Transcript Health Terminologies: From Products to Process

Health Terminologies:
From Products to Process
Pieter E Zanstra
Radboud University Nijmegen Medical Center
Co-ordinator EU SemanticHEALTH Specific Support Action:
Semantic Interoperability Deployment and
Research Roadmap
Health Terminologies: Criteria for decision making
eHealth Working Group Workshop, Brussels, March 8, 2006
Presentation Overview
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•
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About this workshop
A bit history
Clinical perspective
Coding practice
Assessment
Next Steps from here
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About this workshop
• Induced by Snomed SDO invitation
– To join or not to join, that’s the question?
• Criteria for decision making
– Scoping the problem
• How to collect criteria
– National needs/experiences
– What is available
– How to organise
• Round table
• Follow-up workshops?
– In depth on topics arising from round table
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A Typical Record
Reviewed. Primip FT No ANC probs
F/D at 08:45
Needed synto for contractions about 7cm
Decent progress since.
Epidural in-situ
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
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Competing demands on recording
ICD, ICPM
DRG
Classifier
Reimburse
?
ManageGrouper
Referral letters
Documentation
Categorise
Record
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What kind of business logic do we need?
ICD, ICPM
DRG
Classifier
Grouper
Documentation
Reference
Terminology
Record
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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.
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Clinical terminology
• A clinical terminology is the collection of standard
terms with their synonyms, which in the context
of patient care support the recording of
complaints, signs, symptoms, circumstances,
process of illness, interventions, results,
diagnoses, as well as the decision making of the
care providers
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What are the boundaries of Terminology
• Blood pressure
– Evaluation result (high, low)
– Measurement (diastolic, systolic) Archetype?
– Guideline (how to measure?)
• Rheumatoid arthritis
– Evaluation result
– Measurement (criteria)
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What binds Records, Interface, Reporting,
Knowledge…?
Interface
Terminology
Reporting
Terminology
Reference
Terminology
(ICD)
Discharge
Referral..
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Health
Record
Example Interface terminology
PURKINJE
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Record architecture terminology (mediation)
Name, Context and Content
physical examination
breast
palpation
lump
NAME
present
CONTENT
CONTEXT
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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
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Some Myths
Stage of development
Open Source
Evidence Based Medicine
International Standards
Open source will most definitely not
be free
of cost;
complex
Only
about
5-8%A of
present
terminology
is required,
andon
we
medical
knowledge
is based
The
national
marketplace
is to
shouldevidence.
not expect
this are
to appear
sound
RCT’s
small
for domestic
suppliersvery
to
without
significant
investment
costly and
time-consuming.
We can
survive.
Early
adoption of new
Thelonger
criticalignore
mass the
of skilled
&
not
need
for
standards,
and active
participation
dedicatedcollected
contributors
to a large
routinely
observational
in
their development
will increase
Health
is too small for a
data
of terminology
high edge.
quality.
competitive
Today
sustainable
system‘outliers’ in the
Problem
of finding
‘developing’
countries are already
literature
strong
contenders in systems
design. They are the knowledge
marketeers!
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A bit of Archeology (1)
• 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
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A bit of Archeology (2)
• 2nd 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
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Terminology generations and their roles
• 1st Generation
– Monoaxial, relatively short
– ICD, ICF, MESH,…
• 2nd Generation
– Multiaxial, more detail
– Snomed 2, UMLS, …..
• 3rd Generation
– Network, Compositional, Formal, Software,
– Very detailed
– SNOMED CT, OpenGALEN, FMA,…
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Multiprofessional Records and terminology
• Differences in vocabulary
• Differences in the meaning of the vocabulary
• Differences in aspects/abstractions
– Nurse: ‘constipation’ is an elimination problem
– Doctor: ‘constipation’ is a bowel function disorder
• Difference in operational significance
– Reflecting differences in professional tasks
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What’s in use? (2001)
HOSPITALS
PRIMARY
ICD-10
ICPC
ICD-10
ICD-10
ICD-10/OPCS-4
READ
ICD-10
NONE
NONE
ICD-10
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Codes, codes everywhere...
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
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
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And there is more to come……
• Official Inventory on IT systems
– 52 ‘alien’ patient record systems
– 1 system used by 200 physicians of which 70 daily
• Inventory by students
– Estimated 200 ‘alien’ systems
– At least 200 shortlists for diagnosis, treatment
– Only some terminologies properly documented/maintained
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Variability in Coding Practice
Hospital
1
Nasendoscopy
EMG
Trans urethral
prostate resection
Liver biopsy
Gastroscopy
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3
4
5
6
11 51
4 20
1 5
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12
5
0
16
7
37
10
93 0
9
18
15 5
5 17
53
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10
23
13
22
3
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0
Cultural differences?
SNOMED-CT
Term
C-F0811
Bounty bar
UbOVv
? C-F0816
Crème egg
UbOW2
C-F0817
Kit Kat
UbOW3
C-F0819
Mars Bar
UbOW4
C-F081A
Milky Way
UbOW5
C-F081B
Smarties
UbOW6
C-F081C
Twix
UbOW7
C-F0058
Snickers
Ub1pT



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ReadV3
ICD9: 8 Codes for cycling accidents
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The exploding bicycle accidents
•
•
•
•
ICD-9 (E826)
READ-2 (T30..)
