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Traditionally, after a hospital patient has been discharged, coding specialists search patient records to identify diagnoses and interventions to which they assign codes from the classifications (International Statistical Classification of Diseases and Related ������ϱ� Problems, 10th Revision, Canada [ICD-10-CA] and Canadian Classification of ������ϱ� Interventions [CCI]). With electronic systems that use a terminology such as the Systematized Nomenclature of Medicine — Clinical Terms (SNOMED CT), there is an opportunity to expedite the coding process by mapping the SNOMED CT terms directly to appropriate ICD-10-CA codes. ICD codes are then readily available at any point during the episode of care for validation by a coding specialist and submission to CIHI. This supports the “collect once, use many” principle.

What is SNOMED CT?

SNOMED CT is a structured clinical vocabulary designed to be used within an electronic health record (EHR) or electronic medical record (EMR) system to allow a clinician to digitally capture diagnostic, procedural and related terms at the point of care. SNOMED CT’s standardized vocabulary supports direct care and management of the patient and can enable the sharing of patient information within and across all health care settings.

SNOMED CT is distributed by SNOMED International to member countries, with Canada ������ϱ� Infoway serving as the National Release Centre (NRC) for the SNOMED CT Canadian Edition (SNOMED CT CA). SNOMED CT CA will be updated quarterly starting in February 2024 (February, May, August and November).  

For more information regarding SNOMED CT, including questions about adding terms to SNOMED CT, please contact .
 

Laying the groundwork for semi-automated coding within Canada

As health care organizations in Canada adopt SNOMED CT within their EHRs, there is an increased demand for cross-maps to enable semi-automation of classification code assignment. SNOMED CT can be mapped directly to a classification to apply the principle of collecting information once and using it multiple times. 

For this purpose, ������ϱ�has created a comprehensive map from SNOMED CT CA to ICD-10-CA. The map has been compiled in line with classification rules, principles and the Canadian Coding Standards. These classification maps can be incorporated into system software to provide a semi-automated link from clinical information recorded by the clinician in the EHR using SNOMED CT CA to ICD-10-CA codes. Semi-automated coding will 
 

• Enhance efficiency and reduce coder burden
• Facilitate data reuse
• Expedite submission and response to national reporting requirements
• Support interoperability between EHRs and health care systems
• Improve data quality
• Create specialty driven subsets (e.g., rehabilitation, mental health, strokes) to support data capture in clinic environments, for example.

Pan-Canadian ������ϱ� Concern Value Set (PHCVS)

We have also developed a value set of maps from SNOMED CT CA to ICD-9 and to the Canadian Emergency Diagnosis Shortlist (CED-DxS) — called the Pan-Canadian ������ϱ� Concern Value Set (PHCVS) — to provide a standardized approach for collecting primary care health concern information and to support patient-level physician billing.