WHO

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WHO SNOMED SDO

• Opportunity
• Potential Relations
• Challenges Other issues

T. Bedirhan Üstün MD World Health
Organization Classifications Terminology www.wh
o.int/classifications
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Outline

• WHO's vision for Health Information Systems
• SNOMED-CT summary evaluation
• Declaration of possible Conflict of Interest
• Vision for a global terminology standard
• Possible Options for WHO involvement
• Organizational Issues towards as an
  international public good
• Summary
• Desiderata for a global terminology
• Future Steps

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WHO Vision for Classifications and Terminology
in HIS
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SNOMED-CT

• SNOMED-CT is currently the most advanced system
  of health care terminology
• Centrally maintained and updated by CAP and UK
  NHS
• About 414,808 terms (about 15 have definitions)
  and 1.465 million (and counting) relations
  defined which supports consistency in
  communication
• Gaps in some areas questions about underlying
  ontology
• Key to computerization of health information
  electronic health records for coding, retrieval
  and analysis
• Increased benefits for Health Information
  Systems
• Mainly ICD and potential to link to ICF, ICHI
  through adequate mapping and knowledge
  representation
• Potential Use for
• Decision support for clinical users ? Map
  of Medicine
• error reduction patient safety ?
  Reduced prescription errors
• Administrative support ? Payment by
  results

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Declaration of Possible Conflict of Interest
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Rewriting ICD Using SNOMED an example F32.0
Depressive Disorder
Declaration of Possible Conflict of Interest

• Low mood 41006004
• Loss of interest 417523004
• Low energy 248274002
• Appetite (decrease, increase) 64379006,
  72405004
• Body weight (decrease, increase) 89362005,
  8943002
• Sleep (decrease, increase) 59050008,
  77692006
• Psychomotor (decrease, increase) 398991009,
  47295007
• Libido loss 8357008
• Low self esteem 286647002, 162220005
• Guilt, self blame 7571003
• Thoughts of death
• Suicide Ideation 102911000, 6471006

B.
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SNOMED Old and Proposed
and Future
College American Pathologists
Open Enterprise Multi-county Medicine
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WHO and Proposed SNOMED SDOPossible Options
Degrees of Collaboration

• -1 WHO leads opposite development competing
  terminology/(ies)
• 0 WHO remains inert / ignores SNOMED SDO
• 1 WHO watches/regulates the health terminology
  space
• Establishes HIS needs, application rules that
  SNOMED applies
• 2 WHO takes part in the SNOMED SDO Management
  Board
• Representing 104/192 Countries
• Takes part in "Harmonization Board" for
  Classifications Terminology link
• Takes part in RD
• Includes SNOMED in WHO e-Health Projects
• 3 WHO owns the IPR of SNOMED CT
• Runs the Executive Secretariat
• Management operations
• Translation platform

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WHO and Proposed SNOMED SDOOption 1 WHO leads
opposite development competing
terminology/(ies)

• Pro's
• more global multilingual health care terminology
  can be created with open source technology
  involving multiple partners
• Competition ? may induce better products
• Con's
• will take time ? delays in eHR
• Will require substantive funding
• Redundancy duplication of effort
• Multiple standards at least two
• Not conducive to collaboration

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WHO and Proposed SNOMED SDOOption 2 WHO
remains inert / ignores SNOMED SDO

• Pro's
• No WHO involvement no effort - invest energy in
  other areas
• Neutrality may increase chances for free
  development
• Con's
• Seems to neglect a core function of WHO
• Future complications with classifications (
  terminologies)
• Multiple terminologies may evolve
• Digital divide for the developing countries !!

