Ian Herbert
Vice Chair, BCS Health
Director, S I Herbert & Associates Ltd
With thanks to Dr David Gain of NHS CFH
Healthcare terminologies Healthcare terminologies – from Read to Snomed– from Read to Snomed
A presentation for the ISKO UK Conference, A presentation for the ISKO UK Conference, 11stst November 2011 November 2011
How is the information How is the information usedused??
Direct care
Indirect Care
Decision support
Clinical audit Summaries
Reporting
Documentation in electronic records
Epidemiology
ResearchResource
management
Aggregation functionality
Billing & reimbursement
Administrative / management
information
Knowledge representati
on
What’s wrong with free text?What’s wrong with free text?
Free text is an extremely valuable and flexible way of recording details about individual circumstances, but…
• The meaning may be ambiguous, & open to misinterpretation
• Its meaning not readily available for computation, e.g. • it can’t automatically be analysed for audit or payment• it can’t direct care pathways• it can’t trigger automatic warnings about allergic reactions or
interactions □
Why healthcare terminologies?Why healthcare terminologies?
We need key healthcare concepts in a consistent& readily-computable form in order to:
• count instances of the same concept• relate knowledge about concepts to the individual patient-case• help standardise terms for concepts & their meanings
But there are lots of other things a terminologycould do for us …□
A compendium of terminologiesA compendium of terminologies
Read 4 byte 1983
Oxmis 1978
Snomed-CT 2001
ICHPPC-1 1975 ICPC-1
1987
ICD8 1978
ICD9 1988
ICD10 1998
ICD9-CM 199?
Snomed RT
ICHPPC-2 1979 ICPC-2
1998
RCGP 1984
Read 5 byte 1990
Read Clinical Terms v3 1998
RCGP 1984
1975 2011
Limitations of the Read codesLimitations of the Read codes
They are hierarchical with a• fixed number of levels• fixed no. of entries per level (some levels overflowing)• some entries belong naturally to 1+ hierarchy
Designed for UK general practice• not detailed enough for specialist use• GP ‘heart attack’ vs ‘left anterior myocardial infarction’
No facility to combine concepts to clarify meaning• ‘emergency’ + ‘thoracotomy’• ‘recurrent’ + ‘IGTN’ + ‘left’ + ‘great toenail’ □
Why not use ICD10 or OPCS4?Why not use ICD10 or OPCS4?
Not not rich enough (or intended) for patient records
No facility to combine expressions to clarify meaning• ‘emergency’ + ‘thoracotomy’• ‘recurrent’ + ‘IGTN’ + ‘left’ + ‘great toenail’
Updates too slow (every 10 years for ICD)
They are designed for use as classifications □
How is the information How is the information usedused??
Direct care
Indirect Care
Decision support
Clinical audit Summaries
Reporting
Documentation in electronic records
Epidemiology
ResearchResource
management
Aggregation functionality
Billing & reimbursement
Administrative / management
information
Knowledge representati
on
Why do we need Snomed-CT?Why do we need Snomed-CT?
To enable consistent representation & retrieval of clinical info:• about individual patients• in knowledge sources, e.g. drug formularies & guidelines
To avoid a combinatorial explosion of the terms needed
To provide a flexible set of classifications of terms
Need a terminology that can be extended quickly & indefinitely
This necessary (but not sufficient) for:• analysing patient information, e.g. for mgmnt & research• automated decision support, e.g. for safe prescribing• semantic interoperability between care providers & systems □
What is SNOMED CT?What is SNOMED CT?
Dictionary of Clinical Concepts
Thesaurus of Terms
Thesaurus of Terms Health
Lexicon
A controlled clinical vocabulary
A controlled clinical vocabulary
A conceptual classification
SNOMED CT is a terminological resource that can be implemented in software applications to represent clinically relevant information reliably and reproducibly □
Some of the descriptions associated with ConceptID 22298006:
• Fully Specified Name: Myocardial infarction (disorder)DescriptionID 751689013
• Preferred term: Myocardial infarctionDescriptionID 37436014
• Synonym: Cardiac infarctionDescriptionID 37442013
• Synonym: Heart attackDescriptionID 37443015
• Synonym: Infarction of heartDescriptionID 37441018
One concept, many namesOne concept, many names
To a neurologist
Cord compression means Spinal cord compression
To a midwife
Cord compression means Umbilical cord compression
Transmission and sharing of information requires consistency of terminology – and its use □
Avoiding ambiguityAvoiding ambiguity
Will the computer limit what I Will the computer limit what I cancan say? say?
More concepts• 400,000 health care concepts
More descriptions• 1,000,000 clinical terms
More information• 1,500,000 semantic relationships
Contextual modification of expressions• possible, Family history of, planned, refused,
aborted etc. □
Depth of clinical expressionDepth of clinical expression
peripheral angiography
special peripheral angiography procedures
peripheral graft arteriogram
femoral-femoral crossover arteriogram □
How is it organised?How is it organised?
