Mayo Foundation: Clinical Perspective on Comparable Data By Peter L. Elkin, MD Director, Laboratory of Biomedical Informatics Department of Internal Medicine Mayo Clinic © Copyright Mayo Foundation for Medical Education and Research 2004
Document Management The Tip of the Iceberg • Millions of Documents are Generated by Healthcare Organizations each Year • All are lost with respect to retrieval purposes (Except by MR#) – Lost Opportunity to Learn about your practice – Lost Opportunity to Manage your practice © Copyright Mayo Foundation for Medical Education and Research 2004
Document Management The Tip of the Iceberg • Other Applications – Linking Images to Patient Records – Linking the Literature to Patient Records – Aggregate Retrievals for Research – Cost Justification by Better Documentation (links to Clinical Guidelines, Definitions, etc. ) – Linking Documents to Web pages Dynamically • Challenge is that this Linkage must be robust enough to characterize today’s practice of medicine © Copyright Mayo Foundation for Medical Education and Research 2004
Clear Return on Investment • Automated Vocabulary Management • Better Asset Management • Automated evaluation of records to see if they meet the E&M coding guidelines? • Expert System to Maximize DRG reimbursement…. . • Decision Support (Patient Safety) © Copyright Mayo Foundation for Medical Education and Research 2004
Granular Encoding © Copyright Mayo Foundation for Medical Education and Research 2004
Mayo Technology • Concept Based Indexing – SNOMED-CT – ACE – ACD – Vocabulary Server – Comparable Data © Copyright Mayo Foundation for Medical Education and Research 2004
© Copyright Mayo Foundation for Medical Education and Research 2004
System Architecture Enterprise Java Beans © Copyright Mayo Foundation for Medical Education and Research 2004
EMR © Copyright Mayo Foundation for Medical Education and Research 2004
Record Entry Process Web Server Enterprise Java Bean Container Transcribed Record Processed Record to Storage EMR Repository Map Text To Terminology and Terminology Store Intelligent Query to Database Handle Query and Explode Matches Query Record Retrieval Process © Copyright Mayo Foundation for Medical Education and Research 2004 Record to Processor and Return Terminology Server Query to Processor and Return
Terminology in Healthcare: “The nomenclature is of as much importance in this department of inquiry, as weights and measures in the physical sciences, and should be settled without delay. ” William Farr, 1839; Regarding the Cullenian system of 1785 First Annual Report of the Registrar-General of Births, Deaths, and Marriages in England. London: 1839 p. 99. © Copyright Mayo Foundation for Medical Education and Research 2004
“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. ” - Florence Nightingale, 1893 © Copyright Mayo Foundation for Medical Education and Research 2004
Electronic Health Record • Comparable Data – Granularity C/W the Practice • Outcomes Research • Utilization Review • Managing the Financial Side of the Practice – Controlled Medical Vocabulary • Maintenance • Coverage • Formal Definitions • Unambiguous (Within a Context) • Non-Redundant – Ease of Data Acquisition © Copyright Mayo Foundation for Medical Education and Research 2004
Current Large Vocabulary Efforts • SNOMED-RT – SNOMED-DICOM Microglossary • • • Clinical Terms v 3 (Read Codes) SNOMED-CT UMLS NIC, NOC, NANDA NDF-RT © Copyright Mayo Foundation for Medical Education and Research 2004
TOMMY G. THOMPSON, SECRETARY OF HEALTH AND HUMAN SERVICES July 1, 2003 • I am very excited about the tremendous potential for information systems to improve the quality of health care, and I have been pushing everyone in the Department very hard to move forward as rapidly as possible. • My first charge ……… is to develop incentives for all parts of the health care community to use SNOMED, the electronic medical records, and other standards as they are adopted. We want to see the integration of health information systems through to its logical conclusion. • I challenge you to adopt and use interoperable electronic health records. © Copyright Mayo Foundation for Medical Education and Research 2004
