Transcript Copyright Notice Usage of semanticHEALTH public presentations

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Health Terminologies:
From Ideas to Reality
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
i2010 Subgroup on eHealth Workshop, Brussels, November 8, 2006
Presentation Overview
• Summary 8 March 2006 Workshop
• This workshop i2010 From Ideas to Reality
• Context of Semantic Interoperability
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The SNOMED Standards
Development Organization
• This started the debate
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Setting the scene (Iakovidis)
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Terminology is the heart of the record
Most complex domain of eHealth
Takes long time to understand
Needs corporate knowledge (expertise) that
continues
• Semantic IOp THE Issue for Europe to act
• This is the start of a process, continue as needed
with help of semanticHEALTH & RIDE projects
• Primary scope ‘patient summary’
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eHWG GOAL for the First Workshop (Thonnet)
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Explain general concepts & processes
Describe the state of the art
Clarify « perceived needs »
Express the level of importance of the subject
Detail the present usages
Create awareness
Collect existing expectations, constraints
Try to identify common challenges, questions,
needs
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What kind of business logic do we need?
ICD, ICPM
DRG
Classifier
Grouper
Documentation
Mediation
Service
Record
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What binds Records, Interface, Reporting,
Knowledge…?
Interface
Terminology
Reporting
Terminology
Mediation
Service
(ICD)
Discharge
Referral..
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Health
Record
Record architecture terminology (mediation)
Context, Name and Content
physical examination
breast
palpation
lump
NAME
present
CONTENT
CONTEXT
©Angelo Rossi Mori
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National Institute
for Public Health and
the Environment
Classification & the Law
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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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SNOMED CT (Martin Severs)
• Why a terminology
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Increase Precision, Accuracy
Safety
Reduce ambiguity
Record keeping, high quality secondary uses
Record once with fidelity to clinical situation
Reimbursement coding skews clinical data
Support clinical innovation
Link to knowledge sources, grey literature (Reuters)
Knowledge discovery (potential hazardous drugs)
Quick targeted response emergencies (withdrawing drugs
from market)
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Why Join the SNOMED SDO?
Sustainable Governance
• Validated Product
• Sustainable Model
• Shared Ownership
• Code of Conduct
• Localization Support
• Simple Licensing
• Global Collaboration
• Vendor Engagement
• Compatible with Other
Standards
• Clear Management
Processes
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WHO and Proposed SNOMED SDO
Possible Options: Degrees of Collaboration
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1: WHO leads opposite development – competing terminology/(ies)
2: WHO remains inert / ignores SNOMED SDO
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3: WHO watches/regulates the health terminology space
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4: WHO takes part in the SNOMED SDO Management Board
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5: WHO owns the IPR of SNOMED CT
• Establishes HIS needs, application rules that SNOMED applies
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Representing 104/192 Countries
Takes part in "Harmonization Board" for Classifications –Terminology link
Takes part in R&D
Includes SNOMED in WHO e-Health Projects
• Runs the Executive Secretariat
• Management operations
• Translation platform
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Clinical Terminology Summary
• Evolving use case
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Epidemiology
Organising care
Documenting Care
Access to knowledge
Epidemiology?
• Technological Barriers
• Evolving Technology
– Enumeration – ICD
– Interlingua – UMLS
– Formal Ontology – SNOMED CT
• Unsolved Problems
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– 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
Recommendation: 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 likely to fail
• Governments develop & adhere to longer term visions
– Value and maintain your corporate knowledge
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What to do next?
1 To investigate the different MS (nat.) stakeholders
2 To appoint an ad hoc EU (Technical) Committee
or Workshop (eHWG , CEN,...) with experts from
Snomed, Galen, FMA,WHO FIC network, GO to
define the outline of a work program for a
Terminology / Ontology international coordinated
development
3 To assess the Danish model as a case study for
MS : Snomed SDO choice : compare - criteria/method
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Today’s Workshop
• What is our task?
– Do what is necessary to respond to EU needs
– Maximise synergies for National solutions
• It is YOUR workshop
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Not a beauty contest, not a sales pitch
Focus on discussion in the afternoon
Identify what will work
Identify barriers
Realistic scoping of tasks
• Plan for the next 2-5 years
– Joint activities, co-financing
– ….It’s up to yourselves
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Homework from 8-3-2006
• EU
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Inventory on costs of developing terminologies
Organise follow-on workshop(s)
More background on terminology ‘theory’
Make Canadian materials available
• Member States
– Define precise requirements for additional workshops
– List your priorities, so we can define tasks
• SNOMED SDO
– Identify SCT implementations that:
• Have real data demonstrating good ROI
• Have potential to demonstrate ROI
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What Has this Meant for Kaiser Permanente’s Members?
• Dramatically lowered cardiac disease mortality
• Improved use of preferred drugs
 COX-II inhibitor story
• Better Syndromic Surveillance
 Rotavirus Vaccine and Intussusception
• Data about Clinician Performance
• Improved Clinical Research Capabilities
• More to Come
 Adult oncology standardization and protocol
improvement
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© Kaiser Permanente, 2006
Why do it This Way?
