Why is a common clinical terminology standard needed for the electronic communication of health information and in the interoperable Electronic Health Record (iEHR), in Canada?

SNOMED CT® provides the core clinical terminology for the interoperable Electronic Health Record (iEHR). Currently it contains more than 357,000 concepts with unique meanings and formal logic-based definitions organized into hierarchies. When implemented in software applications, SNOMED CT® represents clinically relevant information consistently, reliably and comprehensively as an integral part of producing and populating clinical information in interoperable Electronic Health Records.

How was the decision to select SNOMED CT® arrived at in Canada? What recommendations were made?

In October 2005, the Infoway Clinical Terminology Integration (CTI) project recommended SNOMED CT® as the best choice for the reference terminology for priority clinical information groupings (or sub-domains) of the core interoperable Electronic Health Record (iEHR). As the pan-Canadian iEHR must serve the Canadian population (providers and patients alike), that also necessitates the need for SNOMED CT® to be available in both official languages.

In February 2006, acting on the recommendations of the Infoway CTI project and the EHR Standards Advisory Committee (SAC), the Infoway EHR Standards Steering Committee (SSC) agreed:

- To select SNOMED CT® for evaluation and piloting in both English and French as the Canadian standard for the reference terminology of the pan-Canadian iEHR; and

- To move to the next phase of the Standards Life Cycle where further detailed analysis work will be carried out so that SNOMED CT® is evaluated and tested as rapidly as possible.

They also indicated that:

- SNOMED CT® must be made available in both official languages as soon as possible; and

- Canada should immediately become a Charter Member of the International Health Terminology Standards Development Organisation (IHTSDO®) and establish a National Product Centre (NPC).

Additionally, in consultation with the Canadian Institute for Health Information (CIHI), Health Canada (HC) and the EHR SSC, Infoway acted on behalf of Canada to finalise Canada’s Charter Membership in the IHTSDO®. Canada’s NPC will reside for the first two years at Infoway under the Standards Collaborative.

As part of its Standards collaboration and coordination mandate, Infoway contributed Canada’s “share” to the acquisition of the member countries purchase of the SNOMED® intellectual property. Therefore, in accordance with the SSC recommendations, Infoway has now secured a national license for the SNOMED CT® standard for Canada.

The IHTSDO® is responsible for the maintenance and overall quality of the core international edition of the SNOMED CT® standard. For more information about this or about the IHTSDO® please refer to http://www.ihtsdo.org

In Canada, SNOMED CT® is available through the Infoway Standards Collaborative to Members. The Collaborative has begun to set up a Canadian National Product Centre (NPC) that provides a central service for managing, distributing, supporting and monitoring the use of the standard and related assets.

Why was SNOMED CT® recommended as the preferred clinical terminology standard for Canada?

SNOMED CT® was recommended because it captures clinical information at the level of detail needed by clinicians for the provision of care in all healthcare disciplines and most healthcare settings. It is the terminology "standard of choice" for semantic interoperability of Electronic Health Records.

Additionally, the global strategy today is to unite the many silos of healthcare delivery. Several countries, including Canada, are taking this unification a step further not only by creating an standards-based interoperable Electronic Health Record, but by ensuring that the SNOMED CT® core terminology, which provides a common language that enables a consistent way of capturing, sharing, and aggregating healthcare data across specialties and sites of care, becomes a global standard. Canada, through its Charter Membership in the IHTSDO®, is now positioned to effectively contribute and influence the ongoing development and maintenance of the SNOMED CT® standard.

Is SNOMED CT® going to replace ICD-10-CA and CCI?

No. The purpose, use and application of a clinical terminology such as SNOMED CT® to express primary clinical information in a real-time mode within an EHR differs from that of classifications such as ICD-10-CA or CCI.

The question of completeness is a difficult one to answer because it can be interpreted to mean as many things as there are clinical constituencies that ask the question.

