mediation between people, languages, cultures, and machines pieter e zanstra radboud university...
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Mediation between People, Languages, Cultures, and
Machines
Pieter E Zanstra
Radboud University Nijmegen Medical CenterCo-ordinator EU SemanticHEALTH Specific Support Action:Semantic Interoperability Deployment and
Research Roadmap
eHealth2006: High Level Conference and Exhibition, Malaga, May 12, 2006
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Reviewed. Primip FT No ANC probsF/D at 08:45Needed synto for contractions about 7cmDecent progress since.Epidural in-situNo urges to push really according to patientContractions 4:10 but poor duration & strength (on 60 u/s /synto)
PA: Ceph 0/5VE: Head at +1
Caput +1 No ???OA positionCx F/D NO DESCENT
Tried pushing – poor maternal effort despite instructionAlthough epidural working well, doesn’t stop longstandingspasmodic hip pain.Very problematicFHR CTG
No descent with attempts at pushing – poor effort.Plan… a) Push synto
b) Need really try to push & work on techniquec) reassess at interval 15 mins & D/W consultant
Would not be happy to have to exert traction withForceps when no effort & no descent
Where are we coming from..
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Competing demands on recording
Record
Categorise
ICD, ICPM
DRG
Documentation
Referral letters?
Grouper
ClassifierReimburse
Manage
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What kind of business logic do we need?
Record
ICD, ICPM
DRG
Documentation
Grouper
Classifier
ReferenceTerminology
Service
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CEN/ISSS eHealth FG Recommendation 13 (2005)
• The Member States, with the Commission, should:– ensure the Europe wide referencing and easy access to the
content of existing health coding systems based on registration of such systems by the Eurorec Institute;
– support the international convergence towards a common framework for formal representation, and eventually the development and maintenance of a multilingual clinical reference terminology. This effort should build on existing efforts in formal representation as GALEN, FMA and SNOMED, and be carried out in liaison with the WHO Family of International Classifications
– make the targeted reference clinical terminology publicly available free of charge;
– support a common approach to link national classifications of procedures, to support cross-border reimbursement of health care.
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Clinical terminology
• A clinical terminology is the collection of standard terms with their synonyms, which in the context of patient care support the recording of complaints, signs, symptoms, circumstances, process of illness, interventions, results, diagnoses, as well as the decision making of the care providers
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What binds Records, Interface, Reporting, Knowledge…?
Interface Terminology
Reporting Terminology
(ICD)
ReferenceTerminology
Health Record
DischargeReferral..
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Record architecture terminology (mediation)
Name, Context and Content
physical examinationbreast
palpationlump
present CONTENT
NAME
CONTEXT
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Sound semantics underpinning continuity in care
status of lump by palpation of breast
observation by palpation of breast
observation by physical examination of breast
observation by physical examination
restore the terminological CONTINUUMbetween Content
present
presence
and Structure
of lump by palpation of breast
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What is a term referring to?
• Blood pressure– Evaluation result (high, low)– Measurement (diastolic, systolic)
Archetype/Template?– Guideline (how to measure?)
• Rheumatoid arthritis– Evaluation result– Measurement (criteria)
11Reinhold A. Mainz, BMGS, Germany, Project Group Telematics – Health Card14./15. February , Bruxelles, EC / WHO Workshop on Semantic Interoperability
Semantic interoperabilitySemantic interoperability(example of drugs with different trade marks)(example of drugs with different trade marks)
The example:
A patient coming from Switzerland to a German pharmacy is looking for a drug well known in Swiss:
„DROSANA Resiston Trpf.“
The name of this drug is not known in German pharmacies!
The pharmacist
will not find this drug in his drug data bases,
is not able to identify the ingredients of the drug,
can not look for an equivalent drug available in Germany.
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Multiprofessional Records and terminology
• Differences in vocabulary• Differences in the meaning of the vocabulary• Differences in aspects/abstractions
– Nurse: ‘constipation’ is an elimination problem– Doctor: ‘constipation’ is a bowel function disorder
• Difference in operational significance– Reflecting differences in professional tasks
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National Institutefor Public Health andthe Environment
Classification & Model of Use
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National Institutefor Public Health andthe Environment
Classification & Model of Use
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Codes, codes everywhere...
