Controlled Terminology in Clinical Practice James J Cimino

Controlled Terminology in Clinical Practice James J. Cimino, M. D. Department of Medical Informatics Columbia University

Definition Terminology: A finite, enumerated set of terms intended to convey information unambiguously

Some General Classes of Terms Diagnostic Procedures l Therapeutic Procedures l Medications l Diagnoses l Findings l Organisms l Anatomy l

Uses of Terminology l Storing in database l Querying database l Transfering data l Billing l Monitoring data

Term - Basic Features l Unique Identifier (Code) n 12345 l Official Name n aspirin l Synonyms n ASA l Translations n NDC: 5502; UMLS: C 0004057

Term - Advanced Features l Classes n antipyretic, l anti-inflammatory, analgesic Semantic Links n CAUSES: gastritis n TREATS: arthritis l Attributes n UNITS: mg

Desiderata for Terminology l Content l Concept Orientation n Nonredundant n Nonambiguous n Permanent l Nonsemantic Concept Identifiers l Polyhierarchy l Semantic relationships

Strict Hierarchy disease heart attack arrhythmia lung disease pneumonia

Polyhierarchy disease heart attack lung disease arrhythmia infectious disease pneumonia

Semantic Network specimen is_a test is_a serum has_specimen substance is_a potassium serum potassium test measures_substance

ICD-9/10 and -CM 9 th International Classification of Diseases l WHO for collecting health statistics l Clinical Modifications added l 10 th edition l Clinical modifications under construction l Strict hierarchy l Synonyms and “index” terms l Code determines place in hierarchy l

ICD 9 -CM Examples ------Diseases----003. @ OTHER SALMONELLA INFECTIONS 003. 0 SALMONELLA GASTROENTERITIS 003. 2 @ LOCALIZED SALMONELLA INFECTIONS 003. 20 LOCALIZED SALMONELLA INFECTION, UNSPECIFIED 003. 21 SALMONELLA MENINGITIS 003. 29 OTHER LOCALIZED SALMONELLA INFECTIONS ------Procedures----01. @ INCISION AND EXCISION OF SKULL, BRAIN, . . . 01. 0 @ CRANIAL PUNCTURE 01. 01 CISTERNAL PUNCTURE 01. 09 OTHER CRANIAL PUNCTURE

SNOMED Systematized Nomenclature of Medicine l College of American Pathologists l Organized into axes l Synonyms l Assemble complex terms from axes l SNOMED-RT (Reference Terminology) under development l

SNOMED - Axes l l l D - Diseases C - Drugs F - Function L - Living Organisms X - Manufacturers G - Modifiers M - Morphology J - Occupations A - Physical Agents P - Procedures S - Social Context T - Topography

SNOMED - Examples "D 3 -15000" "D 3 -15010" "C-C 137 A" "C-C 137 B" "M-54700" “M-54700" "M-54701" "S-10120" "01" "02" "01" "02" "05" "01" "02" "01" "Myocardial infarction, NOS" "Infarction of heart, NOS" "Cardiac infarction, NOS" "Heart attack, NOS” "Microinfarct of heart” "Bufferin Analgesic Tablets" "Bufferin Analgesic Caplets" "Infarct, NOS" "Infarction, NOS" "Infarcted" "Focal infarct" "Microscopic infarct" "Mother, NOS" "(T-32020) (M-54700)" "(T-32020) (M-54700)” "(T-32020) (M-54700)" "(T-32000) (M-54701)”

Me. SH Medical Subject Headings l National Library of Medicine l Indexing the medical literature l Multiple hierarchy l Synonyms l

Me. SH Example D 011014: Pneumonia D 018410: Pneumonia, Bacterial D 007877: Legionnaires' Disease D 011018: Pneumonia, Pneumococcal D 011019: Pneumonia, Mycoplasma D 009175: Mycoplasma Infections D 011002: Pleuropneumonia, Contagious D 011022: Pneumonia, Rickettsial D 011023: Pneumonia, Staphylococcal D 001996: Bronchopneumonia D 009956: Ornithosis D 011001: Pleuropneumonia D 011015: Pneumonia, Aspiration D 011017: Pneumonia, Lipid D 011020: Pneumonia, Pneumocystis carinii D 011024: Pneumonia, Viral

Nursing Terminologies

UMLS Unified Medical Language System l National Library of Medicine l Metathesaurus groups terms under single concept id l No new hierarchy l Translation of terms l

Metathesaurus l 80+ sources l 1, 358, 891 strings l 626, 893 concepts l Strings have attributes l Concepts have attributes, including Relations

Metathesaurus Concept Lexical group String String

Metathesaurus - MRCON C 0153957|ENG|P|L 0180790|PF|S 1084242|benign neoplasm of heart C 0153957|ENG|P|L 0180790|VC|S 0245316|Benign neoplasm of heart C 0153957|ENG|P|L 0180790|VO|S 1446737|Benign neoplasm of heart, NOS C 0153957|ENG|S|L 0524277|PF|S 0599118|Benign tumor of heart C 0153957|ENG|S|L 0524278|PF|S 0599510|Benign tumour of heart C 0153957|ENG|s|L 0018787|PF|S 0900815|Heart <3> C 0153957|ENG|s|L 0018787|VO|S 0047194|Heart C 0153957|GER|P|L 1258174|PF|S 1500120|Gutartige Neubildung: Herz