In response to user-driven requests especially from application software developers, new content within existing areas of the terminology that is useful to all/the majority or Members may be submitted by National Product Centres or others for consideration for inclusion in the "core" standard.

On a regular basis, new content domains will also be considered for inclusion based on recommendations by the appropriate IHTSDO® Committees and on input and analysis from sanctioned Working Groups.

Alternatively, new content that is not relevant to all/the majority of Members may comprise an individual Member's extensions and subsets and if these are nationally applicable, when approved through due process, they may be distributed as part of that Member's national edition/release.

Traditionally, new core content is driven by advances in clinical knowledge, new procedures and changes in the practice and delivery of care.

Lastly, existing content must also be subject to regular review and refinement (including retirement) as necessary.

For these reasons SNOMED CT® will never truly be complete, but will continue to develop and evolve to reflect the current understanding and information requirements for clinical care processes.

Yes. Infoway recently approved the first phase of translation of SNOMED CT®. The goal of the SNOMED CT® French Translation Project is to provide Canadians with a French version of the terminology. The initial objective is to translate the priority sections of SNOMED CT® in French, using qualified vendor(s) and a proven software tooling environment capable of supporting such a complex multi-year project. Based on this experience, recommendations will be made for translation of remaining contents. More information on the project and its progress can be found on the Forum.

Relevant contents of SNOMED CT® are prioritized for translation in order to meet the requirements of various projects and Pan-Canadian Standards such as Public Health Surveillance (PHS), Lab, and iEHR. For example, EHR projects underway in Quebec need different groups of SCT concepts throughout 2008 and 2009. PHS projects are underway in Quebec, New Brunswick, Ontario and Manitoba. They also require a French translation of SCT.

The first translation phase in 2008-09 will focus on providing some 120,000 high quality French SCT concepts accepted for use in Canada. This involves the definition of editorial guidelines including linguistics rules for quality translation, and the development and integration of quality control mechanisms throughout the translation and acceptance processes. Infoway is benefiting from the previous experience of CIHI (translation of ICD-10-CA and CCI), the ongoing efforts of Denmark in translating SCT into Danish, the collaboration of the Office québécois de la langue française (OQLF) who has a very long experience in providing high quality translations through their Grand Dictionnaire Terminologique (over 100,000 terms relevant to health care), and the collective experience on the IHTSDO Translation Standard Committee, where in particular the 10-year Spanish experience and knowledge is shared. Canada is an active member of this committee and will continue to maintain a leadership role in the development of an international SCT translation standard.

It has been decided that there will be only one French version for the whole of Canada. French vocabulary will grow as translation of initial terms progresses and regular releases will be made available to SC members. A user-friendly browser will be provided to view French and English Canada extensions. An estimated 60,000 concepts already exist in French but must be verified and validated within the context of SCT concept based Description Logic to ensure that clinical meaning is preserved. To simplify and speed up access to French version, the English language synonyms available in SNOMED CT® will not be translated. French synonyms are not in scope; it is expected that implementation projects will identify candidate synonyms for some concepts and will make recommendation to the SC for addition to the French extension of SNOMED CT®.

Bilingual SNOMED CT® will allow EHR interoperability independent of language. French SNOMED CT® will be a key enabler for implementing terminology standards at all levels in jurisdictions using French in health care services.

The project will also be a major step towards fulfilling the February 2006 recommendations of the Standards Steering Committee to select for evaluation and piloting SNOMED CT® in both English and French as the Canadian standard for the reference terminology of the pan-Canadian iEHR.

The purpose of the National Product Centre (NPC) is to provide a central and single point within Canada to:

- Interface to the IHTSDO®;
- Interface to other NPCs;
- Interface to all entities within Canada that have an interest in the products or business of the IHTSDO®;
- Manage and control the use of the IHTSDO®'s assets within the member's territory;
- Interface to the IHTSDO Support Organisation and or to any Division of the CAP but only in accordance with IHTSDO® policies, procedures and regulations.

