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Expectations to an International Terminology in Health(care)

Pieter E Zanstra

Radboud University Nijmegen Medical Center Co-ordinator EU SemanticHEALTH Specific Support Action:

Semantic Interoperability Deployment and Research Roadmap

Semantic Mining Conference on SNOMED CT; Copenhagen 20061001

Presentation Overview

• • • • • •

Clinical perspective Coding practice A bit history Why it is so hard The magic of

π

The challenge

3

Where are we coming from..

Reviewed. Primip FT No ANC probs F/D at 08:45 Needed synto for Epidural in-situ  contractions about 7cm Decent progress since.

No urges to push really according to patient Contractions 4:10 but poor duration & strength (on 60 u/s /synto) PA: Ceph 0/5 VE: Head at +1 Caput +1 No ???

OA position Cx F/D NO DESCENT Tried pushing – poor maternal effort despite instruction Although epidural working well, doesn’t stop longstanding spasmodic hip pain.

Very problematic FHR  CTG  No descent with attempts at pushing – poor effort.

Plan… a) Push synto  b) Need really try to push & work on technique c) reassess at interval 15 mins & D/W consultant Would not be happy to have to exert traction with Forceps when no effort & no descent 4

Competing demands on recording

ICD, ICPM DRG Categorise Classifier

?

Manage Grouper Referral letters Documentation

Record 5

Example Interface terminology

PURKINJE 6

7

What kind of business logic do we need?

ICD, ICPM Classifier Grouper DRG Documentation Mediation Service

Record 8

GALEN Vision

• • • • •

A means to cope with size and diversity

–

“Coherence without uniformity” Patient information and clinical knowledge

–

available,

relevant

, in your language, Specialised clinical component software

–

interworking systems exchanging

meaning

Libraries of knowledge big enough to matter An open resource for Europe and beyond

9

What binds Records, Interface, Reporting, Knowledge…?

Interface Terminology Reporting Terminology (ICD) Mediation Service Health Record Discharge Referral..

10

Record architecture terminology (mediation) Name, Context and Content

physical examination breast palpation lump

CONTEXT NAME

present

CONTENT

©Angelo Rossi Mori 11

Sound semantics underpinning continuity in care

restore the terminological CONTINUUM between Content and Structure

observation by physical examination observation by physical examination of breast observation by palpation of breast status of lump by palpation of breast present presence of lump by palpation of breast ©Angelo Rossi Mori 12

What is a term referring to?

•

Blood pressure

– –

Evaluation result (high, low) Measurement (diastolic, systolic) Archetype/Template?

–

Guideline (how to measure?)

•

Rheumatoid arthritis

– –

Evaluation result Measurement (criteria)

13

National Institute for Public Health and the Environment

Classification & the Law

14

Semantic interoperability (example of drugs with different trade marks) The example:

The name of this drug is

not known

in German pharmacies!

A patient coming from Switzerland to a German pharmacy is

looking for a drug

well known in Swiss: The pharmacist „

DROSANA

Resiston Trpf.“    will not find this drug in his drug data bases, is

not able to identify the ingredients

of the drug,

can not look for an equivalent drug

available in Germany. Reinhold A. Mainz, BMGS, Germany, Project Group Telematics – Health Card 14./15. February , Bruxelles, EC / WHO Workshop on Semantic Interoperability 15

SNOMED-3 READ-2 MeSH ICD-9 ICD-9-CM ICD-O NCSP ICPM OXMIS ECRI-UMDNS SNOP HCFA ACR-NEMA IUPAC-NPU LOINC DICOM-SDM MCTGE CDAM NGAP ICPC OPCS-4 CPT-4 NDC NANDA ICNP AIDSLINE MED80 MED66 AIDSDRUGS

Codes, codes everywhere...

AIDSTRIALS ChemID CHEMLINE GENE-TOX HISTLINE SDLINE TOXLINE TOXLINE65 TOXLIT PDQ AVLINE BIOETHICS CANCERLIT CATLINE DENTALPROJ MEDLINE POPLINE SERLINE DOCUSER Dxplain AI/RHEUM Iliad GenBank OMS PSY TRIFACTS NIOSH NPIRS NEDRES MED85 MED75 HSTAT HDA MED90 HealthSTAR ACR92 AIR93 BRMP96 NIC ULT BRMS96 COSTAR CPM CRISP COSTART DMD DSM III & IV DOR HHC INS LCH MCM MIM Neuronames WHOART CTV3 CCHI (Canada) MBS-E (Australia) ICD-10-PCS (USA) ICPM-NL (Netherlands) NCSP (Swedish Version) NCSP (Finnish Version) ICPM-DE (Germany) CCAM (France) SNOMED-CT (USA-UK) OPCS-5 (UK) SKS (Denmark) ICIDH (WHO) Digital Anatomist (UW) Nomina Anatomica 16

And there is more to come……

• •

Official Inventory on IT systems

– –

52 ‘exotic’ patient record systems 1 ‘undiscovered summary-system’ used by 250 physicians of which 70 daily containing 20.000 patients Inventory by students

– – –

Estimated 200 ‘exotic’ systems At least 200 shortlists for diagnosis, treatment Only some terminologies properly documented/maintained

17

System ICD Procedures

Maintenance dynamics

Major Update

10-20 years 10+ years Annual Quarterly

Snomed Genome

?