Multiple top level concepts, e.g:- body structure
Each with a hierarchy of concepts beneath
Strictly organised by ‘IS A’ relationships- index finger ‘is a kind of’ finger- finger ‘is a kind of’ hand part, etc
Each concept may have permitted qualifiers, e.g.- pain ‘has qualifier’ severity □
Hierarchies Examples
Clinical Finding: Contains the sub-hierarchies of Finding and Disease Important for documenting clinical disorders and examination findings
Finding: Swelling of arm Disease: Pneumonia
Procedure/intervention: Concepts that represent the purposeful activities performed in the provision of health care
Biopsy of lung Diagnostic endoscopy Foetal manipulation
Observable entity Concepts represent a question or procedure which, when combined with a result, constitute a finding
Gender Tumour size Ability to balance
Body structure Concepts include both normal and abnormal anatomical structures Abnormal structures are represented in a sub-hierarchy as morphologic abnormalities
Lingual thyroid ( body structure) Neoplasm (morphologic abnormality)
Hierarchies Examples
Organism Coverage includes animals, fungi, bacteria and plants Necessary for public health reporting and used in evidence-based infectious disease protocols
Hepatitis C virus Streptococcus pyogenes Acer rubrum (Red maple) Felis silvestris (Cat)
Substance Covers a wide range of biological and chemical substances Includes foods, nutrients, allergens and materials Used to record the active chemical constituents of all drug products
Dust Oestrogen Haemoglobin antibody Methane Codeine phosphate
Physical object Concepts include natural and man-made objects Focus on concepts required for medical injuries
Prosthesis Artificial organs Vena cava filter Colostomy bag
Physical force Includes motion, friction, electricity, sound, radiation, thermal forces and air pressure Other categories are directed at mechanisms of injury
Fire Gravity Pressure change
How is it constructed?How is it constructed?
Defining and qualifying characteristics used to construct & refine a terminological model of healthcare
Concepts combined with Attribute-Value pairs• Procedure with:
- method – excision- site – both tonsils- using – laser device(the post-coordinated representation)= Bilateral laser tonsillectomy(the pre-coordinated equivalent & a ‘kind of’ tonsillectomy)
‘Method’, ‘site’ & ‘using’ are defining characteristics An additional ‘success’ attribute would be a qualifier □
• Search for term if you think it’s in there• Search the term hierarchies to find the term• Use a combination of the two• Info. can always be entered in post-coordinated form, q.v.
the bilateral laser tonsillectomy example, but equivalent pre-coordinated term may be available
• Where system constrains context, a data entry template can have possible terms in manageable drop-down lists (including post-coordination qualifiers)
• Automatic encoding of entered text• highly desirable, but not totally reliable at present• generated codes must be approved by user before commital □
Getting the right Snomed CT termGetting the right Snomed CT term
Snomed-specific issuesSnomed-specific issues
• Detecting equivalence of same thing said in pre-coordinated & various post-coordinated representations
• Expressing negation - this comes in many forms, e.g:• diabetes excluded• appendectomy not done• no pain in right leg• NAD - nothing abnormal detected
• Consistent authoring of the terminology• Enabling accurate speedy use in unconstrained situations, e.g.
when taking a patient history □
- & non-Snomed-CT specific issues- & non-Snomed-CT specific issues
• Human beings are lazy & good at inference
• So patient records full of short cuts, e.g:• BP 140/80 means ‘blood pressure taken and systolic pressure
observed to be 140 mm hg, and diastolic pressure 80 mm hg’. Assumed to be of patient whose record it’s in, & taken during the encounter it lies within, by the GP …
• Computers are pedantic & pernickety. So is Snomed. It has xx codes for a blood pressure
• Users want biggest bang per keystroke buck, so unconstrained searching for terms & post-coordination not popular
• Users do not use terms consistently, e.g. asthma
• Many medical terms not (yet?) clearly defined, e.g. CFS / ME □
Why is Snomed CT ‘not sufficient’?Why is Snomed CT ‘not sufficient’?
• Snomed CT consists (almost entirely) of concepts, i.e. types• Doesn’t deal with numeric values, e.g. weight 70 kg• Doesn’t usually identify object instances, e.g. people
• no longer totally true – now identifies pharmaceutical companies
• So needs to be used within structures to bind Snomed concepts to their context, e.g.:• who it’s about - the subject (typically a patient)
• when action / event occurred or observation made
• who performed action / made observation
• where action / event occurred or observation made
• any associated observation value(s) □
Where are we now?Where are we now?
• Snomed CT adopted by the NHS• Accepted as fundamental standard by NHS ISB, June 2011
• Now in the hands of an independent international body• International Health Terminology Standard Development
Organisation (IHTSDO)
• Adopted by several countries, more coming
• Has no significant global rivals
• UK practical experience in patient record keeping with it limited, but growing fast □
Are we winning?Are we winning?
“We will know we have succeeded when clinical terminologies in software are used and re-used,and when multiple independently developed medical records, decision support, and clinical information retrieval systems sharing the same information using the same terminology are in routine use.”
Alan Rector 2000“Clinical Terminology: Why is it so hard?”