Under normal circumstances there should be no direct contact between entities within Canada and any division of the CAP with respect to access to SNOMED CT®. A limited amount (2 hours/month) of technical support/advice is provided to a designated Member representative by the IHTSDO Support Organisation. Support beyond the stipulated allowance is chargeable. The NPC has total responsibility for the distribution and support of the IHTSDO®'s Terminology Products within Canada. Therefore, the IHTSDO® has no obligation to perform or provide any such distribution or support.

Is SNOMED CT® here the same thing than the one in UK?

The "UK Edition" consists of the same core files we are providing plus UK national content (extensions, subsets, cross-maps, additional documentation). Extension material is relevant only to the Member/Country in which it is used (i.e., it is not part of "Core"/not of interest to all/majority of NPCs). The UK TC (their NPC) has been established for many years, so over the years has developed and supports SNOMED CT® cross-maps to READ Codes and other coding schemes, national subsets, national drugs extension, etc. The UK NPC also models and proposes new content for inclusion into the "Core" (i.e., this is content that does not currently exist as core content and is felt to be of use to all/majority of the NPCs). Going forward, one may expect the other NPCs to follow suit.

Can Canada create new SNOMED CT® concepts?

Yes. The Canadian NPC will be able to develop new content that either may comprise part of "extension content" (i.e., relevant on a national level to Canadian stakeholders) or, be proposed for approval and inclusion in the "Core" for use by all Members. Canada currently does not yet have a process for this, but will be developing one in the future.

Will you produce a Canadian version?

Yes, in future, we (Canada) will produce a "National Edition". That is already the case with some NPCs and will in the future, be the case with all NPCs. Under the Articles of Association each NPC has up to 90 days from receipt of alpha core release materials to produce a National Edition. The Canadian NPC which is housed within the Infoway Standards Collaborative will in future release a National Edition that includes the "Core" release files and any necessary approved national extension content. That process will begin shortly, as one of the other important priorities noted in the presentation is the availability of SNOMED CT® in French to support our two official national languages.

When will the Canadian NPC be implemented?

The formation and operationalization of the Canadian NPC (which is part of the Standards Collaborative and housed within Infoway) is already underway.

What types of software applications use SNOMED CT®?

There are many applications for SNOMED CT® including Electronic Health Records and Computerized Patient Order Entry systems (CPOE), as well as e-prescribing, laboratory order entry, problem lists, disease templates, laboratory results reporting, cancer reporting, therapeutic decision support, genetic databases, radiology image banks, surgical procedures, literature encoding, clinical research and global benchmarking, just to name some of them.

Note: SNOMED CT® itself is not software.

How comprehensive is the core terminology?

SNOMED CT® contains the vast majority of concepts required to record the process of care across the range of clinical professions in practice. The July 2007 release contains over 310,000 active concepts portrayed by more than 790,000 active descriptions and associated to each other by in excess of 923,000 defining relationships.

These concepts with their inherent unique meanings and formal logic-based definitions are arranged into 19 hierarchies covering the following areas, named as follows:

