Advanced Controled Medical Terminology: The Medical Entities Dictionary (MED)

1. “Nursing Interventions and Outcomes in Three Older Populations” Effectiveness StudyProject Consultant MeetingUniversity of Iowa College of NursingFebruary 10-11, 2003Advanced Controlled Medical TerminologyWireless Palm-based Access to Health InformationJames J. CiminoColumbia University Department of Medical Informatics

2. Advanced Controled Medical Terminology:The Medical Entities Dictionary (MED) • Columbia Presbyterian Medical Center • Health data repository since 1988 • Multiple uses of data • Automated decision support • Merger with New York Hospital

3. New York Presbyterian HospitalClinical Information Systems Architecture Medical Logic Modules Clinical Database Alerts & Reminders Database Monitor Results Review Database Interface Administrative Medical Entities Dictionary Research Reformatter Reformatter Reformatter . . . . . . Radiology Discharge Summaries Laboratory

4. Central Controlled Terminology

5. Substance Laboratory Specimen Event Chemical Anatomic Substance Plasma Specimen Diagnostic Procedure Substance Sampled Plasma Laboratory Test Laboratory Procedure Has Specimen Carbo- hydrate Bioactive Substance CHEM-7 Part of Glucose Substance Measured MED Structure Medical Entity Plasma Glucose Test

9. The MED Today • Concept-based (73,000) • Multiple hierarchy (90,000) • Synonyms (180,000) • Translations (125,000) • Semantic links (134,000) • Attributes (175,000)

10. Applications of the MED • Communicating terminology changes • Data modeling to support clinical applications • Terminology management • Conceptual mapping for decision support • Problem-based views of the EMR • Translation to link to information resources

11. K#3 = 2.6 K#3 Retrieving Results Individually K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 K#1 K#2

12. K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 K#3 = 2.6 K K#3 Retrieving Results by Class K#1 K#2

13. Lab Display Lab Test Chem20 Display Intravascular Glucose Test Fingerstick Glucose Test Serum Glucose Test Plasma Glucose Test Supporting Clinical Applications: Example: Summary Reports

14. DOP Summary

15. WebCIS Summary

16. Maintenance: “Pushing” a Term Medical Entity Chemical Laboratory Test Carbo- hydrate Stat Glucose Test Bioactive Substance Chemistry Test Plasma Glucose Test Glucose Chem-7 Glucose Test Chem-20 Glucose Test

17. Maintenance: “Pushing” a Term Medical Entity Chemical Laboratory Test Carbo- hydrate Stat Glucose Test Bioactive Substance Chemistry Test Plasma Glucose Test Glucose Stat Glucose Test Chem-7 Glucose Test Chem-20 Glucose Test

18. Maintenance: “Pushing” a Term Medical Entity Chemical Laboratory Test Carbo- hydrate Stat Glucose Test Bioactive Substance Chemistry Test Plasma Glucose Test Glucose Stat Glucose Test Chem-7 Glucose Test Chem-20 Glucose Test Stat Glucose Test

19. Maintenance: Finding a New Class Medical Entity Laboratory Test Chemical Chemistry Test Antigen Core Antigen HBC Hepatitis B Core Antigen

20. Maintenance: Finding a New Class Medical Entity Medical Entity Laboratory Test Laboratory Test Chemical Chemical Chemistry Test Chemistry Test Antigen Antigen Core Antigen HBC Hepatitis B Core Antigen Test Hepatitis B Core Antigen Hepatitis B Core Antigen Core Antigen HBC

21. Maintenance: Automated Classification Medical Entity Allergy Class Chemical Drug Sulfa Allergy "S1" Trimethoprim Allergy "65" Antibiotic Pharmacologic Substance Trimethoprim/ Sulfamethoxizole Preparations Sulfameth- oxizole Trimeth- oprim Septra "S1" Bactrim "S1", "65"

22. 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 • Decision support concepts are more general than clinical data • MED provides mapping • Example: Tuberculosis culture result

23. Automated Decision SupportExample: “Positive” TB Cultures • Alert checks for late results of TB tests • IF Result Not Equal “No Growth”… • One day, an apparent epidemic of positive results… …but checking the lab shows “No Growth to Date”

24. 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.

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

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

27. MED Chest Cardiac Enzyme Heart Disease Chest X ray Creatine Kinase Congestive Heart Failure Angina Chest X ray 2 View Intravascular CK Test Admission :3/14/96 Stroke Lab :12/28/96 Sickle Cell Test Radiology :2/28/96 Head CT Medical Record Lab :1/1/99 Blood Type Test Admission :2/14/98 Angina Admission :2/14/98 Angina Radiology :2/1/97 Knee X Ray Radiology :2/23/99 Chest X Ray Radiology :2/23/99 Chest X Ray Discharge :1/15/99 CHF Discharge :1/15/99 CHF Lab :1/1/99 Cardiac Enzyme Test Lab :1/1/99 Cardiac Enzyme Test Problem-Oriented Views of the EMR Heart

32. Intravascular Gentamicin Tests Summary Reports is-a Has ingredient Substance Measured Decision Rule Measures Sensitivity Etiology Drug Information Expert System Translations with the MED Injectable Gentamicin Serum Gentamicin Level Gentamicin Gentamicn Sensitivity Test Gentamicin Toxicity

36. Linking to Expert Systems

37. Linking to Expert Systems

38. Linking to Expert Systems

39. Wireless Palm-based Access to Health Information:The Palm-Based Clinical Information System (PalmCIS) • Lack of information contributes to errors • Inadequate communication contributes to errors • Multimodal studies of information and communication • PalmCIS • Virtual Whiteboard • Infobuttons

40. Studies of Information and Communication • Modalities • questionnaires • focus groups • observational studeis • Information needs: • nurses: diagnoses, labs, policies, drug information, educational materials • physicians: diagnoses, labs, notes, disease management, prescribing • Communication needs: • nurses: who’s the doctor? • physicians: who’s the nurse?

41. PalmCIS • Hand-held, wireless platform • Kyocera SmartPhone • Sprint PCS • Eudora Web • Security • HTTPS • Login/ID • SecureID • IP Address • Device ID • Clinical Data • WebCIS Functions • Shortcuts

42. PalmCIS

43. PalmCIS

44. PalmCIS

45. PalmCIS

46. Virtual Whiteboard • Matches patients, teams, and roles • Notes added to team-member’s “to do” list • Answers “Who’s taking care of…?” • Asynchronous communication channel • Data capture/display interfaces • Scheduling systems

50. Virtual Whiteboard