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Mayo Foundation: Clinical Perspective on Comparable Data

Mayo Foundation: Clinical Perspective on Comparable Data. By Peter L. Elkin, MD Director, Laboratory of Biomedical Informatics Department of Internal Medicine Mayo Clinic. Millions of Documents are Generated by Healthcare Organizations each Year

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Mayo Foundation: Clinical Perspective on Comparable Data

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  1. Mayo Foundation: Clinical Perspective on Comparable Data By Peter L. Elkin, MD Director, Laboratory of Biomedical Informatics Department of Internal Medicine Mayo Clinic

  2. 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 Document ManagementThe Tip of the Iceberg

  3. 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 Document ManagementThe Tip of the Iceberg

  4. 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) Clear Return on Investment

  5. GranularEncoding

  6. Concept Based Indexing SNOMED-CT ACE ACD Vocabulary Server Comparable Data Mayo Technology

  7. Colloquial Terminologies Local National International Entry Presentation Pre-Coordinated Terms Structure within the Colloquial Terminology Context Coordination Atomic Reference Terminology Description Logic Predicate Logic

  8. System ArchitectureEnterprise Java Beans

  9. EMR

  10. Record Entry Record Entry Process Process Web Server Web Server Enterprise Enterprise Transcribed Record Transcribed Record Java Bean Container Java Bean Container Processed Record Processed Record Record to Processor Record to Processor to Storage to Storage and Return and Return Map Text To Map Text To Map Text To Map Text To Terminology and Terminology and Terminology Terminology Store Store EMR EMR Terminology Terminology Repository Repository Server Server Intelligent Query Intelligent Query to Database to Database Handle Query and Handle Query and Explode Matches Explode Matches Query to Processor Query to Processor and Return and Return Query Query Record Retrieval Record Retrieval Process Process

  11. “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. Terminology in Healthcare:

  12. “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

  13. 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 Electronic Health Record

  14. SNOMED-RT SNOMED-DICOM Microglossary Clinical Terms v3 (Read Codes) SNOMED-CT UMLS NIC, NOC, NANDA NDF-RT Current Large Vocabulary Efforts

  15. 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. TOMMY G. THOMPSON, SECRETARY OF HEALTH AND HUMAN SERVICES July 1, 2003

  16. Placing a Stake in the Groundby 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!!!

  17. Data Exchange Between and Among Computers and Computer Systems Reliable Complete Accurate Interoperability Standards HL7 ASTM ISO Interoperability

  18. 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 3rd Metatarsal. Statement:

  19. 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 Answer: Compositionality

  20. 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. Glossary:

  21. 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. Glossary:

  22. Post-coordinated Concepts: Example: The concept “Status-Post CABG” is not a unique concept within the SNOMED-CT Reference Terminology. Glossary:

  23. 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. Glossary:

  24. 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. Glossary:

  25. Standards Vocabulary Structure Semantic Representation Formalism for Content Representation Formalism for Composition Formalism for Medical Knowledge Representation Reliable Set of Views Vocabulary Messaging (HL7 CDA and Templates Conformant) If We Build It, They Will Come Field of Dreams (Early 90’s)

  26. 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. Usability Laboratory Experience

  27. SNOMED-CT Description Logic-Based Terminology Compositional System ~340,000 Concepts ~800,000 Terms LBI version adds 400,000 Terms Over 30,000,000 Indices to the SNOMED-CT Terminology Comparable Data

  28. Compositional Systems

  29. Acute myocardial infarction of the anterolateral wall Heart attack, Anterolateral cardiac wall, Acute AMI, Anterolateral Wall Acute MI of the Anterolateral Wall Compositional Systems • - Myocardial infarction (disorder) [22298006] • - [has Finding Site] . Entire myocardium of anterolateral region (body structure) [190762001] • - [is Modified By] . Acute (qualifier value) [53737009]

  30. By Peter L. Elkin, MD1, Steven H. Brown, MD2, Casey Husser, MD1, Brent A. Bauer, MD1, Dietlind Wahner-Roedler, MD1, S. Trent Rosenbloom, MD2, Ted Speroff, PhD2 1. Mayo Foundation for Medical Education and Research 2. Vanderbilt University An Evaluation of the Content Coverage of SNOMED-CT for Clinical Problem Lists