- Clinical Finding
  - Finding - e.g. Normal breath sounds; Clear sputum; Ataxic respiration; Mucoid sputum
  - Disease (Disorder) – e.g., Tuberculosis
- Procedure - e.g., Replacement of epidural electrode; Intravenous steroid injection
- Observable entity - e.g., Arterial pulse pressure; Left ventricular end-diastolic pressure, Colour of nail
- Body structure - e.g., Entire vortex of the heart; Mitral valve structure; Uterine structure
- Organism - e.g., Streptococcus pyogenes; Creutzfeldt-Jakob agent; Cryptosporidium parvum
- Substance - e.g., Aspirin; Acetaminophen; Capillary blood; Insulin; Albumin; Endorphin
- Pharmaceutical/biologic product - e.g., Aspirin; Acetaminophen; Tuberculosis vaccine
- Specimen - e.g., Tissue specimen from throat; Specimen from prostate obtained by needle biopsy; Calculus specimen
- Qualifier value - e.g., Avoid exposure of skin to direct sunlight or sun lamps; worsening, proven, unproven, intentional, unintentional, human to human transmission, fatal, unilateral, left, right
- Physical object - e.g., Dropper; Latex rubber gloves; Artificial kidney, device
- Physical force - e.g., Friction; Alternating current; Sunlight
- Event – e.g., Exposure to excess sunlight; Unexplained sudden death; Blizzard, Flash flood
- Environment or geographic location - e.g., Place of occurrence of accident or poisoning; Intensive Care Unit
- Social context - e.g., Divorced parents; Afro-Caribbean (ethnic group); Caregiver (person)
- Situation with explicit context - e.g., No bacterial antibody present, Family history: Myocardial infarction; No family history of stroke; Suspected epilepsy; Nasal discharge present; Diabetes mellitus excluded
- Staging and scales - e.g., Breathlessness rating; Staging classification for lymphoma; Optic nerve invasion stage N3 in retinoblastoma
- Linkage concept
  - Link assertion - e.g., Has reason, Has explanation, Is manifestation of
  - Attributes - e.g., Part of; Laterality, Procedure site; Finding site; Associated morphology
- Special concept - e.g., Inactive concept
- Record artefact - e.g., Death certificate; Advance directive report; Family record folder

What is the difference between the two releases?

Historically, there have been two releases of the Core SNOMED CT® standard produced each year.

With each of these two retrospective releases that are being provided, a History file is included. For further information about the History file, please consult the Technical Reference Guide.

In response to user-driven requests especially from application software developers, new content within existing areas of the terminology that is useful to all/the majority or Members may be submitted by National Product Centres or others for consideration for inclusion in the "core" standard. New content that is not relevant to all/the majority of Members may comprise an individual Member's extensions and subsets and if these are nationally applicable, when approved through due process, they may be distributed as part of that Members national edition/release. Canada currently does not yet have a process for this, but will be developing one in the future.

As new core content is driven by advances in clinical knowledge, new procedures and changes in the practice and delivery of care, so SNOMED CT® will continue to develop and evolve, with each release. Additionally with each release, regular review and refinement (including retirement of concepts) is also performed.

For future releases, general release notes will also be provided.

Is there a cross map yet? How much mapping do we have to do in Canada?

While some cross-maps were previously created within specific jurisdictions (the United Kingdom and the United States) for constrained purposes, such as the ICD-9-CM billing reimbursement maps created specifically for use in the U.S., these are not part of the release material being provided in Canada.

The World Health Organization (WHO) and the International Health Terminology Standards Development Organization (IHTSDO) have identified a requirement to collaborate on mapping between SNOMED-CT® and the WHO Family of International Classifications (FIC) which will include ICD-10 Second Edition. The Standards Collaborative approach will include participation from Canada in this collaborative mapping effort.

At this time, there is no current Canadian mapping projects underway. No cross maps between SNOMED CT® and ICD-10-CA and CCI exist. In order to move forward on a decision to map these terminologies several items need to be addressed such as needs, priorities, feasibility, and requirements. Any such determination and undertaking must involve the SDOs and/or maintenance bodies responsible for each standard, including Canada Health Infoway (CHI) and the Canadian Institute for Health Information (CIHI).

For mapping per se, there is none currently required if the use is for primary clinical information in the iEHR, or, for use in HL7 messages used to populate the EHR where a coded value is specified by the HL7 Datatype and SNOMED CT® is specified. Work will need to be done by application software developers to create SNOMED CT®-enabled software applications (i.e. creation of "pick-lists," etc.) but this is a different undertaking from mapping.

The International Health Terminology Standards Development Organisation (IHTSDO®) has been established as an association and not-for-profit corporation under Danish Law, based in Copenhagen, Denmark. The postal address is:

IHTSDO®
Rued Langgaards Vej 7,5
2300 Copenhagen S
Denmark

The URL for the IHTSDO® website is – http://www.ihtsdo.org

The purpose of the IHTSDO® is to:

- Acquire, own and administer the rights to SNOMED CT®, other health terminologies, and/or cross-maps to allied standards and other relevant assets (collectively known as "Terminology Products");

- Develop, maintain, promote and enable the uptake and correct use of its Terminology Products in health systems, services and/or products around the world; and

- Undertake all related incidental activities conducive to achieving this Purpose.