SNOMED-3READ-2MeSHICD-9ICD-9-CMICD-ONCSPICPMOXMIS ECRI-UMDNSSNOPHCFAACR-NEMAIUPAC-NPULOINCDICOM-SDMMCTGECDAMNGAP ICPC OPCS-4CPT-4 NDCNANDAICNP AIDSLINEMED80MED66AIDSDRUGS
AIDSTRIALSChemIDCHEMLINEGENE-TOXHISTLINESDLINETOXLINETOXLINE65TOXLITPDQAVLINEBIOETHICSCANCERLITCATLINEDENTALPROJMEDLINEPOPLINESERLINEDOCUSERDxplainAI/RHEUMIliadGenBankOMSPSYTRIFACTSNIOSHNPIRSNEDRESMED85
MED75HSTATHDAMED90HealthSTARACR92AIR93BRMP96NICULTBRMS96COSTARCPMCRISPCOSTARTDMDDSM III & IVDORHHCINSLCHMCMMIMNeuronamesWHOARTCTV3
CCHI (Canada)MBS-E (Australia)ICD-10-PCS (USA)ICPM-NL (Netherlands)NCSP (Swedish Version)NCSP (Finnish Version)ICPM-DE (Germany)CCAM (France)
SNOMED-CT (USA-UK)OPCS-5 (UK)SKS (Denmark)ICIDH (WHO)Digital Anatomist (UW)Nomina Anatomica
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And there is more to come……
• Official Inventory on IT systems– 52 ‘exotic’ patient record systems– 1 ‘summary-system’ used by 250 physicians of which
70 daily containing 20.000 patients
• Inventory by students– Estimated 200 ‘exotic’ systems– At least 200 shortlists for diagnosis, treatment– Only some terminologies properly
documented/maintained
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The exploding bicycle accidents
• ICD-9 (E826) 8 • READ-2 (T30..) 81• READ-3 87• ICD-10 587
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The next Challenge: Adequate data capture !
Structured Data Entry
File Edit Help
What you hit
Your Role
Activity
Location
Cycling Accident Cycling Accident
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The classification of Chocolate
C-F0811
C-F0816
C-F0817
C-F0819
C-F081A
C-F081B
C-F081C
C-F0058
SNOMED-CT
UbOVv
UbOW2
UbOW3
UbOW4
UbOW5
UbOW6
UbOW7
Ub1pT
ReadV3
Bounty bar
Crème egg
Kit Kat
Mars Bar
Milky Way
Smarties
Twix
Snickers
Term
?
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Some Myths
Stage of development
Open Source
Evidence Based Medicine
Open source will most definitely not be free of cost; A complex terminology is required, and we should not expect this to appear without significant investmentThe critical mass of skilled & dedicated contributors to a large Health terminology is too small for a sustainable system
Only about 5-8% of present medical knowledge is based on sound evidence. RCT’s are very costly and time-consuming. We can not longer ignore the need for routinely collected observational data of high quality.Problem of finding ‘outliers’ in the literature
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A bit of Archeology (1)
• 2nd EU/CEN Workshop (1997)– Central resources - public or private - are urgently
needed for European Industry to address a single market• Central reference resource of concepts• Multilingual lexicons• Language independent development tools
– A strategy to maximise European influence on international developments is needed
• New developments in HL7, CorbaMed, DICOM, UMLS• Establishing evolutionary pathways from existing systems to
future systems
– Communication architectures should address mediation & conversion
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A bit of Archeology (2)
• SESAME Committee (1990)
– Medical Semantics Advisory Task (Mesat) – Establish national standardisation organisations for
semantical aspects in medicine – European medical termbank (Eumet) – European Model of Health Care (Euromodel) – European Classification of Medical Procedures (Euclamep) – Harmonization of validation and coding rules for ICD
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Still many open questions
• What level of detail is required
• Revolutionairy/evolutionairy implementation
• How do we cope technically
• How do we cope in the business process
• How do users cope cognitively
• How do we cope with version control in the
new highly interdependent architectures
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Observations
• Development still driven by ‘perceived need’• No yet hard evidence to prove added value• For the next five year seen by industry as
exhaustive list of fixed terms• Growing evidence to reconsider the ontologies
behind systems– Both SNomed CT and GALEN stem from early 90s
• Systems not plug and play– Significant cost of translation– Multitude of base cost goes into localisation
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Clinical Terminology Summary
• Evolving use case– Epidemiology– Organising care– Documenting Care– Access to
knowledge
• Unsolved Problems– Quality Assurance– Efficient data
capture– Interrater
variability– Cost Model
• Technological Barriers– Enumeration doesn’t
scale– Computers can’t
read– Humans can’t
organise– Tower of Babel
• Evolving Technology– Enumeration – ICD– Interlingua – UMLS– Formal Ontology – SNOMED
CT
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Recommendation: Establish the process
• Focus on real immediate needs, and realistic time scales
• Be prepared to throw away what you loved and cherised!
• Be aware and secure solutions for different cultures/ languages
• Do not just select a single product, but join forces to redesign with best of breed
• Involve and explain to those who have the burden of recording (registration dividend)
• Without a well managed network of compentent expertise centres, the process is likely to fail
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Acknowledgements
Specific Support Action co-funded by the European Commission SIXTH FRAMEWORK PROGRAMME
Communication & Technology Research, Germany
Radboud University Nijmegen Medical CenterDepartment of Medical Informatics (Co-ordinator)
World Health Organisation Dept. Measurements & Health Information Systems, Switzerland
Uppsala UniversityNordic Centre for Classifications in Health Care, Sweden
University of St. EtienneDepartment of Public Health & Medical Informatics, France
National Institute for Strategic Health ResearchHungary
University of Manchester Health and Bioinformatics Group, UK
University College LondonCentre for Health Informatics, UK
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Thank you for your attention!
Further information:
Pieter E ZanstraRadboud University Nijmegen Medical Center