  31. 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 Methods

  32. Results

  33. The sensitivity of SNOMED-CT without the use of composition was only 51.4%. Using the McNemar 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). Results

  34. 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). Conclusions Regarding Medical Knowledge Representation using SNOMED-CT

  35. Representational Complexity

  36. Variable Complexity

  37. Avoid the Compositional Tower of Babel

  38. “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” Ambiguous Representation

  39. 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”)))) Inter-Semantic Relationships

  40. Dx = (defconcept Dxxxxxx (and disease (and (some Assoc-Morphology x) (some Assoc-Topography (at least 1 Topography {or t1, t2 ,t3, …tm (m1)})) (and (some Assoc-Etiology y) (some Assoc-Topography (at least 0 Topography {or t1, t2, t3, …tn (n1)))))) Generic Rule

  41. 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: ((ScT/Sp * (LevelT-Levelp)) * DistLevel –1) Conceptual Relativity

  42. Myocardial Infarction HasMorphology Infarct HasFindingSite Myocarium And Heart Attack HasMorphology Infarct HasFindingSite Myocarium Semantic Distance from Feature Set Recognition Acute Myocardial Infarction HasMorphology Infarct HasFindingSite Myocarium HasModifier Acute

  43. HEALTH LEVEL 7 REFERENCE INFORMATION MODEL RIM_0100 released January 2001 reflects RIM changes through Harmonization on 11/17/2000 Enitites Acts (Services) Participation Roles 0..* 0..* Message_control Act has_as_participant Entity 1 1 type_cd : CS Act_relationship Role participates_in id : SET<II> tmr : IVL<TS> id : SET<II> is_played_by plays_a_role type_cd : CS type_cd : cc note_text : ED mood_cd : CS Entity_name type_cd : CC is_source_of effective_tmr : IVL<TS> inversion_ind : BL 0..* 0..* signature_cd : CV is_source_for has_source 0..1 0..1 type_cd : CC determiner_cd : CS Role-role relationships Appointments & has addr : SET<AD> is_target_for for sequence_nbr : INT effective_tmr : IVL<TS> 1 1 1 1 function_cd : CD importance_status_txt : ED txt : ED scheduling telecom : SET<TEL> priority_nbr : INT nm : EN 1 1 1 1 0..* 0..* awareness_cd : CV qty status_cd : CS is_for 0..* 0..* purpose_cd : CV has pause_qty : PQ signature_txt : ED telecom : SET<TEL> activity_time : GTS checkpoint_cd : CS encounter_accommodation_cd : CV Healthcare_finances desc 0..* 0..* 1 1 critical_time : GTS is_target_for split_cd : CS Billboard produced by: has_target status_cd : CS status_cd : CS confidentiality_cd : SET<CV> Rochester Outdoor Advertising join_cd : CS sends 1..1 1..1 1 1 max_repeat_nmr : IVL<INT> 0..* 0..* negation_ind : BL shall_receive 1..* 1..* interruptible_ind : BL conjunction_cd : CS priority_cd : SET<CV> orderable_ind : BL originates_in_context_of 1..* 1..* Military_person availability_dttm : TS Healthcare_provider Notary_public military_branch_of_service_cd : CV specialty_cd : CV military_rank_nm : ST notary_county_cd : CE Act Act military_status_cd : CV notary_state_cd : CE Place gps_txt : ST position_txt addr : AD Health_chart directions_txt 1 1 Financial_act 0..* 0..* provides_context_for Individual_healthcare_practitioner has_an_assessment_of effective_tmr : IVL<TS> fellowship_field_cd : CE reason_cd : CE Medication Act_context Living_subject graduate_school_nm : ON Working_list status_dttm form_cd : CD level_cd birth_dttm : TS graduation_dttm : TS ownership_level_cd route_cd : CD Patient_encounter deceased_dttm : TS board_certified_ind : BL dose_qty : PQ Material deceased_ind : BL discharge_disposition_cd : CV strength_qty : PQ is_assessed_against administrative_gender_cd : CE Organization form_cd : CV acuity_level_cd : CV rate_qty : PQ Referral organ_donor_ind : BL danger_cd : CE 0..