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WHO and Proposed SNOMED SDOOption 3 WHO
watches/regulates the health terminology space

• Pro's
• WHO involvement solely in regulation for health
  terminology
• Better content management (input from health
  sector)
• Con's
• Multitude of players SOs mandate confusion
• Not leading by example top down regulation role
• Limited implementation penetration
• Digital divide for the developing countries

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WHO and Proposed SNOMED SDOOption 4 WHO takes
part in Management Board and SD Activities

• Pro's
• Opportunity to represent 104/192 Member States'
  overall concerns
• Harmonization with Classifications and other HIS
  elements
• Work towards global multilingual health care
  terminology
• Con's
• May seem as undue preference declaration
• Will require substantive resources
• Reduce competition

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WHO and Proposed SNOMED SDOOption 5 WHO owns
and runs the SNOMED SD Activities

• Pro's
• WHO represents all Member States more
  participation and acceptance
• Work towards global multilingual health care
  terminology in which SNOMED becomes an
  international public good like ICD
• Support of the WHO International Terminology
  Network
• Harmonization HIS elements ( classifications,
  patient safety, e-health)
• Expertise on Multiple languages and translations/
  cultural adaptations
• Provision to developing countries for free with
  appropriate arrangements
• Con's
• WHO bureaucracy may slow down progress
• Will require substantive resources

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Added Value of WHO

• WHO expertise on
• International Health Systems Health Information
  Systems
• Networking multiple stakeholders
• Multiple languages and translations - Cultural
  adaptations
• Management and consensus building
• Link to other HIS elements ( classifications,
  patient safety, e-health)
• More international participation - representation
• Acceptance by Member States, other IGO, NGO's,
  stakeholders
• Acceptance by Academic Research Centers
• Acceptance by Industry
• Easier set-up and swifter take-off maintenance

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CEN/ISSS eHealth Standardization Focus Group 

• Recommendation 13 Towards an international
  multilingual reference terminology
• The Member States, with the Commission, should
• ensure the Europewide 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  such 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
  crossborder reimbursement of health care."
• Furthermore
• "Considerable advantages could accrue if SNOMED
  CT became the standard for the EU as a whole.
  However this raises questions of licensing,
  translations and mechanisms for maintenance
  whereby EU Member States could influence future
  SNOMED developments and maybe additions to the
  terminology (some terms will be peculiar to
  particular Member States)."

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Future Steps on SNOMED SDO Proposal

• Discussions, clarifications and establishing a
  mutual agreement by all stakeholders
• Member States discussion in WHO Executive Board
  May 2006
• Finalization of current options and take off and
  implementation
• Further Research and Development on Standardized
  Terminologies

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Potential Risks Issues

• Failure in international consensus
• Different needs
• eHR vs other usage
• Differences in development phase
• English, Spanish, Nordic languages,
• National products in conflict ? Japan, Germany,
  
• Technological failures
• Supporting members sign off
• Conflict with WHO rules and regulations
• Unforeseen IPR problems

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Reinventing the Wheel?
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Designing Wheels for Future
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Alternatives

• No wheel solutions
• Legs
• Sledge, Sleigh, skis
• Spheric wheels
• Rolling bands
• Hovercrafts
• Magnetic rails
• Nature mimicry
• Wheel bugs (Arilus cristatus) ? Toy cars

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Connecting for Health // GSM
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Desiderata for a global terminology

• Comprehensiveness
• Coverage for all aspects of health care
• Adequacy
• Is it fit or purpose multiple purposes?
• Does it have a good information model and
  ontological basis?
• Multilingual applicability
• language independent formal concept
  representation
• Representation in multiple languages more than
  translation
• Utility
• Is it beneficial for
• Care providers decision making, outcome
  evaluation
• Consumers participation ownership
  evaluation risk reduction
• Policy/Decision Makers informed decision making
  on costs, benefits, efficiency
• Reliability
• does it give the same results in different users

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Summary

• Network Management of an International Public
  Good
• Harmonization with overall Health Information
  Systems
• Analog to Digital Needs for eHR
• Reporting frameworks Population Health,
  Clinical, Admin
• Linguistic, cultural adaptation know-how,
  Knowledge Representation
• ? Better ontology
• Future research and development
• Vision for a European/ Global standard system
• EC, CEN, eHSCG, ISO
• Action plan formulation and implementation