Title: 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
1Health TerminologiesFrom Products to
ProcessPieter E ZanstraRadboud University
Nijmegen Medical CenterCo-ordinator EU
SemanticHEALTH Specific Support ActionSemantic
Interoperability Deployment and Research Roadmap
Health Terminologies Criteria for decision
makingeHealth Working Group Workshop, Brussels,
March 8, 2006
2Presentation Overview
- About this workshop
- A bit history
- Clinical perspective
- Coding practice
- Assessment
- Next Steps from here
3About this workshop
- Induced by Snomed SDO invitation
- To join or not to join, thats 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
4A Typical Record
Reviewed. Primip FT No ANC probs F/D at
0845 Needed synto for ?contractions about
7cm Decent progress since. Epidural in-situ No
urges to push really according to
patient Contractions 410 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, doesnt 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
5Competing demands on recording
ICD, ICPM
DRG
Documentation
Categorise
6What kind of business logic do we need?
ICD, ICPM
DRG
Documentation
7CEN/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.
8Clinical 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
9What 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)
10What binds Records, Interface, Reporting,
Knowledge?
Interface Terminology
ReferenceTerminology
Health Record
Reporting Terminology (ICD)
Discharge Referral..
11Example Interface terminology
PURKINJE
12Record architecture terminology (mediation)
Name, Context and Content
physical examination
CONTEXT
breast
palpation
lump
NAME
present
CONTENT
13Sound semantics underpinning continuity in care
14Some Myths
Stage of development
Open Source
Open source will most definitely not be free of
cost A complex terminology is required, and we
should not expect this to appear without
significant investment The critical mass of
skilled dedicated contributors to a large
Health terminology is too small for a sustainable
system
Evidence Based Medicine
Only about 5-8 of present medical knowledge is
based on sound evidence. RCTs are very costly
and time-consuming. We can not longer ignore the
need for routinely collected observational data
of high quality. Problem of finding outliers in
the literature
International Standards
The national marketplace is to small for domestic
suppliers to survive. Early adoption of new
standards, and active participation in their
development will increase competitive edge. Today
developing countries are already strong
contenders in systems design. They are the
knowledge marketeers!
15A 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
16A 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
17Terminology 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,
18Multiprofessional 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
35
19Whats in use? (2001)
20Codes, 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
AIDSTRIALS ChemID CHEMLINE GENE-TOX HISTLINE SDLIN
E TOXLINE TOXLINE65 TOXLIT PDQ AVLINE BIOETHICS CA
NCERLIT CATLINE DENTALPROJ MEDLINE POPLINE SERLINE
DOCUSER Dxplain AI/RHEUM Iliad GenBank OMS PSY TR
IFACTS NIOSH NPIRS NEDRES MED85
MED75 HSTAT HDA MED90 HealthSTAR ACR92 AIR93 BRMP9
6 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
21And 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
22Variability in Coding Practice
23Cultural differences?
Term
ReadV3
SNOMED-CT
Bounty bar Crème egg Kit Kat Mars Bar Milky
Way Smarties Twix Snickers
- C-F0811
- C-F0816
- C-F0817
- C-F0819
- C-F081A
- C-F081B
- C-F081C
- C-F0058
UbOVv UbOW2 UbOW3 UbOW4 UbOW5 UbOW6 UbOW7 Ub1pT
24ICD9 8 Codes for cycling accidents
25The exploding bicycle accidents
- ICD-9 (E826) 8
- READ-2 (T30..) 81
- READ-3 87
- ICD-10 587
26Formalised coding rules for ICD ?
Cycling Accident
What you hit Your Role Activity Location
27Unified 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
28UMLS 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 cant 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
29GALEN 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
30GALEN designed to drive systems
Best Practice
Best Practice
31Ontologies The invisible unifying foundation?
Decision support
Clinical Applications
Medical Records
Data entry
32GALENs Approach Compositional
Pathological fracture of the neck of the right
femur caused by osteoporosis
- Fracture which
- lthasLocation-(AnatomicalNeck which
-
isDivisionOf-(Femur which -
hasLaterality-right)) - hasCause-Osteoporosisgt
-
12
33Simplicity for Users
34Wrap-up
35Still 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
36Maintenance dynamics
37Exploitation 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
38Attention 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?)
39Observations
- 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
40Clinical Terminology Summary
- Evolving use case
- Epidemiology
- Organising care
- Documenting Care
- Access to knowledge
- Evolving Technology
- Enumeration ICD
- Interlingua UMLS
- Formal Ontology SNOMED CT
- Technological Barriers
- Enumeration doesnt scale
- Computers cant read
- Humans cant organise
- Tower of Babel
- Unsolved Problems
- Quality Assurance
- Efficient data capture
- Interrater variability
- Cost Model
41Establish 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
42Acknowledgements
Radboud University Nijmegen Medical
Center Department of Medical Informatics
(Co-ordinator)
University College LondonCentre for Health
Informatics, UK
World Health Organisation Dept. Measurements
Health Information Systems, Switzerland
University of Manchester Health and
Bioinformatics Group, UK
Uppsala UniversityNordic Centre for
Classifications in Health Care, Sweden
National Institute for Strategic Health
ResearchHungary
University of St. EtienneDepartment of Public
Health Medical Informatics, France
Communication Technology Research, Germany
43Thank you for your attention!
- Further information
- www.semanticHEALTH.org
- semantichealth_at_eski.hu
- Pieter E Zanstra
- Radboud University Nijmegen Medical Center
- P.Zanstra.mi_at_xs4all.nl