?

Quaterly Daily 18

CEN/ISSS eHealth FG Recommendation 13 (2005)

•

The Member States, with the Commission, should:

– – – – ensure the Europe wide referencing and easy access to the content of existing health coding systems based on registration of such systems by the Eurorec Institute; support the international convergence towards a common framework for formal representation, and eventually the development and maintenance of a multilingual clinical reference terminology. This effort should build on existing efforts in formal representation as GALEN, FMA and SNOMED, and be carried out in liaison with the WHO Family of International Classifications make the targeted reference clinical terminology publicly available free of charge; support a common approach to link national classifications of procedures, to support cross-border reimbursement of health care.

19

A bit of Archeology (1)

•

2 nd

– – –

EU/CEN Workshop (1997)

Central resources - public or private - are urgently needed for European Industry to address a single market • • • Central reference resource of concepts Multilingual lexicons Language independent development tools A strategy to maximise European influence on international developments is needed • • New developments in HL7, CorbaMed, DICOM, UMLS Establishing evolutionary pathways from existing systems to future systems Communication architectures should address mediation & conversion 20

A bit of Archeology (2)

•

SESAME Committee (1990)

– – – – – – Medical Semantics Advisory Task (Mesat) Establish national standardisation organisations for semantical aspects in medicine European medical termbank (Eumet) European Model of Health Care (Euromodel) European Classification of Medical Procedures (Euclamep) Harmonization of validation and coding rules for ICD 21

Do you recognise this?

• • • • • • •

Airbus 380 delay on delay on delay… Software project over budget, over time, under performing Railroad development 3-fold budget increase Gulf wars Fight bioterrorism ….

22

Tame versus Wicked Problems

• • • •

Well defined stable problem statement Known when the solution is reached Solution can be objectively assessed right/wrong Belongs to class of similar problems with similar solutions

• • •

Ill defined problem, ambiguous Strong moral, political, professional issues Strong stakeholder dependence Rittel & Webber (1973)

23

Observations

• • • •

Step to HL7 version 3 probably too big leap Galen and probably Snomed CT too complex Combination HL7v3 – SCT unpredictable Many clinical projects too ambitious Time to complete = Estimate *

π

Outcome = Expectation /

π 24

The New Economy effect

• • •

Withdrawal of government from public domain

– – –

Tasks moving to market parties Dynamic workforce Globalisation Human factors

– –

More career oriented labour force on short contracts Government policies more driven by political agenda Effects

–

More effective services

– –

Dramatic loss in corporate knowledge at gov. level Investments horizon on next elections

25

Dealing with Infrastructures

• • • • • •

Role in supply of Water, Electricity, Telephone?

–

Different response in gov withdrawal Role in railways?

–

Responsible for infrastructure?

Role in road construction maintenance?

–

Withdrawal unthinkable (some public/private partnering) Role in maintenance of dikes waterways?

–

In NL withdrawal out of the question; life threatening! Role in national life threat alarm system?

Role in maintenance of healthcare infostructure

–

Utter confusion

26

Still many open questions

•

Why do this at all

•

What level of detail is required

•

Revolutionairy/evolutionairy implementation

•

How do we cope technically

•

How do we cope in the business process

•

How do users cope cognitively

•

How do we cope with version control in the new highly interdependent architectures

27

Bioterrorism case revisited

• •

but

•

Many more related problems wrt disease detection

•

Establisment of EU Centre Disease Control Focus on communicable diseases Call for a more generic approach

• •

SemanticHEALTH recommendation of 30-09-2006:

•

Activitity on the “Real time public health record” Data derived mostly from routine health records Common Terminology probably within the EU mandate

28

Distinction of roles and collaborations

• • • • • •

National terminology centres (networked) Standards bodies Healthcare providers Vendors Governments Universities Challenge to let this orchestra play

29

Recommendation: Establish the process

• • • • • • • Focus on real immediate needs, and realistic time scales Do not just select a single product, but join forces to redesign with best of breed Be prepared to throw away what you loved and cherised!

Be aware and secure solutions for different cultures/ languages Involve and explain to those who have the burden of recording (registration dividend) Without a well managed network of compentent expertise centres, the process is likely to fail Governments develop & adhere to longer term visions – Value and maintain your corporate knowledge 30

The challenge

From Snomed Commonwealth Terminology To Snomed Global Terminology

31

Acknowledgements

Specific Support Action co-funded by the European Commission SIXTH FRAMEWORK PROGRAMME Radboud University Nijmegen Medical Center

Department of Medical Informatics

(Co-ordinator) World Health Organization

Dept. Measurements and Health Information Systems, Switzerland

University College London

Centre for Health Informatics and Multiprofessional Education (CHIME), UK

University of Manchester

Health and Bioinformatics Group, UK

Uppsala University

Nordic Centre for Classifications in Health Care, Sweden

University of St. Etienne

Department of Public Health & Medical Informatics, France

National Institute for Strategic Health Research

Hungary

Communication & Technology Research,

Germany 32

Thank you for your attention!

Further information:

www.semanticHEALTH.org

[email protected]

Pieter E Zanstra

Radboud University Nijmegen Medical Center [email protected]

www.OpenGALEN.org

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