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by Charles Gutteridge
Published on 24 September 2019

In this edition of our Cerner blog, Charles Gutteridge, CCIO at Barts Health NHS Trust, shares how staff across the organisation are using a standard terminology to communicate with one another and to document patient information within their Cerner Millennium® electronic health record (EHR). This aligns with the industry’s push towards full interoperability, besides supporting more efficient delivery of care, improving research capabilities across the system, and moving the Trust forward in their digital excellence journey.

Charles was recently honoured with a lifetime achievement award at this year’s Digital Health Awards ceremony. The recognition praises, among other achievements, his national leadership in clinical informatics matters and his personal mission to encourage the adoption of SNOMED Clinical Terms across the NHS.

Right data that's right for care

From the moment a patient enters a hospital’s doors, a number of doctors, nurses and healthcare professionals come into play to start recording hundreds – or even thousands – of facts about the individual’s medical condition, factors that could have an effect on it, and other relevant information that could turn out to be critical for their treatment and the outcomes of care. This can include past medical history, family history, social history, smoking status and alcohol use, along with other assessments, the processes of care, and surgeries, which can all contribute to improving care quality.

Used effectively, this information has enormous potential to improve the health of not only the patient, but also other individuals across the hospital and potentially in other care venues. It can also help an organisation, and the entire healthcare system, run more efficiently, understand the needs of the community they look after, and guide local and national healthcare policy.

The first challenge, of course, is capturing this real-time data in a way that turns it into an enabler for improvement, rather than an obstacle for providing quality care. This requires the information to be gathered in a consistent manner by many different people, and it must be easily shared with and understood by other teams and organisations.

For all this to happen, the health professionals in the team and anyone else involved in the patient’s journey must use standardised and encoded terms to describe what they know about their patient. More importantly, all of the systems used to capture this data must be able to understand that language.

This is where SNOMED CT comes in – short for Systemized Nomenclature of Medicine Clinical Terms, SNOMED CT is a structured clinical vocabulary that is used within different EHR systems in over 80 countries. 

This standard represents a core part of what we all want to achieve: making data interoperable for the betterment of our own patients and, in fact, whole populations. We want to access easily viewable data at the point of care – data that we all understand and can therefore easily explain to the patient in front of us. This will immediately have an impact on both the patient and clinician experience.

Crucially, as we think more about the data we want to collect and the things we want to be able to do with that data, such as identifying cohorts of patients, creating an index of those patients and building registries that we can then apply analytics to, having structured data becomes fundamental – and making sure the right systems are in place to support these standards is the critical first step.

An integrated, consistent source of truth

Across our Trust, we have been leveraging the power of SNOMED and our Cerner Millennium EHR to achieve exactly these goals.

In addition to supporting patient care, the information we are gathering and recording in the EHR and the insights we are able to create from it are also helping us meet our local and national oversight requirements for quality.

One clear example is infection control, which is a high priority for any hospital – besides a top national priority. To prove good practice, we are required to demonstrate that all inpatients with infections are isolated appropriately.

In the past, this was attempted with a manual process that involved scrolling through bed boards and individual patient records. For a trust with 2,100 beds across 110 wards at five different sites, this process was both time-consuming and prone to human error.

We now have an automated system of reporting based on SNOMED terms, which pulls in data directly from every patient’s laboratory results. This means we have the capability to just tap something in, find what we need, and flag it immediately on the patient’s record.

As a result, clinical decisions are now better guided and supported by reliable, up-to-date information. It also allows nurses on the ward and in the infection control team to instantly spot patients who should be moved to isolation, and it assists with contact tracing when needed. The impacts on patient safety are self-explanatory.

30% reduction in the number of patients inappropriately located in open bays over the past 12 months.

Another requirement for hospitals is to screen all patients for methicillin-resistant Staphylococcus aureus (MRSA) within 24 hours of admission and isolate them if needed. Again, SNOMED CT’s common terminology has made it possible for us to switch from a manual, retrospective data collection exercise to a proactive response in real time.

Addressing local needs

Smoking is also a key area where hospitals need timely, robust data in order to provide and demonstrate high-quality care, besides being essential for payment under NHS commissioning arrangements for smokers to be identified, advised, and referred to smoking cessation services.

More importantly, looking at our local smoking rates and indicators, a great public health need within our community becomes evident. Compared to national benchmarks, there are higher numbers of smokers in east London – this in turn, results in higher rates for smoking-related disease admissions to hospital and higher mortality rates for cancer and respiratory disease.

Our area also has an unusual profile in which the use of chewing tobacco is high too: among our local Bangladeshi community, 60% of men and 50% of women use chewing tobacco. Tackling this is of great importance given the links between chewing tobacco, oral cancer, and adverse outcomes in pregnancy.

The level of granularity that SNOMED CT allows makes it possible to accurately record the use of chewing tobacco directly in our EHR and, later on, extract that data in a meaningful way.

The data is then shared with clinicians, so they can monitor screening rates themselves. Comparing their data has inspired collaboration through a bit of friendly competition between wards – this encourages best practice and improves the quality of care that we are providing to our local community and their specific needs.

Looking ahead, colleagues at Barts have started putting SNOMED CT to work in COPD (chronic obstructive pulmonary disease), another priority area for our Trust.

This condition is the second most common cause of emergency hospital admissions in the UK, costing the NHS in excess of £800 million every year, says Dr Richa Singh, respiratory consultant at the Royal London Hospital, part of our Barts family. Approximately a third of patients admitted to hospital as a result of their COPD are readmitted within a month of discharge.

To collect mandatory audit data on COPD patients, the Trust’s respiratory clinicians and the ICT team have been moving from a paper-based system, to a hybrid of paper-based and electronic methods.

The data required is already being collected on a routine basis, but the old approach is labour-intensive and unsustainable.

The next stage is a move to a fully integrated system that will pull data from respiratory teams in all of the Trust’s hospital and community sites, based on SNOMED terminology agreed with clinicians. Collaboration with other departments, including acute medicine and mental health, is also vital.

The hard work is already paying dividends and should ultimately enable us to use the data to prove our commissioners that we are doing the right thing for our patients.

A look into the future – without barriers

In fewer words, standardised data collection can only lead to easier data extraction and more accurate data utilisation – but why is this important?

As we all look at collaborating more closely with neighbouring organisations, local authorities and different parts of the system to collectively deliver the NHS Long Term Plan and provide truly integrated care, recording data in a structured way - regardless of systems used - is an essential step to bring down interoperability barriers and successfully implement region and nation-wide initiatives to improve population health management.