For more information about the IHTSDO®, its purpose and governance please refer to - http://www.ihtsdo.org/about-us/governance

Who are the IHTSDO® Members?

Members can be either agencies of national governments or other bodies (such as corporations or regional government agencies) endorsed by an appropriate national government authority within the country they represent.

Membership is open to all countries who are interested in using SNOMED CT® and working towards furthering the goals and purpose of the IHTSDO®.

All prospective Members of the IHTSDO® must meet certain criteria to join the IHTSDO®. For further information refer to the Articles of Association. The full version may be downloaded from http://www.ihtsdo.org/about-us/governance and the condensed version may be found at - http://www.ihtsdo.org/about-us/governance/articles-of-association-condensed-version

Information about current IHTSDO® Members is found at - http://www.ihtsdo.org/members/#c409 and http://www.ihtsdo.org/members/ca or http://www.ihtsdo.org/members/ca/canada-francais

Is there any way that I could access the License Agreement and Articles of Association within the Canada Health Infoway site after I have signed in?

The Articles of Association of the IHTSDO are in the public domain and available as a link within the body of the "Standards Collaborative" text from the "What We Do" page, or, via the IHTSDO website. The URL for the IHTSDO website is http://www.ihtsdo.org.

The License Agreement is presented to those Standards Collaborative (SC) members prior to accessing the link to the SNOMED CT® materials. From the main page - http://www.infoway-inforoute.ca access the "What We Do" link and then under "Standards Collaborative", the "SNOMED CT®" link. In addition to being a member of the SC in good standing, in order to access SNOMED CT® materials you will also be prompted to sign in via your Infoway passport.

If you do not have an Infoway passport, please access the link in the top centre of the "What We Do" page - http://www.infoway-inforoute.ca/en/WhatWeDo/Overview.aspx

If you are not a Member of the SC, please use the following links to find out more how to become a member, membership categories and the benefits of Membership:

http://sl.infoway-inforoute.ca/content/dispPage.asp?cw_page=sc_membership_e (English version) or

http://sl.infoway-inforoute.ca/content/disppage.asp?cw_page=sc_membership_f (French version).

Who are the IHTSDO® Charter Members and what does this mean?

The Charter Members are those countries that worked together to form the IHTSDO® organisation and include Australia, Canada, Denmark, Lithuania, Sweden, the Netherlands, New Zealand, United Kingdom and United States.

Representatives from these nine nations led negotiations with the College of American Pathologists (CAP) to acquire the Intellectual Property (IP) and put in many hours of work to develop the guiding principles and governance structures for the IHTSDO®. In addition, their financial contributions (or “set-up fees” as described in Clause 7.4 of the Articles) provided funds to secure the IP of SNOMED CT® and antecedent works.

Charter Members are given special status for the first five years of the IHTSDO® Association, in that they have an assured seat on the Management Board. Any vacancies during that time, and all seats after that time, shall be elected on a regional basis.

What are the rights and obligations of Members of the IHTSDO®?

The rights and obligations of Members are fully outlined in the Articles of Association. The full version of the Articles may be downloaded from http://www.ihtsdo.org/about-us/governance, and the condensed version is located at - http://www.ihtsdo.org/about-us/governance/articles-of-association-condensed-version

In essence Members, through the IHTSDO®, are joint owners of SNOMED CT® and have the right to influence its ongoing further development. The annual membership fee provides for the use of SNOMED CT® within their Territory.

As outlined in Clause 5 of the Articles of Association, Members manage the release, adaptation, distribution and sub-licensing of SNOMED CT® and other products of the IHTSDO® within their Territory. Details of the conditions under which Members may access and modify SNOMED CT® are fully outlined in Schedule 3 (Attachment 2) of the Articles.