Placing a Stake in the Ground by Don Berwick, MD Clinicians and Researchers need a comparable mechanism for accessing Medical Record Data. Let’s place that stake in the ground where we think it Really Ought To Be!!! © Copyright Mayo Foundation for Medical Education and Research 2004
Interoperability • Data Exchange Between and Among Computers and Computer Systems – Reliable – Complete – Accurate • Interoperability Standards – HL 7 – ASTM – ISO © Copyright Mayo Foundation for Medical Education and Research 2004
Statement: • In Medicine, we will never be able to create a vocabulary, with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary. • E. g. Cellulitis, Left foot, with Osteomyelitis of the 3 rd Metatarsal. © Copyright Mayo Foundation for Medical Education and Research 2004
Answer: Compositionality • Unambiguous – The Composite Term and its formalism should be specified in such a way as not to allow two or more interpretations of the term’s meaning. • Non-Redundant – Normalization of Pre-Coordinated Terms – Normalization of Post-Coordinated Terms © Copyright Mayo Foundation for Medical Education and Research 2004
Glossary: • Atomic Concept: • Example: Colon has a unique concept identifier in SNOMED-CT and cannot be represented by combining two or more other codes from within the terminology. © Copyright Mayo Foundation for Medical Education and Research 2004
Glossary: • Pre-coordinated Concept: • Example: Colon Cancer is non-atomic, however it has a single unique identifier in SNOMED-CT, which means to the SNOMED that it represents a “single” concept. © Copyright Mayo Foundation for Medical Education and Research 2004
Glossary: • Post-coordinated Concepts: • Example: The concept “Status-Post CABG” is not a unique concept within the SNOMED-CT Reference Terminology. © Copyright Mayo Foundation for Medical Education and Research 2004
Glossary: • Qualifier: A string which when added to a term changes the meaning of the term in a Temporal or Administrative sense. For example, “History of” or “Recurrent”. • Modifier: A string which when added to a term changes the meaning of the term in a Clinical sense. For example, clinical stage or severity of illness. • Ontology: An organization of concepts for which one can make a rational argument. Colloquially this term is used to describe a hierarchy constructed for a specific purpose. For example a hierarchy of Qualifiers would be a Qualifier Ontology. • Canonical Term: A preferred atomic or pre-coordinated term for a particular medical concept. © Copyright Mayo Foundation for Medical Education and Research 2004
Glossary: • Content Normalization When all the Pre-coordinated terms in the Vocabulary are mapped to the combinations of Atomic terms in the same Vocabulary, which can be said to be equivalent in meaning. © Copyright Mayo Foundation for Medical Education and Research 2004
If We Build It, They Will Come Field of Dreams (Early 90’s) • Standards – – – – Vocabulary Structure Semantic Representation Formalism for Content Representation Formalism for Composition Formalism for Medical Knowledge Representation Reliable Set of Views Vocabulary Messaging (HL 7 CDA and Templates Conformant) © Copyright Mayo Foundation for Medical Education and Research 2004
Usability Laboratory Experience • Compositionality is Essential for a robust and clinically useful Document Retrieval Tool • Modifiers and Qualifiers provided the greatest Utility • The Interface Design is integral to the acceptance of the Search Engine • Designers must work to minimize Cognitive Overhead and potential sources of Disorientation. © Copyright Mayo Foundation for Medical Education and Research 2004
