Breaking the pharmacy code: Promoting health care information sharing

SNOMED CT codes standardize medical terms, treatment recommendations, and disease states within a patient’s electronic medical record

Codes have been used for centuries to capture the content of a message or to communicate information secretly. From ancient symbols to Morse code to the genetic code, this system of communication is still used today, especially in the field of health information technology (HIT). Although billing codes are typically the first thing that comes to mind, pharmacists and physicians are using specialized codes called Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) codes to standardize medical terms, treatment recommendations, and disease states within a patient’s electronic medical record (EMR). When incorporated into an EMR, SNOMED CT codes can represent a patient’s medical information consistently and reliably.

Patty Lind, PharmD, Clinical Pharmacist at FirstLight Health System

There are currently more than 300,000 SNOMED CT codes, but only about 300 codes are specific to documenting medication therapy management (MTM) services, including clinical intervention such as resolving drug therapy problems or medication recommendations. Patricia R. Lind’s, PharmD, personal mission is to help create more SNOMED CT codes for pharmacists to use in MTM clinics and beyond.

“Computers have been used in pharmacy for years to help us manage the drug distribution process,” said Lind, a Clinical Pharmacist at FirstLight Health System, formerly Kanabec Hospital. “Now, with the availability of SNOMED CT codes, pharmacists will have a method to code their clinical care and their patient’s response to medications, which will allow this information to be retrieved for analysis or shared with other providers to help improve patient care on an individual as well as societal level.”

FirstLight is located in Mora, MN, a small town with a population of approximately 3,500 people. Although rooted in a rural setting, the health system has been acknowledged for its innovation in implementing HIT. Thanks to a health system–wide team effort, FirstLight was recognized in 2009 by HIMSS Analytics, the authoritative source on EMR adoption trends, for its adoption of the EMR model.

Lind has been a practicing pharmacist for more than 30 years, with one foot in pharmacy and the other in HIT. About 5 years ago she became interested in creating a clinical coding system to be used to document patients’ medication outcomes. “Imagine if there was a code that could be used in the EMR to document clinical information about a patient’s medication responses and the clinical care that a pharmacist provides,” Lind said in an interview with Pharmacy Today.

Coding for MTM services

Along with a team of five pharmacists and an ambulatory care resident, Lind currently sees patients at one of FirstLight’s MTM clinics, where she conducts comprehensive medication reviews. “When I see patients in the clinic, I write clinical notes about a patient,” explained Lind. She documents who referred the patient, why the patient was referred, and what the referral was for. The clinical note also documents her comments about the medication review, any drug therapy problems, and a plan to resolve those problems. Documenting the information using SNOMED CT codes creates an opportunity to capture actual patient response to drug therapy. “We will be able to see which drug therapies are getting patients to their goals and which drug therapies are not, which drug therapies are stopped due to adverse effects, and what those adverse effects are,” said Lind.

Patty Lind, PharmD, Clinical Pharmacist at FirstLight Health System, and Emily Neumann, PharmD, a pharmacy resident, discuss coding options using SNOMED CT.

Ultimately, the goal is to associate each clinical point in a patient’s MTM note with a SNOMED CT code and use this information to evaluate and improve the MTM practice and the quality of information within the health system, exchange information with other health care systems, and improve patient care.

Creating codes

For the past year, Lind has volunteered for a group called the Pharmacist Collaborative, formerly known as the Pharmacist Services Technical Advisory Coalition, which was formed in April 2002 to improve the coding infrastructure necessary to support billing and documentation for pharmacist-provided patient care services. The organization comprises several pharmacy organizations, and Lind serves as APhA’s representative on the Professional Service Documentation and Coding Work Group (WG2). Lind’s role is to help develop SNOMED CT codes that correspond to notes that pharmacists make in an MTM clinic. “Lind and the entire WG2 develop, update, and maintain pharmacists’ professional service documentation codes and look for coding aspects within professional guidance documents, such as medication reconciliation guides,” Shelly Spiro, BSPharm, Executive Director, Pharmacy e-HIT Collaborative, told Today.

Once Lind and the WG2 team develop the definition and explanation behind a code, it is submitted to the National Library of Medicine for consideration as a SNOMED CT code. “Once the codes are okayed, they are released so the electronic medical record vendors can incorporate them into the software so providers can use them,” said Lind.

At FirstLight, Lind and her team are very close to being able to use the SNOMED CT codes throughout the MTM clinics. The next step toward implementation is to start testing the SNOMED CT codes that are currently available. “I’m really excited about this. This is the infrastructure we need to ensure interoperability of our clinical notes,” said Lind.

Interoperability is key

According to Lind, one of the biggest challenges in health care is managing patients across health care settings. “A patient may see their regular physician, who might refer them to a cardiologist, and then the patient may be hospitalized,” said Lind. “Along the way medication changes often occur and uncertainty develops as to what medications the patient is supposed to be taking. Pharmacists, when they conduct a comprehensive medication review, work with the various providers and the patient to ensure the correct medications are being used.”

Lind discusses the electronic medical record with the team at FirstLight.

Once SNOMED CT codes are implemented in the MTM notes at FirstLight, pharmacists and physicians will be able to review critical elements of their clinical notes and can use them to help evaluate and improve their patient care and their MTM practice. Eventually, these EMRs, along with the notes, will be able to be transferred from one health system to another health system, promoting interoperability and continuity of care.

HIT in the ED

Lind assists with the development and maintenance of the HIT components at FirstLight that pertain to medications. She was a member of the implementation team for the EMR and computerized physician order entry (CPOE) system in the hospital and emergency department (ED).

In addition to her work with SNOMED CT codes, Lind answers patients’ medication-related questions.

“In the ED you have so many critical medicines involved, so I spent a lot of time going through all of the different drugs used in the ED and came up with proper dosing recommendations for how to administer these ED medications,” said Lind. “I built the guides into the computer system so that in an emergency situation, physicians are directed to common dosing strategies for commonly used ED medications.”

FirstLight is currently in a “maintenance phase” for HIT, although Lind will participate in a large hospital-wide HIT update that is scheduled for later this year.

HIT potential

Lind believes that the implementation of HIT, along with the development of new SNOMED CT codes for pharmacists in MTM clinics, has the potential to improve a health system’s cost, quality of care, and patient experience. Technology makes it easier for health professionals to review a patient’s medical history. “Once HIT records are interoperable, the patient’s EMR can be moved between health care settings, saving physicians and pharmacists time and reducing redundant medical tests and evaluations,” Lind explained. True EMR interoperability would mean that EMRs could be transferred from not just a hospital to an outpatient clinic, but also between health systems in different geographic locations.

HIT may also improve the health of the entire population, noted Lind. Categorizing data by using SNOMED CT codes allows for better analysis of medical and patient data. This will help reduce treatment costs by allowing pharmacists and other health care providers to make better decisions about what therapies are the most effective.

Clinical pharmacist Kati Dvorak, PharmD, works with Lind at one of FirstLight’s MTM clinics.

According to Lind, using SNOMED CT codes to evaluate medical data across health care settings could give pharmacists a global perspective on how well medications and pharmacist intervention work. Imagine the potential to improve the quality of care if we had a way “to capture [and share] a patient’s ongoing medication history and [his or her] response to medications,” said Lind.

“With the creation and implementation of SNOMED CT codes in health systems and outpatient clinics, we’re almost there.”