One of the key aims of establishing the IHTSDO® has been to foster international collaboration and contributions to accelerate the ongoing development of SNOMED CT®. It is anticipated that Members will work together collaboratively and thereby more efficiently improve the quality and comprehensive nature of SNOMED CT®.

What is a Harmonization Body?
 

Therefore, this form of interoperation is in itself a standard. However, this type of standard must be owned both by the IHTSDO® and the associated standard, along with any other required supporting material and managed as a SNOMED® Allied Standard.

Allied Standards may take the form of a specification, a service or a product. Regardless of format, the joint ownership of the Allied Standard means its definition and alteration can only be achieved through agreement between the IHTSDO® and the maintenance body or SDO for the associated standard.

These collaborative efforts will be supervised through the creation of a Harmonization Board to manage each SNOMED® Allied Standard. This will create a strong link to the governance processes of the Management Board of the IHTSDO® yet leave sufficient flexibility for the Allied Standard to be managed in a way that best suits its particular requirements.

How much does it cost for Canada to be a Member of the IHTSDO®?

Members’ fees are structured on a fair-share formula based on each nation’s Gross Domestic Product (GDP) and population plus the total cost to the IHTSDO® of maintaining SNOMED CT®. The ability to pay is reliant on the trusted third party body, namely the World Bank GNI Atlas. Information about this body is published on the IHTSDO® website.

The spreadsheet on fees published on the IHTSDO® website indicates how much Canada paid for the joining fee and as an annual fee. More detail on how fees are controlled is contained in the Articles of Association. The full version of the Articles may be downloaded from http://www.ihtsdo.org/about-us/governance.

What is the General Assembly?

The General Assembly is the highest authority of the IHTSDO® and will meet at least twice a year in April and October. All Members have voting rights at the General Assembly and can bring forward items for consideration.

Strategic direction for the IHTSDO® will be provided by the Management Board (of twelve) which reports to the General Assembly.

What does the SNOMED Intellectual Property (IP) transferred to the IHTSDO® include?

The SNOMED® enterprise IP exists at the moment as a number of specifications, processes and activities which produce a number of outputs that can be broadly categorized as follows:

Documents describing the SNOMED CT® standard(s)/specification(s)

The terminology in tab delimited text files consisting of:

  - Concepts

  - Descriptions

  - Relationships

A set of specified technical tools for supporting content development and content request processing

A set of SNOMED® allied standards, which enable SNOMED® to effectively interoperate with and/or map to via cross-maps to other international information standards

Implementation guidance and instructions for the successful use of SNOMED including:

  - Existing foreign language translations/editions

  - Establishing "reference" implementations

Services:

  - Keeping the terminology current with respect to clinical concepts needed for care delivery

Derivative works that help in the uptake and use of SNOMED CT®, such as:

  - User manual/quick start guide,

  - Technical Implementation Guide

  - Technical Reference Guide

  - Technical documents that are proceeds from sanctioned Working Groups.

  - Basic training materials, etc.

The way that the IHTSDO® has been structured will enable all Members needs to be supported in a way that enables international interoperability.

Up until April 2007, the SNOMED® International Division of the College of American Pathologists (CAP) maintained the technical design, the core content architecture, the SNOMED CT® core content, the technical documentation and owned all the related Intellectual Property (IP). The College of American Pathologists (CAP) and a group of nine nations (Australia, Canada, Denmark, Lithuania, Sweden, New Zealand, The Netherlands, the United States and the United Kingdom) agreed to establish a Standards Development Organisation (SDO) to maintain and promote the SNOMED CT® standard. The nine nations further agreed to establish the SDO known as the International Health Terminology Standards Development Organisation (IHTSDO®) as a not-for-profit association and corporation under Danish law.