Comparable Data • SNOMED-CT – Description Logic-Based Terminology – Compositional System – ~340, 000 Concepts – ~800, 000 Terms – LBI version adds 400, 000 Terms – Over 30, 000 Indices to the SNOMED-CT Terminology © Copyright Mayo Foundation for Medical Education and Research 2004
Compositional Systems © Copyright Mayo Foundation for Medical Education and Research 2004
Compositional Systems • • Acute myocardial infarction of the anterolateral wall Heart attack, Anterolateral cardiac wall, Acute AMI, Anterolateral Wall Acute MI of the Anterolateral Wall • - Myocardial infarction (disorder) [22298006] – - [has Finding Site]. Entire myocardium of anterolateral region (body structure) [190762001] – - [is Modified By]. Acute (qualifier value) [53737009] © Copyright Mayo Foundation for Medical Education and Research 2004
An Evaluation of the Content Coverage of SNOMED-CT for Clinical Problem Lists By Peter L. Elkin, MD 1, Steven H. Brown, MD 2, Casey Husser, MD 1, Brent A. Bauer, MD 1, Dietlind Wahner. Roedler, MD 1, S. Trent Rosenbloom, MD 2, Ted Speroff, Ph. D 2 1. Mayo Foundation for Medical Education and Research 2. Vanderbilt University © Copyright Mayo Foundation for Medical Education and Research 2004
Methods • 4, 996 Most Common Unique Mastersheet Index Entries were Mapped to SNOMED-CT • Two expert reviewers (Consultants) independently graded the mappings (using the automated mappings plus a SNOMED-CT browser) • Disagreements were adjudicated by a third reviewer # engin e SNOMEDCT 16 TP FP TN FN 17 TP FP TN FN Misspellin g Match Type Concept Mapping Decomposition TP FP TN FN CID abdominal hernia Hernia of abdominal cavity (disorder) [52515009] [K] TP FP TN FN CID abdominal mass Abdominal mass (finding) [271860004] [K] © Copyright Mayo Foundation for Medical Education and Research 2004
Results SNOMED-CT Results Smart. Access Vocabulary Server Results 383 FN 256 FN 9 FP 36 TN 419 TN 4568 TP 4312 TP Results SNOMED-CT Smart. Access Vocabulary Server SAVS with Synonyms Sensitivity 92. 3% 94. 4% 99. 7% Specificity 80. 0% 97. 9% Positive Likelihood Ratio 4. 62 45. 0 47. 5 Positive Predictive Value 99. 8% Negative Predictive Value 8. 6% 62. 1% 97. 0% © Copyright Mayo Foundation for Medical Education and Research 2004
Results • The sensitivity of SNOMED-CT without the use of composition was only 51. 4%. Using the Mc. Nemar Chi-Square Test there was a significant difference between the sensitivity of SNOMED-CT with and without using composition (51. 4% vs. 92. 3%; p<0. 001). © Copyright Mayo Foundation for Medical Education and Research 2004
Conclusions Regarding Medical Knowledge Representation using SNOMED-CT • SNOMED-CT has good coverage of the terms used commonly in medical problem lists. • Improvements to synonymy and the addition of missing modifiers would lead to the greatest return on investment toward improved coverage of common problem statements. • Compositional expressions are required to exactly represent a significant portion of common problem statements (p<0. 001). © Copyright Mayo Foundation for Medical Education and Research 2004
Representational Complexity © Copyright Mayo Foundation for Medical Education and Research 2004
Variable Complexity © Copyright Mayo Foundation for Medical Education and Research 2004
Avoid the Compositional Tower of Babel © Copyright Mayo Foundation for Medical Education and Research 2004
![Ambiguous Representation • “Hepatoma Metastatic to the Lungs” – Malignant neoplastic disease (disorder) [363346000]](https://present5.com/presentation/f8dedf95cc7c27c03c937742b8def848/image-38.jpg "Ambiguous Representation • “Hepatoma Metastatic to the Lungs” – Malignant neoplastic disease (disorder) [363346000]")
Ambiguous Representation • “Hepatoma Metastatic to the Lungs” – Malignant neoplastic disease (disorder) [363346000] – Entire liver (body structure) [181268008] – Entire lung (body structure) [181216001] – Secondary malignant neoplastic disease (disorder) [128462008] • “Liver Cancer” “Lung” or • “Lung Cancer” “Liver” © Copyright Mayo Foundation for Medical Education and Research 2004
