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Home-Grown Coding Systems—A Critical Step in EMR Implementation. Eric Rose, MD Associate Director for Clinical Informatics Information Systems Department University of Washington Physicians Network http://faculty.washington.edu/momus/. SUMMARY.

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home grown coding systems a critical step in emr implementation

Home-Grown Coding Systems—A Critical Step in EMR Implementation

Eric Rose, MD

Associate Director for Clinical Informatics

Information Systems Department

University of Washington Physicians Network

http://faculty.washington.edu/momus/

Eric Rose, MD

summary
SUMMARY
  • Implementation of any EMR (including vendor-supplied) requires the that the user institution create coding systems
  • This can be done well or badly
  • It matters

Eric Rose, MD

some definitions
Some definitions
  • Concept: an idea encompassing a class of objects ("unit of knowledge created by a unique combination of characteristics"-ISO)
  • Term: A word denoting a concept
  • Terminology/Controlled Vocabulary/Ontology: a set of terms pertaining to a given domain, not necessarily with any structure
  • Nomenclature: A terminology “structured systematically according to pre-established naming rules” (ISO)

Eric Rose, MD

some definitions cont d
Some definitions (cont’d)
  • Coding system: A terminology + context-free symbolic codes for each term
  • Classification/taxonomy: A terminology system + specified relationships between terms (“concept system”-ISO 1087-1)

Eric Rose, MD

what is a coding system and what does it do
What is a coding system and what does it do?
  • Represents in a standardized fashion
  • Groups
  • Separates
  • Abbreviates
  • Facilitates automated data-processing & transmittal

Eric Rose, MD

types of coding systems
Types of coding systems
  • Simple, 1-1 (CA, NY, TX)
  • Categorical (record store bins)
  • Hierarchical (homo sapiens)
  • Multiaxial (Dewey-decimal, SNOMED)

Eric Rose, MD

slide8

THE UNIVERSE OF CONCEPTS

READ

LOINC

NANDA

SNOMED

CT

CPT

ICD-10

NDC

ICD-9-CM

NCPDP

Eric Rose, MD

what does this have to do with emr implementation9
What does this have to do with EMR Implementation?
  • Most EMR’s allow customized choices for various database items
  • Each one of these is a small coding system

Eric Rose, MD

what does this have to do with emr implementation cont d
What does this have to do with EMR Implementation? (cont’d)

If developed carefully, home-grown coding systems facilitate:

  • Intuitive data entry
  • Interpretable data @ individual patient level
  • Usable data at population level
  • Usable data for automated decision-support systems
  • Data that is shareable with other systems

Eric Rose, MD

examples of mini coding systems you might need to create
Examples of mini-coding systems you might need to create
  • Disease Categories for Family History
  • Reason for Visit
  • Allergic Reaction Type
  • Delivery Outcome
  • Anesthesia Type for Surgery
  • Source of Diagnostic Specimens
  • Ethnic Group
  • Marital Status

Eric Rose, MD

what makes a coding system good
What makes a coding system good?
  • Completeness
  • Nonredundancy
  • Clarity
  • Stability
  • Granularity appropriate to use or flexible
  • Evolutionary

(Adapted from Cimino, 1998; Chute et al., 1998)

Eric Rose, MD

completeness
Completeness

There should be a term for any possible situation

Eric Rose, MD

completeness example reason for medication discontinuation
Completeness—ExampleReason for Medication Discontinuation

Allergic response

Alternate therapy

Availability

Cost of medication

Discontinued by another Health Care Provider

Discontinued by patient

Dose adjustment

Duplicate

Error

Ineffective

NON Covered Medication

Paradoxical response

Pregnancy

Prescription never filled

Reorder

Resistant Organism

Side effects

Therapy completed

What if medication was never taken by patient? No way to denote that!

Eric Rose, MD

nonredundancy
Nonredundancy

There should be only one term for any given situation

Eric Rose, MD

nonredundancy example next of kin relationship to patient
Nonredundancy-ExampleNext of Kin-Relationship to patient

Domestic Partner

Life Partner

Partner

Significant Other

Eric Rose, MD

clarity
Clarity

The categories in your coding system should be unambiguous to all users

Eric Rose, MD

clarity examples
Clarity-Examples

Family Medical History category “Blood Disease,” “Anesthesia”

Medication reason-for-d/c “Alternative Therapy,” “Error”

Eric Rose, MD

stability
Stability

Once defined, the meaning of a code must not be changed, though it may be inactivated so it is not applied to any new cases

Eric Rose, MD

appropriate or flexible granularity
Appropriate or Flexible Granularity

Granularity = Level of detail described by the coding system, i.e. “fineness” of categorization

Low granularity = Few, broad categories

High granularity = Many, narrow categories

Eric Rose, MD

appropriate granularity examples family history categories
Appropriate Granularity-ExamplesFamily History categories

“Alcohol dependency,” “Drug dependency”—It is sufficient to just have one category for “Chemical Dependency”

“Heart disease”-Not granular enough to meet needs of risk assessment for coronary disease

Eric Rose, MD

evolutionary
Evolutionary

Coding system development is an ongoing process, requiring addition of new categories and inactivation of old ones to keep the system congruent with prevailing ideas.

Example = Family History category, “Venous Thrombosis”

Eric Rose, MD

guiding principles
Guiding principles
  • CENTRALIZE control of the coding system
  • Keep your lists SHORT
  • Respond PROMPTLY to user requests for additions and explain rationale when it’s not appropriate to meet the request
  • Design for the future including new user types & interfaces
  • Careful with “Other”

Eric Rose, MD

for further reading
For further reading:
  • Bakken S et al. Toward Vocabulary Domain Specifications for Health Level 7-coded Data Elements. JAMIA 7:333-342, 2000.
  • Cimino JJ. Desiderata for controlled medical vocabularies in the twenty-first century. Methods Inf Med. 1998 Nov;37(4-5):394-403
  • Chute CG. Cohn SP. Campbell JR. A framework for comprehensive health terminology systems in the United States. JAMIA 5(6):503-10, 1998 Nov-Dec.
  • ISO 1087-1:2000. Terminology Work-Vocabulary-Part 1: Theory and Application

Eric Rose, MD