In Canada, retrospective releases of the core SNOMED CT® standard are now available to Standards Collaborative Members in good standing through the Infoway Standards Collaborative via the Canadian NPC that Infoway has begun to set up. The NPC will provide a central service for managing, distributing, supporting and monitoring the use of the standard and related assets.

The new SNOMED CT® services will be accessible from our Standards pages on the Canada Health Infoway website at either -

http://sl.infoway-inforoute.ca/content/dispPage.asp?cw_page=snomedct_e or

http://sl.infoway-inforoute.ca/content/disppage.asp?cw_page=snomedct_f.

These services are available to Standards Collaborative members in good standing. The Standards Collaborative membership structure offers student, individual and corporate level memberships. By accessing the following links you can learn more about the benefits of Membership and how to become a Member:

http://sl.infoway-inforoute.ca/content/dispPage.asp?cw_page=sc_membership_e or

http://sl.infoway-inforoute.ca/content/disppage.asp?cw_page=sc_membership_f.

As to why the IHTSDO® is licensing the terminology, licensure helps the IHTSDO® ensure that the terminology:

1. Is sustainable;

2. Improves interoperability, and;

3. Does not compromise patient safety.

In terms of sustainability, the IHTSDO® needs an income stream to be able to maintain and improve the quality of SNOMED CT®. Users of the terminology will contribute to the maintenance and running costs of the Association in accordance with their ability to pay. Maintaining interoperability of the terminology requires changes to the terminology to be constrained, with appropriate control over national modifications and enhancements. Both of these factors have the ability to impact patient safety – which requires processes to ensure the quality of the terminology (which in turn incurs costs as outlined in 1. above) and a common understanding of encoded data (which requires interoperability as in 2. above).

For the immediate future, as the structures and processes of the IHTSDO® come into effect and are refined, the IHTSDO® Management Board has opted for a licensing model which is not dissimilar from the status quo. If in future, Members can be convinced that there are alternative models which allow more open access to SNOMED CT® and yet do not adversely affect any of the three primary tenets above, such an alternative model or variation to the licensing conditions may well be accepted through a vote of the General Assembly.

What should I do to obtain SNOMED CT®?

In order to access SNOMED CT® you need to be a member in good standing of the Infoway Standards Collaborative and agree to the terms of the License Agreement. Additionally, in order to access the Standards Collaborative pages or any of the Infoway forums you will first be prompted to sign in with Infoway Passport.

If you do not have an Infoway passport, please access the link in the top centre of the "What We Do" page - http://www.infoway-inforoute.ca/en/WhatWeDo/Overview.aspx

If you are not a Member of the SC, please use the following links to find out more how to become a member, membership categories and the benefits of Membership:

http://sl.infoway-inforoute.ca/content/dispPage.asp?cw_page=sc_membership_e (English) or

http://sl.infoway-inforoute.ca/content/disppage.asp?cw_page=sc_membership_f (French).

Note: If you have an Infoway passport and a corporate membership, you will be able to access SNOMED CT® if you are one of the designated representatives within your organizational membership.

Please note that you can not get access to SNOMED CT® releases without becoming a member of the Standards Collaborative.

What is the process for application software developers to obtain a license for inclusion of SNOMED CT® in their products? What is the timeframe?

Application software developers will require a license (this is formally known as an Affiliate license).

If you are based within Canada and only wish to use SNOMED CT® within Canada you should contact the Infoway Standards Collaborative which will be able to provide further details of membership, how to access the International Release from the NPC and will also inform you of any additional materials or conditions relevant for use within Canada.

The terms and conditions of the License agreement will need to be accepted and a record of your acceptance provided prior to accessing SNOMED CT®.

If you are based within Canada, but wish to deploy SNOMED CT® in other countries you’ll need to first check whether those countries are also members of the IHTSDO®. The Affiliate license is a world-wide license so it can be used in other IHTSDO® Member’s territories. There may however, be additional national extensions or modifications relevant to the use of the standard in a members Territory that you require, so you’ll need to check with that Member.