* 0..* org_nm : SET<ON> birth_encounter_ind : BL dose_check_qty : PQ Supply multiple_birth_ind : BL effective_tmr : IVL<TS> authorized_visits_qty : REAL standard_industry_class_cd : CE status_reason_cd : CV Consent Health_chart_deficiency method_cd : SET<CV> Healthcare_facility handling_cd : CE Healthcare_benefit_product_policy qty : PQ desc : ED addr : SET<AD> classification_cd : CV body_site_cd : SET<CD> Diagnostic_related_group_definition assessment_dttm : TS licensed_bed_nbr : REAL reason_txt : ED Patient_billing_account assignment_of_benefits_ind : BL encounter_classification_cd : CV substitution_cd : CV desc : ED base_rate_qty : MO mobile_ind : BL benefit_product_desc : ED adjustment_cd : CV practice_setting_cd : CV Healthcare_benefit_coverage_item level_cd : CV capital_reimbursement_qty : MO benefit_product_nm : ST certification_required_ind : BL valuables_desc : ED type_cd : CV cost_weight_qty : MO service_category_cd : CV 1 1 benefit_product_type_cd : CE current_unpaid_balance_qty : MO 1 1 pre_admit_test_ind : BL major_diagnostic_category_cd : CE service_cd : CE is_site_for is_utilized_during Transportation benefits_coordination_ind : BL expected_insurance_plan_qty : REAL Procedure 1 1 Document_service source_cd : CV operating_reimbursement_qty : MO 0..* 0..* service_modifier_cd : CE utilizes Role_relationship cob_priority_nbr : REAL expected_payment_source_cd : CV Message_interaction special_courtesies_cd : CV entry_site_cd : SET<CD> completion_cd : CV 0..* 0..* reimbursement_qty : MO authorization_ind : BL has_parts type_cd : CC combine_baby_bill_ind : BL notice_of_admission_dttm : TS valuables_location_desc : ED method_cd : SET<CV> set_id : II standard_day_qty : PQ network_ind : BL effective_tmr : IVL<TS> notice_of_admission_ind : BL group_benefit_ind : BL effective_tmr has_as_target 1 1 body_site_cd : SET<CD> storage_cd : CV 0..1 0..1 standard_total_charge_qty : MO assertion_cd : CE id : SET<II> uses patient_financial_class_cd : CV mail_claim_party_cd : CE version_nbr : INT Person trim_high_day_qty : PQ is_communicated_as covered_parties_cd : CE status_cd : CS price_schedule_id : II release_information_cd : CE copy_dttm : TS Non_Person_living_subject trim_low_day_qty : PQ disability_cd : CE qty : REAL is_authorized_by responsibility_cd : SET<CE> report_of_eligibility_dttm : TS status_cd : CS origination_dttm : TS ethnic_group_cd : CE taxonomic_classification_cd : CE quantity_qualifier_cd : CE is_part_of position_nbr : LIST<INT> coverage_type_cd : CE retention_ind : BL has_as_source race_cd : CE breed_cd : CE 1 1 time_period_qualifier_cd : CE defines qty : PQ agreement_type_cd : CE signature_on_file_dttm : TS ambulatory_status_cd : CV strain_txt : ED 0..* 0..* 0..* 0..* range_low_qty : PQ certificate_txt : ED policy_category_cd : CE special_program_cd : CV birth_order_nbr : INT Diet euthanasia_ind : BL is_defined_by range_high_qty : PQ Observation access_protocol_desc : ED stoploss_limit_ind : BL 0..* 0..* education_level_cd : CV production_class_cd : CE energy_qty : PQ range_units_cd : CV value : ANY suspend_charges_ind : BL Encounter_drg living_arrangement_cd : CV gender_status_cd : CE carbohydrate_qty : PQ eligibility_cd : CE derivation_expr : ST Inpatient_encounter total_adjustment_qty : MO marital_status_cd : CV approval_ind : BL policy_source_cd : CE method_cd : SET<CV> total_charge_qty : MO religious_affiliation_cd : CV confidential_ind : BL length_of_stay_qty : PQ eligibility_source_cd : CE body_site_cd : SET<CD> student_cd : CV total_payment_qty : MO cost_outlier_qty : MO copay_limit_ind : BL credit_rating_cd : CV Access interpretation_cd : SET<CS> separate_bill_ind : BL desc : ED Clinical_document_header 0..1 0..1 addr : SET<AD> bad_debt_recovery_qty : MO grouper_review_cd : CE gauge_qty : PQ availability_status_cd : CV Specimen Champus_coverage special_accommodation_cd : SET<CV> grouper_version_id : II bad_debt_transfer_qty : MO entry_site_cd : CD change_reason_cd : CV body_site_cd : CE Manufactured_material handicapped_program_cd : CE outlier_days_nbr : REAL completion_status_cd : CV body_site_cd : CD outlier_reimbursement_qty : MO non_avail_cert_on_file_ind : BL expiration_dttm : TS confidentiality_status_cd : CV Schedule 1 1 Public_health_case outlier_type_cd : CV retirement_dttm : TS lot_nbr : ST content_presentation_cd : CV status_cd : CS station_id : II detection_method_cd document_creation_dttm : TS communicates_in slot_size_increment_qty transmission_mode_cd file_nm : ST disease_imported_cd last_edit_dttm : TS is_communicated_by Financial_transaction 1 1 reporting_priority_cd : CE manages results_report_dttm : TS extended_qty : MO Practitioner_Certifier Unmapped_financial_classes storage_status_cd : CV 0..* 0..* fee_schedule_cd : CE board_certification_type_cd : CV (from RIM_Healthcare_finances) Employee_Employer Person_Language transcription_dttm : TS insurance_qty : MO certification_dttm : TS document_change_cd : CV Patient_Provider posting_dttm : TS addr : SET<AD> recertification_dttm : TS Outbreak version_nbr : INT hazard_exposure_txt : ED qty : MO 1 1 residency_field_cd : CE version_dttm : TS tmr job_class_cd : CV transaction_batch_id : II is_specified_by job_title_nm : ST unit_qty : MO is_managed_by telecom : SET<TEL> unit_cost_qty : MO 0..* 0..* Insurance_certification 0..* 0..* 1 1 has_coverage_affirmed_by Billing_information_item protective_equipment_txt : ED Guarantor_contract 0..* 0..* specifies_ability_in Resource_slot certification_duration_qty : PQ salary_qty : MO condition_cd : CE billing_hold_ind : BL Language_ability effective_tmr : IVL<TS> status_cd : CS salary_type_cd : CV occurrence_cd : CE Preauthorization Practitioner_provider billing_media_cd : CE affirms_insurance_coverage_for mode_cd : CV id : II time_slot : GTS status_cd : CS occurrence_dttm : TS charge_adjustment_cd : CE authorized_encounters_qty : REAL position_cd : CV proficiency_level_cd : CV insurance_verification_dttm : TS job_cd : CE Container 0..* 0..* occurrence_span_cd : CE contract_duration_cd : CE authorized_period_begin_tmr : IVL<TS> primary_care_ind : BL modification_dttm : TS occurrence_span_from_dttm : TS capacty_qty : PQ is_sited_at contract_type_cd : CE id : II Device Clinical_document non_concur_cd : CE occurrence_span_thru_dttm : TS height_qty : PQ effective_tmr : IVL<TS> issued_dttm : TS manufacturer_model_nm : ST non_concur_effective_dttm : TS quantity_nbr : REAL diameter_qty : PQ Encounter_facility_association interest_rate_nbr : REAL requested_dttm : TS last_calibration_dttm : TS 0..1 0..1 penalty_qty : MO quantity_type_cd : CV barrier_delta_qty : PQ effective_tmr : IVL<TS> periodic_payment_qty : MO restriction_desc : ED software_nm : ST report_of_eligibility_dttm : TS value_amt bottom_delta_qty : PQ is_used_by authorizes status_cd : CS priority_ranking_cd : CV local_remote_control_state_cd : CE status_cd : CS value_cd : CE report_of_eligibility_ind : BL separator_type_cd : CD transfer_reason_cd : CV alert_level_cd : CE status_change_dttm : TS cap_type_cd : CD 0..* 0..* Level One Ontology Entity Entity Role Role Participation Participation Act Relationship Act Relationship Role Relationship Role Relationship

  44. Level Two Ontology

  45. 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………….. Level Three Ontology

  46. Moving Towards a Harmonious Formalism

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