Inter-Semantic Relationships • Dx = (defconcept Hepatoma Metastatic to the Lung • (and disease • (and (some Assoc-Morphology “Metastatic Neoplasm”) • (some Assoc-Topography “Lung”)) • (and (some Assoc-Etiology “Malignant Neoplasm”) • (some Assoc-Topography “Liver”)))) © Copyright Mayo Foundation for Medical Education and Research 2004
Generic Rule • Dx = (defconcept Dxxxxxx • (and disease • (and (some Assoc-Morphology x) • (some Assoc-Topography (at least 1 Topography {or t 1, t 2 , t 3, … tm (m 1)})) • (and (some Assoc-Etiology y) • (some Assoc-Topography (at least 0 Topography {or t 1, t 2, t 3, … tn (n 1)))))) © Copyright Mayo Foundation for Medical Education and Research 2004
Conceptual Relativity • Level 1 - Diseases • | Distance 1. 0 • Level 2 - Cardiovascular Diseases (2000 Siblings) • | Distance = (((256/2000) * (5 -2)) * 1. 0) = 0. 384 • Level 3 - Congestive Heart Failure (250 Siblings) • | Distance = (((6/250) * (5 -3) *. 384) = 0. 0399 • Level – 4 LV Systolic Dysfunction (5 Siblings) • | Distance = (((1/5) * (5 -4) * 0. 0399) = 0. 008 • Level 5 - LV Systolic Dysfunction, Class III HF (1 Sibling) • Generalization: • ((Sc. T/Sp * (Level. T-Levelp)) * Dist. Level – 1) © Copyright Mayo Foundation for Medical Education and Research 2004
Semantic Distance from Feature Set Recognition • Myocardial Infarction • Has. Morphology Infarct • Has. Finding. Site Myocarium • And • Acute Myocardial Infarction Heart Attack • Has. Morphology Infarct Has. Finding. Site Myocarium • Has. Finding. Site Myocarium Has. Modifier Acute © Copyright Mayo Foundation for Medical Education and Research 2004
Level One Ontology HEALTH LEVEL 7 REFERENCE INFORMATION MODEL RIM_0100 released January 2001 reflects RIM changes through Harmonization on 11/17/2000 Enitites Acts (Services) Roles Message_control Role-role relationships Healthcare_finances Billboard produced by: Rochester Outdoor Advertising Participation Role Notary_public notary_county_cd : CE notary_state_cd : CE Place gps_txt : ST position_txt addr : AD directions_txt Health_chart 1 Individual_healthcare_practitioner fellowship_field_cd : CE graduate_school_nm : ON graduation_dttm : TS board_certified_ind : BL is_assessed_against 0. . * Health_chart_deficiency assessment_dttm : TS desc : ED level_cd : CV type_cd : CV Healthcare_facility licensed_bed_nbr : REAL mobile_ind : BL is_site_for Person disability_cd : CE ethnic_group_cd : CE race_cd : CE ambulatory_status_cd : CV birth_order_nbr : INT education_level_cd : CV living_arrangement_cd : CV marital_status_cd : CV religious_affiliation_cd : CV student_cd : CV credit_rating_cd : CV addr : SET<AD> special_accommodation_cd : SET<CV> 1 Role_relationship 0. . * type_cd : CC effective_tmr : IVL<TS> has_as_target id : SET<II> status_cd : CS responsibility_cd : SET<CE> position_nbr : LIST<INT> has_as_source qty : PQ 0. . * certificate_txt : ED Entity Manufactured_material expiration_dttm : TS lot_nbr : ST is_communicated_by 0. . * Person_Language 1 Access gauge_qty : PQ entry_site_cd : CD body_site_cd : CD Clinical_document_header availability_status_cd : CV change_reason_cd : CV completion_status_cd : CV confidentiality_status_cd : CV content_presentation_cd : CV document_creation_dttm : TS file_nm : ST last_edit_dttm : TS reporting_priority_cd : CE results_report_dttm : TS storage_status_cd : CV transcription_dttm : TS document_change_cd : CV version_nbr : INT version_dttm : TS Role Relationship Container capacty_qty : PQ height_qty : PQ diameter_qty : PQ barrier_delta_qty : PQ bottom_delta_qty : PQ separator_type_cd : CD cap_type_cd : CD Clinical_document Working_list ownership_level_cd Referral authorized_visits_qty : REAL desc : ED reason_txt : ED 1 is_utilized_during 0. . * utilizes 1 Supply qty : PQ Transportation Consent Procedure entry_site_cd : SET<CD> method_cd : SET<CV> body_site_cd : SET<CD> is_target_for 1 Act_relationship type_cd : CS inversion_ind : BL has_source sequence_nbr : INT 0. . * priority_nbr : INT pause_qty : PQ checkpoint_cd : CS split_cd : CS has_target join_cd : CS 0. . *negation_ind : BL conjunction_cd : CS is_authorized_by Diet energy_qty : PQ carbohydrate_qty : PQ Observation value : ANY derivation_expr : ST method_cd : SET<CV> body_site_cd : SET<CD> interpretation_cd : SET<CS> Act Relationship originates_in_context_of 1. . * Medication form_cd : CD route_cd : CD dose_qty : PQ strength_qty : PQ rate_qty : PQ dose_check_qty : PQ method_cd : SET<CV> body_site_cd : SET<CD> substitution_cd : CV Document_service completion_cd : CV set_id : II storage_cd : CV version_nbr : INT copy_dttm : TS origination_dttm : TS is_part_of Financial_act effective_tmr : IVL<TS> reason_cd : CE status_dttm Act_context level_cd Message_interaction is_communicated_as 0. . 1 Public_health_case detection_method_cd transmission_mode_cd disease_imported_cd 1 Patient_Provider 0. . * Device manufacturer_model_nm : ST last_calibration_dttm : TS software_nm : ST local_remote_control_state_cd : CE alert_level_cd : CE 1 Healthcare_benefit_product_policy Diagnostic_related_group_definition Patient_billing_account assignment_of_benefits_ind : BL base_rate_qty : MO benefit_product_desc : ED adjustment_cd : CV capital_reimbursement_qty : MO benefit_product_nm : ST certification_required_ind : BL cost_weight_qty : MO benefit_product_type_cd : CE current_unpaid_balance_qty : MO major_diagnostic_category_cd : CE benefits_coordination_ind : BL expected_insurance_plan_qty : REAL operating_reimbursement_qty : MO cob_priority_nbr : REAL expected_payment_source_cd : CV reimbursement_qty : MO combine_baby_bill_ind : BL notice_of_admission_dttm : TS standard_day_qty : PQ notice_of_admission_ind : BL group_benefit_ind : BL standard_total_charge_qty : MO patient_financial_class_cd : CV mail_claim_party_cd : CE trim_high_day_qty : PQ price_schedule_id : II release_information_cd : CE trim_low_day_qty : PQ report_of_eligibility_dttm : TS status_cd : CS coverage_type_cd : CE retention_ind : BL defines 1 agreement_type_cd : CE signature_on_file_dttm : TS policy_category_cd : CE special_program_cd : CV is_defined_by 0. . * access_protocol_desc : ED stoploss_limit_ind : BL suspend_charges_ind : BL Encounter_drg total_adjustment_qty : MO approval_ind : BL total_charge_qty : MO confidential_ind : BL total_payment_qty : MO cost_outlier_qty : MO separate_bill_ind : BL desc : ED bad_debt_recovery_qty : MO grouper_review_cd : CE Champus_coverage grouper_version_id : II bad_debt_transfer_qty : MO handicapped_program_cd : CE outlier_days_nbr : REAL outlier_reimbursement_qty : MO non_avail_cert_on_file_ind : BL outlier_type_cd : CV retirement_dttm : TS station_id : II manages 0. . * Resource_slot status_cd : CS time_slot : GTS 0. . * is_source_for 0. . * Schedule status_cd : CS slot_size_increment_qty is_managed_by specifies_ability_in Language_ability mode_cd : CV proficiency_level_cd : CV has_parts 0. . 1 Act id : SET<II> mood_cd : CS type_cd : CC txt : ED status_cd : CS activity_time : GTS critical_time : GTS confidentiality_cd : SET<CV> max_repeat_nmr : IVL<INT> interruptible_ind : BL priority_cd : SET<CV> orderable_ind : BL availability_dttm : TS Act 1 provides_context_for Patient_encounter discharge_disposition_cd : CV acuity_level_cd : CV birth_encounter_ind : BL status_reason_cd : CV classification_cd : CV encounter_classification_cd : CV practice_setting_cd : CV valuables_desc : ED pre_admit_test_ind : BL 1 source_cd : CV special_courtesies_cd : CV valuables_location_desc : ED effective_tmr uses Inpatient_encounter length_of_stay_qty : PQ Specimen body_site_cd : CE communicates_in is_specified_by 1 Non_Person_living_subject taxonomic_classification_cd : CE breed_cd : CE strain_txt : ED euthanasia_ind : BL production_class_cd : CE gender_status_cd : CE has Military_person Healthcare_provider