CPRI Terminology Activities Heritage, Lessons, and Perspective

1. CPRI Terminology ActivitiesHeritage, Lessons, and Perspective CG Chute, MD DrPH Mayo Foundation SP Cohn, MD MPH Kaiser Permanente NCVHS May, 1999 1

2. Motivation and Context:A Value Proposition “Those with more detailed, reliable and comparable data for cost and outcome studies, identification of best practices, guidelines development, and management will be more successful in the marketplace.” SP Cohn; Kaiser Permanente 2

3. Clinical Database Observational Data Medical Knowledge Clinical Guidelines Expert Systems Heritage of Continuous Improvement Central Role of Terminology Terminology Patient Encounters 3

4. Terminology as Crucial Requirement Without Terminology Standards... • Health Data is non-comparable • Health Systems cannot Interchange Data • Secondary Uses (Research, Quality) are not possible • Linkage to Decision Support Resources not Possible 4

5. Weights and MeasuresPublic Health Metrics “The nomenclature is of as much importance in [health], as weights and measures in the physical sciences, and should be settled without delay.” William Farr, First Annual Report of the Registrar-General of Births,Deaths, and Marriages in England. London: 1839 p. 99. 5

6. Long Heritage of CPRI Involvement withTerminology Questions • Chute CG, Cohn SP, Campbell KE, Oliver DE, Campbell JR, and the Computer-Based Patient Record Institute's Work Group on Codes & Structures. The content coverage of clinical classifications. JAMIA 1996;3(3):224-33. • Campbell JR, Carpenter P, Sneiderman C, Cohn SP, Chute CG, Warren J. Phase II Evaluation of Clinic Coding Schemes: Completeness, Taxonomy, Mapping, Definitions, and Clarity. JAMIA 1997;4(3):238-251. • Chute CG, Cohn SP, Campbell JR. A Framework for Comprehensive Health Terminology Systems in the United States: Development Guidelines, Criteria for Selection, and Public Policy Implications. JAMIA 1998;5:503-510. 6

7. CPRI Coding StudyConclusions - 1996 (1994) • Most coding systems lose information • Some lose more than others • ICD, even with CPT, loses over half of the clinical detail • Misclassification bias is probable in studies which use administrative coding systems 7

8. Joint CPRI ANSI/HISBTerminology Framework (JAIMIA Dec ‘98) • Characteristics • Comprehensive, Coherent, Interlocking ... • Structure of the Terminology Model • Atomic, Compositional, A-cyclic,... • Maintenance • Identifiers, Version Control,... • Administration 8

9. National Summit onHealth Information Solutions CPRI Summit:November, 1996 • Agreed to: • Convene A National Conference • Terminology and Dataset Developers • Health Care Providers • CPR System Vendors • Health Care Payers • Government 9

10. History of Conference ForaFocusing Upon Health Terminology • National Conference on Terminology for Clinical Patient Description • November 12-14, 1997, Arlington, VA • Joint Conference on Lexical Solutions for the Government CPR (GCPR) • Co-Hosted by Health Level-7 (HL7) • Arlington, Virginia August 3-4, 1998 • Terminology II: Establishing the Consensus Lessons from Experience • April 27-29, 1999, Tysons Corner, VA 10

11. Single Web Entry Point • All Presentation Slides • Substantial Summaries • Average 50 page synopses • References to Published Work www.cpri.org/terminology 11

12. National Conference on Terminology forClinical Patient Description Nov 12-14 1997; Arlington, VA • Industry Defined Terminology Requirements • Agree Upon Framework for Progress • Prioritize Requirements • Knowledgeable Input Into National Deliberations 12

13. What is Clinical Terminology Tentative Definition Standardized terms and their synonyms which record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement; and can be efficiently mapped to broader classifications for administrative, regulatory, oversight, and fiscal requirements. 13

14. Continuum from Nomenclature to Classification • Patient Data is Highly Detailed • Modifiers: Anatomy, Stage, Severity, Extent • Qualifiers: Probability, Temporal Status • Aggregate Uses Require Categorization • Granularity of Classifiers • Focused Groups and Strata for CQI/Outcomes • Broad Statistical/Fiscal Groups 14

15. Terminology Systems RelationshipsEngineering Map ...Classifications Entry Terminology Reference Terminology Nomenclatures... Aggregate and Administrative Terminology 15

16. Classifications Emerging from a Nomenclature Summary Nomenclature Granular 16

17. Consensus Point • Recognition that Fair Recovery of Development and Ongoing Maintenance Costs are Justifiable and Necessary 17

18. CPRI II: April 1999Case Studies and Practical Examples • Positing “Interlocking Solutions” Not Enough • Examine Case Studies of Bilateral Coordination or Cooperation • Generalize from Experiences as Examples to Proceed toward Common Goal 18

19. Backdrop of Recent CoordinationUnderstated but Spectacular Success • NLM’s Facilitation of: • CPT, ICD, SNOMED Bilateral Mappings • LOINC-SNOMED Cooperation • “Inclusion” by Reference • Lexical-Ontyx “Letter of Intent” to Merge • Terminology Component Vendors • Merger of SNOMED - NHS “Read” Clinical Terms • Create a New, Common, Hybrid Product 19

20. Centers of GravityEmergent Since “Terminology I” • ISO WG on Terminologies • Newly Merged Public and Private Efforts • HL/7 Vocabulary Working Group • Intention to Register Terminology Systems • NCVHS 20

21. Detailed Updates on Major Systems • CPT-5: Karen Borman MD • ICD-10-PCS: Pat Brooks RRA • SNOMED-RT: Kent Spackman MD PhD • LOINC: Patricia Maloney • ICD-10-CM: David Berglund MD 21

22. Major Points: Terminology II Business Relevance • Clinical Nomenclatures and Reference Terminologies Are Now Broadly Recognized As Crucial to the Optimal Practice of Health Care, Enabling Quality Improvement, Outcomes Analysis, and Treatment Efficacy Studies. • They Can Enhance Clinical Efficiency and Provide Reliable Linkages for Decision Support. 22

23. Major Points: Terminology II Demonstrated Coordination • There Has Emerged a Spirit of Cooperation and Many Case Examples of Fruitful Coordination and Collaboration Among Terminology Developers and Supporters. • A Positive Consolidation in the Field Is Escalating. 23

24. Major Points: Terminology II From Nomenclatures to Classifications • The Importance of Mapping or Linking the Detailed Descriptions of Patients Using Clinical Nomenclatures Against Categorical Classifications (Such as the ICDs) Is Well Recognized and Proactively Adopted by Terminology Developers Across the Continuum From Nomenclatures to Classifications. 24

25. Major Points: Terminology II Public Funding • The Principle of Government Support for Terminology Development and Maintenance As an Infrastructure for the Public Good, With an Aim Toward Reducing the Costs for End Users, Is Welcomed and Encouraged. 25

26. Remaining Tasks • Fully Engage Payers and Providers • “Customer Demand” for Vendors • Reconcile: • Terminology Structures • Reference Information Models • Complete Transition from Esoteric Interest to Crucial Infrastructure for the Public Good 26