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Tuesday, July 21, 2009


There are days when I feel as if I'm at the butt of some massive Federal joke. This is one of them. My day started early to work on completion of some pending IHE publications, when I recieved an e-mail titled CORE Problem List Subset of SNOMED CT® Now Available the content of which you can find in the link. This is great work, but isn't coordinated with the national agenda around interoperability.

ANSI/HITSP has already selected the VA/KP Problem List Subset of SNOMED CT® which contains the controlled terminologies identifying problems used for medication labeling. This was felt to be a good subset by ANSI/HITSP since it clearly identified a set of problems required for patient care.

If you've clicked both links you probably can understand my frustration, given that these overlapping subsets are both available through the National Library of Medicine.

The rationale for creating the CORE subset was, I understand, to create a smaller subset of SNOMED CT® that could be used by institutions that want to get started with SNOMED CT®, but did not want to deal with the entire terminology. I'm pleased with the rationale, however, the end result is that now there are two subsets of SNOMED CT®, both created with the assistance of Federal Agencies (VA and FDA for the first, and NLM for the second), which overlap. This creates a massive interoperability problem in the use of SNOMED that ANSI/HITSP will spend in my estimate at least 400 committee member hours of time upon.

How is one to harmonize these two within ANSI/HITSP? I see two options: 1) create a new subset that is the union of both, and 2) create a new subset that is the intersection of both. Neither of these is desirable. The former creates a bigger subset that does not meet the requirements of institutions that wanted as smaller subset to begin with, and the second creates a subset that is about 70% smaller in size that the CORE subset, and doesn't allow the full detail of problems associated with medications to be exchanged.

Why should ANSI/HITSP be required to resolve these issues. Don't we have an office somewhere nationally that can coordinate these activities? This should not be a problem that ANSI/HITSP needed to solve. Instead, this should have been coordinated as part of a national strategy for the use of SNOMED CT®.

I realize that the current Office of the National Coordinator under HHS is not responsible for creating this problem, but I would certainly like that office to resolve it.

Here is my back of the napkin proposal:
1) Create an NLM Project to support the maintenance of the SNOMED CT® subsets used for federal programs.
2) Include within this project the requirement for managing the subset used for medication labeling.
3) Include within this project the requirement for managing a smaller subset that can be used for healthcare interchange.
4) Ensure that the entire subset is available under the same terms and with the same ease of distribution as the VA/KP subset is presently.
5) Ensure that the technical interoperability issues between the two subsets are addressed (for example, the smaller subset should be able to accurately but less precisely code everything in the larger).



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