military_branch_of_service_cd : CV specialty_cd : CV military_rank_nm : ST military_status_cd : CV has_an_assessment_of Living_subject birth_dttm : TS deceased_dttm : TS Material deceased_ind : BL administrative_gender_cd : CE Organization form_cd : CV organ_donor_ind : BL danger_cd : CE org_nm : SET<ON> multiple_birth_ind : BL standard_industry_class_cd : CE effective_tmr : IVL<TS> handling_cd : CE addr : SET<AD> Participation has_as_participant type_cd : CS tmr : IVL<TS> note_text : ED 0. . * signature_cd : CV for function_cd : CD awareness_cd : CV 0. . * signature_txt : ED encounter_accommodation_cd : CV status_cd : CS 0. . * Role participates_in is_played_by type_cd : cc is_source_of effective_tmr : IVL<TS> 0. . 1 is_target_for 1 addr : SET<AD> 1 1 telecom : SET<TEL> Entity 1 id : SET<II> plays_a_role type_cd : CC determiner_cd : CS importance_status_txt : ED has qty telecom : SET<TEL> 0. . * 1 desc status_cd : CS sends 1. . 1 shall_receive 1. . * Entity_name effective_tmr : IVL<TS> nm : EN purpose_cd : CV is_for Appointments & scheduling is_sited_at Practitioner_provider position_cd : CV primary_care_ind : BL Employee_Employer addr : SET<AD> hazard_exposure_txt : ED job_class_cd : CV job_title_nm : ST telecom : SET<TEL> protective_equipment_txt : ED salary_qty : MO salary_type_cd : CV status_cd : CS job_cd : CE Practitioner_Certifier board_certification_type_cd : CV certification_dttm : TS residency_field_cd : CE Unmapped_financial_classes (from RIM_Healthcare_finances) Outbreak tmr Encounter_facility_association effective_tmr : IVL<TS> is_used_by status_cd : CS transfer_reason_cd : CV 0. . * © Copyright Mayo Foundation for Medical Education and Research 2004 Preauthorization authorized_encounters_qty : REAL authorized_period_begin_tmr : IVL<TS> id : II issued_dttm : TS 0. . 1 requested_dttm : TS restriction_desc : ED authorizes status_cd : CS status_change_dttm : TS Insurance_certification has_coverage_affirmed_by 1 0. . * Guarantor_contract certification_duration_qty : PQ billing_hold_ind : BL effective_tmr : IVL<TS> affirms_insurance_coverage_for billing_media_cd : CE id : II charge_adjustment_cd : CE insurance_verification_dttm : TS contract_duration_cd : CE modification_dttm : TS contract_type_cd : CE non_concur_cd : CE effective_tmr : IVL<TS> non_concur_effective_dttm : TS interest_rate_nbr : REAL penalty_qty : MO periodic_payment_qty : MO report_of_eligibility_dttm : TS priority_ranking_cd : CV report_of_eligibility_ind : BL Billing_information_item condition_cd : CE occurrence_dttm : TS occurrence_span_cd : CE occurrence_span_from_dttm : TS occurrence_span_thru_dttm : TS quantity_nbr : REAL quantity_type_cd : CV value_amt value_cd : CE Healthcare_benefit_coverage_item service_category_cd : CV service_cd : CE service_modifier_cd : CE authorization_ind : BL network_ind : BL assertion_cd : CE covered_parties_cd : CE qty : REAL quantity_qualifier_cd : CE time_period_qualifier_cd : CE range_low_qty : PQ range_high_qty : PQ range_units_cd : CV eligibility_cd : CE policy_source_cd : CE eligibility_source_cd : CE copay_limit_ind : BL Financial_transaction extended_qty : MO fee_schedule_cd : CE insurance_qty : MO posting_dttm : TS qty : MO transaction_batch_id : II unit_qty : MO unit_cost_qty : MO
Level Two Ontology © Copyright Mayo Foundation for Medical Education and Research 2004
Level Three Ontology • Fully Encoded Health Record • Consistent with the Level One and Two Ontologies for Health • Compositional Expressions are assigned Automagically • No Human effort is needed so that the practice of Medicine does not have to be shaped around information systems but instead the Information Systems can unobtrusively improve Patient Care. • Example…………. . © Copyright Mayo Foundation for Medical Education and Research 2004
Moving Towards a Harmonious Formalism © Copyright Mayo Foundation for Medical Education and Research 2004
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