As specified in the Affiliate License, there is charge payable to the IHTSDO® for use in non-member Territories.

If you are not based within Canada, or, another Member nation, you will need to contact the IHTSDO® directly to purchase a license and arrange download access to the core standard. The flowchart diagram at the end of this section illustrates the typical licensing scenario questions and actions.

Two retrospective releases (January 2007 and July 2006) of the core SNOMED CT® standard and related documentation became available in Canada to Members of Infoway's Standards Collaborative on July 30, 2007.

Our hospital or clinic wants to start using SNOMED CT®. What do we need to do? 

If you are planning to develop your own in-house systems, then the conditions for application software developers are applicable to you.

If instead, you are intending to procure a commercial solution, then you need to stipulate the use of SNOMED CT® as one of your requirements during procurement and purchase of the system. The Affiliate license which the vendor must hold and abide to the terms of will cover your use of SNOMED CT®.

I'm an individual who wants to use SNOMED CT® for my own purposes or for research. What do I need to do? 

If you live within Canada then you are entitled to use SNOMED CT® and you should contact the Infoway Standards Collaborative for further information about how to gain access. If you are not a member of the Standards Collaborative, you will have to take out a membership before acquiring the SNOMED CT® standard for your particular use.

If you do not live in a Member nation, you should contact the IHTSDO® office. While the IHTSDO® Management Board recognises the value of research to the progression of SNOMED CT®, they would however, seek to ensure that this is a valid research project, and not the de-facto use of the terminology without making a contribution to its maintenance.

What are the benefits of using the SNOMED CT® Clincial Terminology Standard?


Patient-focused Benefits


- Increased access to standarised patient clinical data can increase the response of care-delivery at the point of service;

- The right information - in the right place - at the right time, aids decision support;

- Improves confidentiality by reducing exchanges of paper-based data;

- Elimination of repeated data entry improves data quality and reduces transcription errors;

- Information sharing between systems can avoid redundant, duplicate service delivery; and

- Elimination of repetitive data entry permits re-allocation of human resources.


Benefits to Healthcare Delivery Organization Administrators and Policy Makers


- Avoids the building and maintenance of customized tables which would otherwise be required in the absence of standards;

- Standardized approach permits cost-effective interoperability;

- SNOMED CT® has evolved to become the predominant terminology standard and is increasingly accepted worldwide through increased international participation in its development and adoption.

How can I find out more about SNOMED CT®?

From the Infoway Standards Collaborative.

The Infoway Standards Collaborative was launched in 2006 as a Canada-wide coordination function to support and sustain health information standards in Canada. It is responsible for the implementation support, education, conformance, and maintenance of EHR standards currently being developed by Infoway. It also encompasses other standards initiatives including the Partnership for Health information Standards, HL7, Canada's participation in DICOM (Digital Imaging and Communications in Medicine) and, in conjunction with the Canadian Standards Association (CSA), the secretariat to the Canadian Advisory Committee to ISO/TC 215 – and now SNOMED CT®.

The Infoway Standards Collaborative has begun to set up a Canadian National Product Centre (NPC) that will provide a central service for managing, distributing, supporting and monitoring the use of SNOMED CT® and related assets within the context of the newly created International Health Terminology Standards Development Organization (IHTSDO®) - of which Canada is a Charter Member.

For more information on SNOMED CT® in Canada, please e-mail the Standards Collaborative Infodesk at standards@infoway-inforoute.ca, or, visit the following links –

http://sl.infoway-inforoute.ca/content/dispPage.asp?cw_page=snomedct_e or

http://sl.infoway-inforoute.ca/content/disppage.asp?cw_page=snomedct_f.

General information on this initiative and other standards initiatives, can be found under "What We Do" on Infoway's website (http://www.infoway-inforoute.ca), in the Interchange newsletters, via Standards Collaborative membership announcements or obtained by e-mailing the Standards Collaborative Infodesk at standards@infoway-inforoute.ca.

We also proactively make public announcements and news releases as significant developments occur.