• We are implementing an EHR, not a vocabulary
• We need to enable clinicians to document in a
language that sounds right
• Extraction of data for financial, performance
management, and research purposes is a crucial
derivative function of the EHR
• SNOMED-CT and the group of vocabularies in
our CMT offer the most robust solution to this
problem set
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© Kaiser Permanente, 2006
Perspective on costs:
• Total size of SNOMED now - roughly 450K terms
– Core size: ≤250,000
– Used codes perhaps 25,000-50,000 (probably ≤ 25K)
• Rebuild (assume all IT costs are underestimates by 50%)
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Raw effort: 50 terms / person / day
Net effort including QA & revision: 25 terms / person / day
450K terms / 25 = 18000 days = 100 person years ≤ €20M-€40M
250Kterms …
≤ €10M-€20M
+ technical / organisational infrastructure
€2-€4M
• 1 large EU Project
• Repair
– Guestimate: repair cost 20% rebuild cost
• But remains to be proven - Do the studies!
• ≤0.1% of UK Health IT budget
– If it has any value, it is worth it; otherwise it is not
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WHO terminology network meeting concerns
• Identification of roles for:
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National terminology centres (networked)
Standards bodies
Healthcare providers
Vendors
Governments
Universities
• Alignment of tasks for:
– Snomed SDO
– WHO
– …..
Let this orchestra play in harmony
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Information on OpenGALEN
http://www.opengalen.org
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Do you recognise this?
• Airbus 380 delay on delay on delay…
• Software project over budget, over time, underperforming
• Railroad development 3-fold budget increase
• Gulf wars
• Fight bioterrorism
• ….
• <your own favourite>
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Tame versus Wicked Problems
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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
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Ill defined problem, ambiguous
Strong moral, political, professional issues
Strong stakeholder dependence
Rittel & Webber (1973)
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Observations
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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 * 
Outcome = Expectation / 
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Why bother about Semantic Interoperability?
• For Direct care: e.g.
– to coordinate patient care between multiple care
institutions/professionals (Stroke Services)
– to support cross border care for EU citizens
– to improve usefulness of automatic decision support
– to help comply with best practice
• For Organisation: e.g.
– to support exchanges across jurisdictions and to support
cross border and multilingual and multicultural issues in
public health
– to incorporate primary care and community based care
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Why bother about Semantic Interoperability?
• For Costs: e.g.
– improve productivity
– eliminate redundant testing and investigation
• For Population: e.g.
– unify clinical data in time and space for disease surveillance
area of vital concern on a global scale
– better cope with emerging pathogens and bioterrorism
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What is the meaning of Interoperability
• Interoperability means the ability of information
and communication technology (ICT) systems and
of the business processes they support to exchange
data and to enable the sharing of information and
knowledge.
• Interoperability is a state which exists between two
application entities when, with regard to a specific
task, one application entity can accept data from the
other and perform that task in an appropriate and
satisfactory manner without the need for extra
operator intervention. (CEN/ISSS 2005)
• …..
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What is the meaning of Semantic Interoperability
• [Semantic interoperability] is concerned with
ensuring that the precise meaning of exchanged
information is understandable by any other
application that was not initially developed for this
purpose.” (IDABC 2004).
• CEN/ISSS 2005 stresses that semantic
interoperability is not an “all-or nothing” concept.
That is “the degree of semantic interoperability
depends on the level of agreement between sender
and receiver regarding the terminology, and the
content of archetypes and templates to be used”.
• ……
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A multilayer approach to interoperability (I2Health)
Action layer and approach Critical Factors
Health policy layer:
cooperation
Vision & strategies
Structures, processes & measures, incentives for actors
Sustainable socio-economic and legal framework
Privacy and confidentiality
Certification of systems and devices
Health service provider
(organisational) layer:
collaboration
Organisational structures and culture
Intra & inter-jurisdictional service processes
Change management, behavioural change
Systems thinking, business process re-engineering
Semantic layer:
interoperation
Terminologies, classifications, ontologies
Translation
Sustainable development and implementation
infrastructures, application support
Technical / functional
layer:
interoperation
Technical standards
Hardware and software connectivity
User interfaces
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What is problematic?
• Interoperability efforts are too fragmented
• Developments still in relative isolation
– E.g. Electronic Health Records (EHRs), terminology &
ontologies, messages, care pathways, data types, security,
and system architectures.
• Member states driven by different needs and
agenda’s
• Dramatic Socio-Economic change in the last decade
• ….
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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
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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
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Bioterrorism case revisited
• Establisment of EU Centre Disease Control
• Focus on communicable diseases
but
• Many more related problems wrt disease detection
• 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
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Today’s Workshop
• What is our task?
– Do what is necessary to respond to EU needs
– Maximise synergies for National solutions
• It is YOUR workshop
–
–
–
–
–
Not a beauty contest, not a sales pitch
Focus on discussion in the afternoon
Identify what will work
Identify barriers
Realistic scoping of tasks
• Plan for the next 2-5 years
– Joint activities, co-financing
– ….It’s up to yourselves
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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 Organization
Centre for Health Informatics and
Multiprofessional Education (CHIME),
UK
Dept. Measurements and 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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