SNOMED CT

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SNOMED® (Systematized Nomenclature of Medicine), a system of standardized medical terminology, was developed by the College of American Pathologists(CAP). It began as a terminology system for pathology in 1965 and over the next 40 years evolved into SNOMED Clinical Terms®, or SNOMED CT®, a comprehensive computerized clinical terminology covering clinical data for diseases, clinical findings, and procedures. It is a “comprehensive and precise clinical reference terminology that provides unsurpassed clinical content and expressivity for clinical documentation and reporting.” [1] It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. [2] It also helps structure and computerize the medical record, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research. [3] SNOMED created a common clinical language that is a necessary element of a health care Information Infrastructure. SNOMED® is a registered trademark of the College of American Pathologists. [4]

1 Development
2 Sample Computer Applications Using SNOMED CT
3 Basic Structure
4 Use
5 For More Information
6 See also
7 References

[edit] Development

Clinicians and organizations use different clinical terms that mean the same thing. For example, the terms heart attack, myocardial infarction, and MI may mean the same thing to a cardiologist, but, to a computer, they are all different. Also, because of the need to exchange clinical information consistently between different health care providers, care settings, researchers, and others, and because medical information is recorded differently from place to place (on paper or electronically), a comprehensive, unified medical terminology system is needed. A medical terminology tool that can link multiple concepts and names systematically would allow clinical data to be communicated more clearly and accurately. [5]

In January 2002, SNOMED CT® was created by the merger, expansion, and restructuring of SNOMED RT® (Reference Terminology) and the United Kingdom National Health Service (NHS) Clinical Terms Version 3 (also known as the Read Codes). [6] The historical strength of SNOMED RT was its terminologies for specialty medicine, while the strength of Clinical Terms Version 3 was its terminologies for general practice. [7] By combining these two systems, SNOMED CT is the most comprehensive clinical vocabulary available in English (or any language), covering most aspects of clinical medicine with over 344,000 concepts. [8] SNOMED CT cross maps to such other terminologies as ICD-9-CM, ICD-O3, ICD-10, Laboratory LOINC and OPCS-4. It supports ANSI, DICOM, HL7, and ISO standards. [9] In April 2002, the SNOMED CT Spanish Edition was released, and in April 2003 the SNOMED CT German Edition was released.

[edit] Sample Computer Applications Using SNOMED CT

Electronic Medical Records
Computerized Patient Order Entry Such As E-Prescribing Or Laboratory Order Entry
Remote Intensive Care Unit Monitoring
Laboratory Reporting
Emergency Room Charting
Cancer Reporting
Genetic Databases [10]

[edit] Basic Structure

Concepts: Basic unit of meaning designated by a unique numeric code, unique name (Fully Specified Name), and descriptions, including a preferred term and one or more synonyms.
Descriptions: Terms or names (synonyms) assigned to a concept.
Hierarchies: 19 higher level hierarchies; each has sub-hierarchies
Relationships: Link concepts either within a hierarchy or across hierarchies [11]

[edit] Use

SNOMED CT is one of a suite of designated data standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information. The National Library of Medicine (NLM), on behalf of the U.S. Department of Health and Human Services, entered into an agreement with College of American Pathologists for a perpetual license for the core SNOMED CT (in Spanish and English) and ongoing updates. The contract provides to NLM a perpetual license to distribute SNOMED within the NLM’s Unified Medical Language System UMLS Metathesaurus for no cost use within the U.S. by both U.S. government (federal, state, local, and territorial) and private organizations. The contract also covers updates to SNOMED CT issued by the College of American Pathologists between June 30, 2003 and June 29, 2008.