by application

(non-repudiation) Access control

Message Development Issues

Developing standards Emerging technologies Government Edicts NHS Strategy Stakeholder buy-in Patient access to reports

Benefits

Delivery times for diagnostic imaging reports to GPs are improved

Availability and speed of access of diagnostic imaging reports by GPs is improved

Confidentiality is enhanced due to direct clinician-clinician communication

Reliability of delivery of reports is increased

Clinical terminology and its application to Radiology

Ian Arrowsmith

NHS Information Authority

Clinical Terminology• What is a clinical terminology?

• Why do we need one?

• What do we use it for?

• What are the properties of a terminology

• SNOMED CT

A collection of health related terms to allow healthcare providers

to accurately record all aspects of patient-related activity

consistently

NHS Information Authority definition

What is a clinical terminology ?

These terms describe the care and

treatment of patients covering areas such

as diseases, operations, treatments, drugs

and administrative items

What does it cover ?

The terminology enables computer

systems to accurately capture, and then

retrieve on demand, patient information,

in a natural clinical language

What is a clinical terminology used for ?

Practical uses

• Clinical summaries

• Integrated computerised decision support

• Prescribing

• Referral/Discharge letters

• Clinical Messaging

• Aggregated data analysis

Fundamental properties of a Terminology

• Codes, Concepts, Terms• Synonyms• Hierarchies• Compositionality• Semantic Definition• Dynamism

Codes, concepts and terms

• “Concept” includes:

• Term: Stomach• Code: 7N301

• Symbol:

Preferred terms and synonyms

• Each concept has one unique preferred term without ambiguity, and may have any number of synonyms

• Synonyms may be shared with other concepts

Ambiguity

• Absent thumb PF263 (Read V2)

• Could be congenital or acquired

Ambiguity

P…. Congenital anomalies

PF… Other congenital limb anomalies

PF2.. Reduction deformity of upper limb

PF26. Agenesis of radial ray

PF263 Absent thumb

Ambiguity in radiology

• Barium enema• Single contrast ?• Double contrast ?• Unprepared ?• Via colostomy ?

Synonymy

Spinal cord compression Xa0NkCord compression

Umbilical cord compression X40CcCord compression

Synonymy in radiology

atlantoaxial X-ray (procedure) atlantoaxial X-ray C1 C2 X-ray craniocervical junction X-ray plain X-ray atlas/axis odontoid peg X-ray

Hierarchies•Arrange randomly

•Arrange by spelling A D O ZApple Dog Orange Zebra

•Arrange by meaningFruit AnimalApple DogOrange Zebra

Hierarchies

Compositionality - eg Laterality

• Departmental system • Left thumb X-ray code 001a

• Terminology• Thumb X-ray code 241074003

• Laterality code 272741003• Left code 7771000

Or Enumeration ?

Primary open fixation of fracture of left femur using locked reamed intramedullary nail

32 possible combinations

Semantic definition

Emergency amputation of leg

Priority: Emergency

Method: Amputation

Site: Leg

Dynamism

• Things change over time – terminology needs to reflect this• Molegraphy• Clivogram• Air encephologram

• Update mechanism

SNOMED® Clinical Terms

Collaboration between the NHS and the

College of American Pathologists

History of Read Codes

• 1985 4 Byte set introduced• 1988 Recommended standard GP computing• 1990 Crown Copyright + Version 2 introduced• 1992 Terms Projects • 1994 Clinical Terms (Version 3) released• 1995 First hospital use Version 3• 1999 Collaboration with SNOMED

History of SNOMED

• 35 year history

• SNOP 1965

• SNOMED International 1993

• SNOMED® RT 2000

SNOMED CT - a superset

SNOMED RT CT V3

International Relations

• Healthcare sub-language

Oesophagus/esophagus

Anaemia/anemia

• General

Cortico-pontine fibres/fibers

Grey/gray matter

Thank you for listening..

• Further information available from

• www.snomed.org• www.nhsia.nhs.uk