Controlled Terminology in Clinical Practice

James J. Cimino, M.D.

Department of Medical InformaticsColumbia University

Definition

Terminology:

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

Some General Classes of Terms

Diagnostic Procedures Therapeutic Procedures Medications Diagnoses Findings Organisms Anatomy

Uses of Terminology

Storing in database

Querying database

Transfering data

Billing

Monitoring data

Term - Basic Features

Unique Identifier (Code) 12345

Official Name aspirin

Synonyms ASA

Translations NDC: 5502; UMLS: C0004057

Term - Advanced Features

Classes antipyretic, anti-inflammatory, analgesic

Semantic Links CAUSES: gastritis TREATS: arthritis

Attributes UNITS: mg

Desiderata for Terminology

Content

Concept Orientation Nonredundant Nonambiguous Permanent

Nonsemantic Concept Identifiers

Polyhierarchy

Semantic relationships

Strict Hierarchy

disease

heart disease lung disease

heart attack arrhythmia pneumonia

Polyhierarchy

disease

heart attack arrhythmia

heart disease lung disease infectious disease

pneumonia

Semantic Network

serum potassium test

testspecimen substance

is_a is_ais_a

serum potassium

has_specimen measures_substance

ICD-9/10 and -CM

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

ICD9-CM Examples

------Diseases-----003. @ OTHER SALMONELLA INFECTIONS003.0 SALMONELLA GASTROENTERITIS003.2 @ LOCALIZED SALMONELLA INFECTIONS003.20 LOCALIZED SALMONELLA INFECTION, UNSPECIFIED003.21 SALMONELLA MENINGITIS003.29 OTHER LOCALIZED SALMONELLA INFECTIONS

------Procedures-----01. @ INCISION AND EXCISION OF SKULL, BRAIN,...01.0 @ CRANIAL PUNCTURE01.01 CISTERNAL PUNCTURE01.09 OTHER CRANIAL PUNCTURE

SNOMED

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

under development

SNOMED - Axes

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

"D3-15000" "01" "Myocardial infarction, NOS" "(T-32020) (M-54700)"

"D3-15000" "02" "Infarction of heart, NOS" "(T-32020) (M-54700)"

"D3-15000" "02" "Cardiac infarction, NOS" "(T-32020) (M-54700)”

"D3-15000" "02" "Heart attack, NOS” "(T-32020) (M-54700)"

"D3-15010" "01" "Microinfarct of heart” "(T-32000) (M-54701)”

"C-C137A" "01" "Bufferin Analgesic Tablets""C-C137B" "01" "Bufferin Analgesic Caplets"

"M-54700" "01" "Infarct, NOS"

“M-54700" "02" "Infarction, NOS"

"M-54700" "05" "Infarcted"

"M-54701" "01" "Focal infarct"

"M-54701" "02" "Microscopic infarct"

"S-10120" "01" "Mother, NOS"

MeSH

Medical Subject Headings National Library of Medicine Indexing the medical literature Multiple hierarchy Synonyms

MeSH ExampleD011014: Pneumonia D018410: Pneumonia, Bacterial D007877: Legionnaires' Disease D011018: Pneumonia, Pneumococcal D011019: Pneumonia, Mycoplasma D009175: Mycoplasma Infections D011002: Pleuropneumonia, Contagious D011022: Pneumonia, Rickettsial D011023: Pneumonia, Staphylococcal D001996: Bronchopneumonia D009956: Ornithosis D011001: Pleuropneumonia D011015: Pneumonia, Aspiration D011017: Pneumonia, Lipid D011020: Pneumonia, Pneumocystis carinii D011024: Pneumonia, Viral

Nursing Terminologies

Diagnoses Interventions Outcomes Goals

NANDA X

NIC XNOC X

GHHCC X X X

PCDS X X X

Omaha X X X

AORN X X X

ICNP X X X

UMLS

Unified Medical Language System National Library of Medicine Metathesaurus groups terms under

single concept id No new hierarchy Translation of terms

Metathesaurus

80+ sources

1,358,891 strings

626,893 concepts

Strings have attributes

Concepts have attributes, including Relations

Metathesaurus

String

String

Lexical groupConcept

String

String

Lexical group

String

String

Lexical groupConcept

String

String

Lexical group

Metathesaurus - MRCONC0153957|ENG|P|L0180790|PF|S1084242|benign neoplasm of heart

C0153957|ENG|P|L0180790|VC|S0245316|Benign neoplasm of heart

C0153957|ENG|P|L0180790|VO|S1446737|Benign neoplasm of heart, NOS

C0153957|ENG|S|L0524277|PF|S0599118|Benign tumor of heart

C0153957|ENG|S|L0524278|PF|S0599510|Benign tumour of heart

C0153957|ENG|s|L0018787|PF|S0900815|Heart <3>C0153957|ENG|s|L0018787|VO|S0047194|HeartC0153957|GER|P|L1258174|PF|S1500120|Gutartige Neubildung: Herz

