Consolidated Health Informatics Initiative
Final Recommendation Information Sheet[1]

Domain Title and Team Lead:

Diagnosis & Problem List:  Karla Porter and Beth Acker, VA Co-chairs

Scope:

A series of brief statements that catalog a patient’s medical, nursing, dental, social, preventative and psychiatric events and issues that are relevant to that patient’s health care (e.g. signs, symptoms, and defined conditions).

Domain/Sub-domain In-Scope (Y/N)
Clinical Diagnosis/Problems Y
Subjective Symptoms/Observed Findings Y
Nursing Diagnoses  N*
Modifiers and Descriptors

N**
Synonyms Y
Dental N
Alternative Medicine N

* Nursing Diagnoses will be addressed by the nursing domain workgroup.

**Note about Modifiers:  Many modifiers or “attributes” of a diagnosis or problem often accompany the concept itself.  These attributes are as a rule not well defined or standardized.  Furthermore, the attributes represent the diagnosis at just one of many possible arbitrary slices in time (i.e., “final” is truly in the eyes of the beholder).  The term “Modifiers and Descriptors” above refers to a grouping of these terms rather than attempting to list each specific one.  The scope of this report does not cover any of these attributes.

Alternatives Identified 

  1. SNOMED-CT
  2. ICD-9-CM
  3. ICD-10-CM
  4. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.)
  5. MEDCIN
  6. ICPC
  7. MedDRA

Final Recommendation:

The workgroup recommends the adoption of Systematized Nomenclature Medicine-Clinical Terms (SNOMED CT), a comprehensive health care reference terminology that includes concepts for diagnoses, findings and disorders.

The specific locations in the SNOMED CT hierarchies that form the basis of our recommendation are:

  • Diseases
  • Findings

Content Coverage:

No terminology is complete, but SNOMED CT is sufficiently complete in the areas of diagnoses and problem lists, especially in comparison to other available terminologies.  However, it is essential that accurate mappings exist between SNOMED-CT and other administrative code sets and terminologies including ICD-9/10-CM, DSM (Mental Health) and MedDRA (Adverse Event Reporting).  Consistent with NCVHS recent recommendations, mapping needs are being referred to the National Library of Medicine.

Acquisition:

An agreement has been signed between the U.S. Government and the College of American Pathologists (CAP) to distribute SNOMED CT in all future releases of the Unified Medical Language System (UMLS) Metathesaurus.  UMLS license terms allow use for all patient record uses and messaging.  In the US, SNOMED CT will be one of the Category 0 codesets.  This permits free distribution and use in the US.

Conditions:

No conditions apply to the above recommendation. The workgroup would like to see mappings of the diagnosis/problem list terminologies in the UMLS to SNOMED-CT to be maintained, validated, and distributed through the UMLS. The workgroup recognizes the importance of the collaboration of the source diagnosis/problem list terminology owners and the SNOMED CT for diagnosis/problem list with the appropriate inclusion and representation of diagnostic terms within SNOMED-CT.

For example, mapping considerations must be given for administrative (ICD-9/10), financial and HIPAA requirements, as well as collaboration with DSM IV for Mental Health and MedDRA for adverse event reporting.

Diagnoses and Problems

Criteria SNOMED CT MEDCIN
(reference terminology)		 ICD-10-CM
Concept Orientation 1 1 0
Concept Permanence 1 1 1
Non-Ambiguity 1 1 0
Explicit Version Ids 1 1 ?
Content Coverage The July 2003 SNOMED-CT contains 73,171 concepts in the Disease hierarchy and 40,106 concepts in the findings hierarchy. MEDCIN contains the entire content of International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) codes. 140,000 including modifiers
Settings (inpatient, outpatient, etc.) All Settings All Settings All Settings
Scope Includes content for multiple disciplines involved in health care MEDCIN’s content applies to physician documentation and appears to contain little content for nurses and allied health care providers, therapists, social workers, dieticians, etc. Physician based coding system
Ownership College of American Pathologists, Multidisciplinary Editorial Board Proprietary, Internal Editorial Board, Physicians Only NCHS
Availability

Cost

 No additional cost (beyond funds expended by Govt) to US users. Available through UMLS Small cost for reference terminology, interface application costly Available free from NCHS
Use Limited current usage Limited Deployment DoD uses interface application Used for mortality reporting since 1999
Mapping Mapped to ICD-9-CM and ICD-10: Needs work if to be used for billing MEDCIN does not include mappings to ICD-10, SNOMED, or ABC codes.  
Considerations Needs interface to enhance use in clinical setting.   Improved structure from ICD-9-CM Developed for administrative purposes

[1] Information Sheet designed specifically to facilitate communication between CHI and NCVHS Subcommittee on Standards and Security resulting from May 20, 2003 testimony.  CHI may seek assistance to help further define scope, alternatives to be considered and/or issues to be included in evaluation process.