Transcript The Challenge: Karen Gibson

Karen Gibson




Significant investment in eHealth is underway
Clinical records:
◦ Not only a record for the author
◦ Essential to inform the next person in the care team
Clinical safety risks of poor quality, ambiguous
communication
Desire to:
◦ make systems more interoperable
◦ improve data quality
◦ improve ability to re-use information for reporting,
management etc.




Clinical Terminology is complex
Humans spend 4-10 years learning medical
terminology at University!
We need to make their language
computable
No silver bullets


Clinicians say things in many different ways
◦ Sometimes legibly
◦ Often in shorthand
Terminology needs
to maintain fidelity
of information – be
true to what clinician
is trying to say



EHR’s need to source information from many
different systems
◦ Legacy systems with legacy data
◦ Legacy terms and ways of coding (if coded at all)
How do we begin to bring this together?
And do so in a way which ensures stakeholders can
be confident that the information is accurate and
capable of being aggregated and reused.


SNOMED CT
◦ Most comprehensive clinical terminology
available
~ 350,000 concepts
~ 1,000,000 terms
◦ Purchased and maintained by a group of
collaborating nations for use in their eHealth
initiatives (IHTSDO)
Only part of the answer:
◦ Supplemented by other terminologies – eg.
medicines and administrative
◦ Knowledge of the information model (context)
◦ Other emerging technologies (eg. NLP)


SNOMED CT
◦ Complexity
~ 350,000 concepts
~ 1,000,000 terms
Only part of the problem
◦ Lack of implementation knowledge
◦ Lack of tools to assist
◦ Lack of funding to meet costs of implementation
◦ ? Lack of will
IHTSDO has addressed (or is working to address):
 International Governance
 Open Standard
 Intellectual Property
 Quality
 ? Mapping to other standard terminologies/ classifications
Others are being tackled by NEHTA:
 Cost – free to use in Australia (as member of IHTSDO)
 ‘Australianisation’
 National reference sets
 Medicines component

Do look to SNOMED CT-AU first
◦ It is endorsed by COAG
◦ It is the most comprehensive clinical
terminology available
◦ It is supported by NEHTA and IHTSDO

A concept and its descriptions
SCTID: 22298006
Fully Specified Name
Myocardial infarction (disorder)
Myocardial
infarction
SCTID: 751689013
Preferred term
Myocardial infarction
SCTID: 37436014
Synonym
Synonym
Synonym
Synonym
MI - Myocardial infarction
SCTID: 1784872019
Infarction
of heart
SCTID: 37441018
Cardiac
infarction
SCTID: 37442013
Heart attack
SCTID: 37443015
Relationships
• Links concepts within SNOMED CT
• Ensures unambiguous meaning
• Create hierarchies which aid navigation and retrieval
Injury of
anatomical site
Structural
disorder of heart
Myocardial
disease
SCTID: 128599005
SCTID: 123397009
SCTID: 57809008
Is a
Is a
Is a
Infarct
SCTID: 55641003
Associated
morphology
Myocardial
infarction
SCTID: 22298006
Finding site
Myocardium
structure
SCTID: 74281007

Consider the user interface carefully:
◦ Don’t show Fully Specified Names to users
 They’re intended to provide a
unambiguous reference point for
computability
 They are not worded in a way clinicians
speak
◦ Do choose a preferred term
Unambiguous
Reference Point
Fully specified name
Amebic appendicitis (disorder)
Semantic tag:
• indicates hierarchy
• not needed at
clinical level
US Spelling
Preferred term (Australia)
Amoebic appendicitis

Consider the user interface carefully:
◦ Don’t show all of SNOMED CT in a drop
down list (too many terms!)
◦ Unless you have tools to assist searching
◦ Do use Reference sets to assist
implementation:
 Reduce the complexity for the user
 Speed identification of the correct
term
Problem/diagnosis :
SNOMED CT in
Drop down list
without any
parameters
implemented
Select term
Problem/diagnosis :
Improved
searching –
limited to clinical
finding hierarchy
Could be further
improved
through Refset
development
Appendi


Reference sets Do require maintenance
Therefore:
◦ Do use NEHTA reference sets wherever possible
(because NEHTA maintain them!)
◦ Do use the hierarchies of SNOMED CT to guide
creation of RefSets wherever possible
◦ Recognise that if you pick ad hoc terms across
hierarchies you will need to manually maintain
the list
◦ Sometimes there is no choice – eg. allergies – but
there is a cost


Minimise mapping and data translation:
◦ There is a safety risk introduced every
time the clinician’s language is translated
(Chinese whispers…)
If you do need to map or translate:
◦ Do keep the original wording/ data entry
as well as the mapped equivalent

Trap for new players:
◦ Synonyms may be found in the wrong
hierarchy (different meaning)
◦ This is why when translating SNOMED CT
translators look at the words within the
hierarchy to establish true meaning
◦ However, this trap is not just for
translators, but also when mapping or
creating reference sets.


Even simple use of SNOMED as a flat code
list can add value:
◦ Allows meaningful exchange of data
◦ Both end-points can cross-reference to a
standard unambiguous definition
◦ Simple decision support can be enabled
For example –
US Centre for Disease Control, HITSP and
NHS all publish simple lists

But for those up to the challenge, more
advanced use of SNOMED CT offers further
potential value


Ability to Exchange data knowing it can be
explicitly and accurately interpreted
Ability to improve data quality:
◦ More structured data entry
◦ Agreed constraints can be applied
Ability to run externally developed queries:
◦ For example:
 Automatically run mandatory reporting
 Identify at-risk populations
 Identify cohorts for clinical trials
 Trigger presentation of evidence based guidelines when
first released
Note Kaiser Permanente have a central area which develop
queries/ scripts which are then distributed throughout
the organisation


Ability to utilise external decision support
engines:
◦ Already happening in medicines area
◦ Opportunity for improved decision
support applications in other areas
Ability to contribute to PCEHR

Ultimate aim is improving health outcomes
and patient safety:
◦ Through better sharing information
◦ Ensuring accuracy of information
◦ Identifying those at risk


Perhaps speaking to the converted, but
unless we can agree and implement
consistent terminology we will never
achieve the goal of better information
sharing….
We’ll just be sharing data….