Metathesaurus - MRSO

C0153957|L0018787|S0047194|ICD10|PS|D15.1|3|C0153957|L0018787|S0900815|MTH|MM|U003158|0|C0153957|L0180790|S0245316|ICD10|PX|D15.1|3|C0153957|L0180790|S0245316|ICD99|PT|212.7|0|C0153957|L0180790|S0245316|RCD98|SY|B727.|3|C0153957|L0180790|S1084242|MTH|PN|U001287|0|C0153957|L0180790|S1446737|SNMI98|PT|D3-F0100|3|C0153957|L0524277|S0599118|RCDAE|PT|B727.|3|C0153957|L0524278|S0599510|RCD98|PT|B727.|3|

C0153957|L1258174|S1500120|DMDICD|PT|D15.1|1|

Metathesaurus - MRSTY

C0153957|T191|Neoplastic Process|

Metathesaurus - MRREL

C0002871|CHD|C0002891|isa|MSH99|MTH||

C0002871|CHD|C0002892||CSP98|||

C0002871|CHD|C0002893||RCD98|||

C0002871|RB|C0221016||MTH|MTH||

C0002871|RL|C0002886|mapped_to|SNMI98|SNMI98||

MED

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

Central Controlled Vocabulary

MED Structure

MedicalEntity

LaboratoryProcedure

CHEM-7PlasmaGlucose

LaboratorySpecimen

PlasmaSpecimen

Substance

Sampled

Part of

Has S

pecimen

Substance Measured

Event

LaboratoryTest

DiagnosticProcedure

Plasma

AnatomicSubstance

Substance

BioactiveSubstance

Glucose

Chemical

Carbo-hydrate

What do we want to do with these data?

Primary use Other patient care reuse Financial Management Information transfer (messaging) Clinical research Expert systems Information retrieval Vocabulary discovery

Primary Use of Data

Spit back the reports

Other Patient Care Reuse

Summaries Comparability of data

Trending of data Time representation

K#1 = 4.2K#1 = 3.3

K#2 = 3.2

K#1 = 3.0

K#3 = 2.6

Retrieving Results Individually

K#1

K#2 K#3

K#1 = 4.2K#1 = 3.3

K#2 = 3.2

K#1 = 3.0

K#3 = 2.6

Retrieving Results by Class

K#1

K#2 K#3

K

Case Study:Summaries in the MED

Plasma Glucose Test

Serum Glucose TestFingerstick Glucose Test

Lab Test

Intravascular Glucose Test Chem20 Display

Lab Display

DOP Summary

WebCIS Summary

Financial

Reporting Accounting Inventory

Case Study:Orderable Tests

HCFA won’t pay for lab batteries Individual tests now treated as

orderable procedures Need to appear in database as

procedures and as tests

Case Study:Orderable Tests

Lab Procedure

Chem 7

Lab Test

Intravascular Glucose Test

Plasma Glucose Test

Serum Glucose TestFingerstick Glucose Test

Case Study:Orderable Tests

Lab Procedure

Chem 7

Lab Test

Intravascular Glucose Test

Plasma Glucose Test

Serum Glucose TestFingerstick Glucose Test

Orderable Test

Management

Quality assurance Case management

Information Transfer (messaging)

Transfer to repository State reporting

Clinical Research

Epidemiology - symptoms, incidence, history of disease

Outcomes - effectiveness of therapy, ideal length of stay

Expert systems

Knowledge base construction Case abstraction Automated decision support

Terminology and Automated Decision Support

Data monitor checks for triggering conditions

Medical Logic Modules decide if warning conditions are present

Message sent to appropriate channel

Example: Tuberculosis culture result

Decision Support Example: TB

Monitors for delayed culture results

Sends message if result not equal to the code “No growth”

One day, dozens of alerts about positive results but no organism was reported

What happened?

How the Lab Fooled the Alert

Alert looked for results = “No Growth”

Lab started reporting “No Growth to Date”

“No Growth to Date” = “No Growth”

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)

No Growth

Medical Logic Module

No Growth to Date

No Growth after ...

How We Outsmarted the Lab(After)

No Growth

No Growth after 48 Hours

No Growth after 72 Hours

“No Growth” Results

No Growth after 24 Hours

No Growth to Date

Medical Logic Module

Linking to On-line Resources with Terminology

Clinician reviewing reports will have information needs

On-line information sources can satisfy that need

Data from report can be used to automate the query

LaboratoryTest

Medical Entities Dictionary

HasIngredient

Measures

Chemical

AminoglycosideAntibiotic

Gentamicin

Serum Gentamicin

Test

Drug

Injectable GentamicinTrade-Name: Garamycin"Has-Ingredient: GentamicinMeasures

Random Gentamicin Level

Main-MeSH:

Supplementary-MeSH: "Gentamicin/bl"

Measures: Gentamicin