Nick Stolls updates us on the implementation of SNOMED CT and what it means for your practice.
With practices in England now open for face to face treatments, attention is turning back to some of the issues facing the profession before lockdown. One such issue was whether or not practices should be using SNOMED CT for all electronic patient level data recording. At the moment, the simple answer is no.
The BDA has been involved in the conversations with OCDO, BSA and the dental software suppliers surrounding the dental implementation of SNOMED since 2017. While we appreciate the system wide benefits of SNOMED CT, we maintain the view that it must enhance, and not hinder, busy NHS practices.
We are calling for any implementation to:
- Easily integrate with the current dental software systems without becoming onerous on the practice
- Work to a clear specification outlining the level of detail required by the NHSBSA on treatment, findings and diagnoses.
- Not be used to penalise dental practices.
SNOMED was scheduled to be implemented by 1 April 2020. However, the COVID-19 pandemic and the difficulties surrounding implementation meant that this was not possible. While no official announcement was ever made, its implementation was postponed in late March. Now as SNOMED looms on the horizon, it is imperative that we stick to the principles set out above.
SNOMED CT is a dictionary or nomenclature of clinical medical terms which aims to standardise the codes attached to each medical/dental/clinical procedure, diagnosis and finding.
What is SNOMED CT?
For example, an early 2018 draft version of suggested codes in restorative dentistry showed there were five different codes for types of examinations:
|51733004||Periodic oral examination||Periodic oral examination (procedure)|
|122856003||Oral examination||Oral examination (procedure)|
|30175009||Initial oral examination||Initial oral examination (procedure)|
|274802005||Examination of tongue||Examination of tongue (procedure)|
|85191009||Emergency oral examination||Emergency oral examination (procedure)|
What are its issues?
Noting procedures is usually fairly simple. However, recording an examination using SNOMED CT requires more care to be taken to ensure the correct code is attributed.
"Whatever the final design, the challenge has always been to mitigate the burden of administrative time..."
It gets more complicated when you introduce findings underneath diagnoses. Again, a single diagnosis may have one or two findings underneath.
For dentistry, if you have a patient with a full complement of teeth and at least four different surfaces, initial charting will mean multiple codes may need to be inputted for each procedure, diagnosis and finding. There may be free text alongside drop down boxes.
Whatever the final design, the challenge has always been to mitigate the burden of administrative time that this would cause.
We are pushing for a well-planned implementation. We believe that to implement SNOMED CT in the initial way that it was presented would mean that every patient previously seen would need a complete re-charting on day one of implementation. This would cause practices some difficulty in meeting activity targets and getting enough patients seen in a day. Without any specific training programme or acknowledgement of the reduced activity, we resisted implementation so that a workable solution could be found. This is a principle that we will continue to stick to.
Why is SNOMED CT being introduced?
SNOMED CT offers the opportunity for health records to be more universally available and understood without the need for language translation. It will capture epidemiological data and can be used across wider geographic areas. Standardising records using SNOMED CT will also support a change to integrated and interoperable health records in England (medical and dental records in England are currently separate).
While the benefits of SNOMED are not really in question on a larger scale, our members ask us what the benefit is for them and their practices. That is the difficult question to answer. For an individual practice, at the moment, it doesn’t seem to offer any positives but instead creates additional work which is an issue we grapple with. Yet another reason to avoid a cumbersome implementation process.
How will it be implemented?
Implementation requires the software suppliers to receive a specification to advise how the NHS wants the system to record and transfer patient level data. In 2006, the dental contract required that dentists only transmit FP17 data on banded courses of treatment, not the number of clinical treatments provided on patients. Currently the software via EDI transmits FP17 data to the BSA usually using old pre-2006 codes, Introducing SNOMED means that a higher level of clinical data would be collected and unless that is utilised by the BSA, there is little point collecting it. Both practices and the BSA would need to be able to send and receive data in SNOMED format.
"Our issue with SNOMED CT remains how to balance information collection and data input pressures."
Our issue with SNOMED CT remains how to balance information collection and data input pressures. The concept behind SNOMED CT makes sense, however, designing its practical implementation hasn’t been smooth. The amount of data that needs to be collected could mean a huge burden on practices. We’ll continue to resist this in the absence of a good plan for training dental teams or an acknowledgement of the impact of reduced activity.
What is the BDA doing to improve the outcome?
Over the next few months NHSX, which now oversees digital issues within the NHS in England, will pick up this issue and work with each care setting to determine manageable enforcement dates.
We remain a significant stakeholder for dentistry. When discussions around implementation come back on the agenda, we’ll stick to the basic principles we have outlined above. While we appreciate the system wide benefits of SNOMED CT, implementation has to work for busy NHS practices.
GDPC Executive member