Metathesaurus - MRSO C 0153957|L 0018787|S 0047194|ICD 10|PS|D 15. 1|3| C 0153957|L 0018787|S 0900815|MTH|MM|U 003158|0| C 0153957|L 0180790|S 0245316|ICD 10|PX|D 15. 1|3| C 0153957|L 0180790|S 0245316|ICD 99|PT|212. 7|0| C 0153957|L 0180790|S 0245316|RCD 98|SY|B 727. |3| C 0153957|L 0180790|S 1084242|MTH|PN|U 001287|0| C 0153957|L 0180790|S 1446737|SNMI 98|PT|D 3 F 0100|3| C 0153957|L 0524277|S 0599118|RCDAE|PT|B 727. |3| C 0153957|L 0524278|S 0599510|RCD 98|PT|B 727. |3| C 0153957|L 1258174|S 1500120|DMDICD|PT|D 15. 1|1 |

Metathesaurus - MRSTY C 0153957|T 191|Neoplastic Process|

Metathesaurus - MRREL C 0002871|CHD|C 0002891|isa|MSH 99|MTH|| C 0002871|CHD|C 0002892||CSP 98||| C 0002871|CHD|C 0002893||RCD 98||| C 0002871|RB|C 0221016||MTH|| C 0002871|RL|C 0002886|mapped_to|SNMI 98||

MED Medical Entities Dictionary l CPMC l Multiple hierarchy l Synonyms l Translations l Semantic links l Attributes l 60, 000 concepts l

Central Controlled Vocabulary

MED Structure Medical Entity Substance Chemical Laboratory Specimen Anatomic Substance sured stance Mea Sub Laboratory Test en Glucose Diagnostic Procedure Laboratory Procedure im Bioactive Substance c pe Carbohydrate ce taned s Sub mpl Sa s. S Ha Plasma Specimen Event Plasma Glucose Part of CHEM-7

What do we want to do with these data? Primary use l Other patient care reuse l Financial l Management l Information transfer (messaging) l Clinical research l Expert systems l Information retrieval l Vocabulary discovery l

Primary Use of Data l Spit back the reports

Other Patient Care Reuse l Summaries n Comparability l of data Trending of data n Time representation

Retrieving Results Individually K#1 = 4. 2 K#1 = 3. 3 K#2 = 3. 2 K#1 = 3. 0 K#3 = 2. 6 K#1 K#2 K#3

Retrieving Results by Class K#1 = 4. 2 K#1 = 3. 3 K#2 = 3. 2 K#1 = 3. 0 K#3 = 2. 6 K K#1 K#2 K#3

Case Study: Summaries in the MED Lab Display Lab Test Intravascular Glucose Test Fingerstick Glucose Test Serum Glucose Test Plasma Glucose Test Chem 20 Display

DOP Summary

Web. CIS Summary

Financial Reporting l Accounting l Inventory l

Case Study: Orderable Tests l HCFA won’t pay for lab batteries l Individual tests now treated as orderable procedures l Need to appear in database as procedures and as tests

Case Study: Orderable Tests Lab Procedure Lab Test Intravascular Glucose Test Fingerstick Glucose Test Serum Glucose Test Plasma Glucose Test Chem 7

Case Study: Orderable Tests Lab Procedure Lab Test Intravascular Glucose Test Fingerstick Glucose Test Orderable Test Serum Glucose Test Plasma Glucose Test Chem 7

Management Quality assurance l Case management l

Information Transfer (messaging) Transfer to repository l State reporting l

Clinical Research l Epidemiology - symptoms, incidence, history of disease l Outcomes - effectiveness of therapy, ideal length of stay

Expert systems l Knowledge base construction l Case abstraction l Automated decision support

Terminology and Automated Decision Support l Data monitor checks for triggering conditions l Medical Logic Modules decide if warning conditions are present l Message sent to appropriate channel l Example: Tuberculosis culture result

Decision Support Example: TB l Monitors for delayed culture results l Sends message if result not equal to the code “No growth” l One day, dozens of alerts about positive results but no organism was reported l What happened?

How the Lab Fooled the Alert looked for results = “No Growth” l Lab started reporting “No Growth to Date” l “No Growth to Date” = “No Growth” l Solution: Use the controlled terminology to map all No-Growth-like lab terms into a single class, and have the alert logic refer to the class.

How We Outsmarted the Lab (Before) Medical Logic Module No Growth to Date

How We Outsmarted the Lab (After) “No Growth” Results No Growth to Date No Growth after 48 Hours Medical Logic Module No Growth after 24 Hours No Growth after 72 Hours No Growth after. . .

Linking to On-line Resources with Terminology l Clinician reviewing reports will have information needs l On-line information sources can satisfy that need l Data from report can be used to automate the query

Medical Entities Dictionary Laboratory Test Serum Gentamicin Test Drug Chemical Aminoglycoside Antibiotic Me asu res Gentamicin Random Gentamicin Level Main-Me. SH: Supplementary-Me. SH: "Gentamicin/bl" Measures: Gentamicin s M ea re su Ha s red ien t Ing Injectable Gentamicin Trade-Name: Garamycin" Has-Ingredient: Gentamicin