READ-3
ICD-10 587
8
81
87
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Formalised coding rules for ICD …?
Structured Data Entry
File
Edit
Help
Cycling Accident
What you hit
Your Role
Activity
Location
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Unified Medical Language System
• US National Library of Medicine
• Defacto common registry for
vocabularies
• Metathesaurus
– 1.8 million concepts
– categorised by semantic net types
• Semantic Net
– 135 Types
– 54 Links
• Specialist Lexicon
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UMLS: Pros and Cons
• An invaluable resource, but...
– No better than the vocabularies which are mapped
• Limited detail for patient care
• Unreliable for indexing or abstraction of knowledge
• Best for relating everything to MeSH for indexing
literature
– Still limited by combinatorial explosion
• Still can’t cope with fractal knowledge
– Not extensible - no help in building or extending
terminologiese
– No help in reorganising existing terminologies to re-use for
new purposes
– Top down
– Information still implicit
• Minimal help with software
– No help with data capture, user interfaces
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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
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GALEN: designed to drive systems
Clinical
Terminology
Data
Entry
Clinical
Record
Decision
Support
Best
Practice
HealthCard
Mr Ivor Bigun
Dun Roamin
Anytown
Any country
4431 3654 90273
NEW
Clinical
Terminology
Data
Entry
Electronic
Health
Records
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Decision
Support &
Aggregated
Data
Best
Practice
Ontologies The invisible unifying foundation?
Coding &
Classification
Decision
support
Clinical Applications
MeSH
ACRNEMA
UMLS
SNOMED
Axes
ONTOLOGY
Medical
Records
`
ICPC
Data entry
READ
OPCS
ICD-9
ICD-10
GALEN’s Approach: Compositional
Pathological fracture of the neck of the right femur caused by
osteoporosis
Fracture which
<hasLocation-(AnatomicalNeck which
isDivisionOf-(Femur which
hasLaterality-right))
hasCause-Osteoporosis>
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Simplicity for Users
FRACTURE
Location Femur
Shaft
left
Cause
trauma
Tibia
Humerus
Neck
Wrist
Gt Troch
...
right
Osteoporosis ...
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...
Wrap-up
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Still many open questions
• 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
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Maintenance dynamics
System
Major
Update
ICD
10-20 years
Annual
Procedures
10+ years
Quarterly
Snomed
?
Quaterly
Genome
?
Daily
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Exploitation Models
• Strong belief in Market forces in the 90s
– GALEN and Snomed failed to reach sustainable state
– Some more limited commercial solutions survived
• But market did not take it
– Was it ready?
– Are HL7v3 and SNOMED/GALEN part of Solution Gap
• Increasing belief in centrally funded Info structures
– Dissimilar structures to costly to maintain
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Attention for
• Safety of patient data
• Guaranteed unrestricted access to patient data
– Pull-out strategies
• Multiple suppliers
– Purchasing rules
•
•
•
•
•
Specification en Certification
Ownership, Influence
Extensions and updates
Usage for all
Availability (open source?)
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Observations
• Development still driven by ‘perceived need’
• No yet hard evidence to prove added value
• For the next five year seen by industry as
exhaustive list of fixed terms
• Growing evidence to reconsider the ontologies
behind systems
– Both GALEN and SCT stem from early 90s
• Systems not plug and play
– Significant cost of translation
– Multitude of base cost goes into localisation
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Clinical Terminology Summary
• Evolving use case
–
–
–
–
• Evolving Technology
Epidemiology
Organising care
Documenting Care
Access to knowledge
• Technological Barriers
– Enumeration – ICD
– Interlingua – UMLS
– Formal Ontology – SNOMED CT
• Unsolved Problems
– Enumeration doesn’t
scale
– Computers can’t read
– Humans can’t organise
– Tower of Babel
–
–
–
–
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Quality Assurance
Efficient data capture
Interrater variability
Cost Model
Establish the process
• Focus on real immediate needs, and realistic time scales
• Be prepared to throw away what you loved and cherised!
• Be aware and secure solutions for different cultures/
languages
• Do not just select a single product, but join forces to
redesign with best of breed
• 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 very likely to fail
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Acknowledgements
Specific Support Action co-funded by the European
Commission SIXTH FRAMEWORK PROGRAMME
Radboud University Nijmegen Medical Center
Department of Medical Informatics
(Co-ordinator)
University College London
World Health Organisation
Centre for Health Informatics, UK
Dept. Measurements & Health
Information Systems, Switzerland
University of Manchester
Health and Bioinformatics Group, UK
Uppsala University
Nordic Centre for Classifications
in Health Care, Sweden
National Institute for
Strategic Health Research
Hungary
University of St. Etienne
Communication &
Technology Research,
Department of Public Health &
Medical Informatics, France
Germany
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Thank you for your attention!
Further information:
www.semanticHEALTH.org
[email protected]
Pieter E Zanstra
Radboud University Nijmegen Medical Center
[email protected]
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