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Clinical Terminologies and Classifications

Hi7 Clinical Records and Healthcare Computing - 18 March 02. Clinical Terminologies and Classifications. Maged N Kamel Boulos MIM Centre, City University London, UK E-mail: M.Nabih-Kamel-Boulos@city.ac.uk. Lecture Outline - 1. Clinical Terminologies - SNOMED Clinical Terms

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Clinical Terminologies and Classifications

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  1. Hi7 Clinical Records and Healthcare Computing - 18 March 02 Clinical Terminologies and Classifications Maged N Kamel BoulosMIM Centre, City UniversityLondon, UKE-mail: M.Nabih-Kamel-Boulos@city.ac.uk

  2. Lecture Outline - 1 • Clinical Terminologies - SNOMED Clinical Terms • What is a Clinical Terminology? • Knowledge-based Terminologies/Terminology Servers • From April 2003 No More Read Code-based Systems • Example: SNOMED RT Breadth of Coverage - Multiple Root Hierarchies • What Does a Clinical Terminology Do? • What a Clinical Terminology Doesn’t Do? • What are the Real Benefits of Using a Standard Clinical Terminology? • What Specific Benefits Can SNOMED Clinical Terms Bring? • Sharing Clinical Data across Diverse Multilingual Systems • SNOMED CT for Literature Search and Retrieval

  3. Lecture Outline - 2 • Clinical Classifications and Groupings • What are Clinical Classifications? • What are ICD & OPCS-4? • Uses of ICD & OPCS-4 • How ICD & OPCS-4 are Structured? • How has ICD been Developed? • How has OPCS-4 been Developed? • Guidelines for Applying a Classification • How Can Hospitals Use Clinical Terms and Provide Data for Central Returns? • Clinical Terms, Classifications, and Groupings: What are the Relationships? • References/Recommended Readings

  4. Clinical TerminologiesSNOMED Clinical Terms

  5. What is a Clinical Terminology? • A clinical terminology is a comprehensive structured list of terms for use in clinical practice by healthcare professionals. • These terms describe the care and treatment of patients covering areas such as diseases, operations, treatments, drugs, administrative items, and so on. • This allows detailed and unambiguous recording of treatment, whether as a single episode of care or a full electronic patient record, at the level of specification the clinician chooses to use. See: http://www.nhsia.nhs.uk/terms/Source: http://www.nhsia.nhs.uk/terms/pages/snomedct/sno_faqp1.asp

  6. About Knowledge-based Terminologies • Knowledge-based terminologies, e.g., SNOMED Clinical Terms (SNOMED CT), are concept-based, supporting terms/synonyms, multiple hierarchies and multiple parentage, semantic relationships and inheritance. • They are the future:“Knowledge-based terminologies are here to stay” --J.J. Cimino • Terminologies of the past could be browsed with simple word processors and queried with simple relational databases. These approaches have proven to be inadequate for more complex terminologies (Cimino, 2001). Tomorrow’s terminology-enabled applications need terminology servers*. * See: Chute CG, Elkin PL, Sheretz DD and Tuttle MS. Desiderata for a Clinical Terminology Server. In: Proceedings of AMIA'99 Annual Symposium, 1999. Available from: http://www.amia.org/pubs/symposia/D005782.PDF

  7. The white paper, Building the Information Core (NHS Executive, January 2001) states: • “By March 2003 - clinical information systems start to use SNOMED Clinical Terms” • Building the Information CoreSection 1.7 • “After 1 April 2003 any computerised information system . . . should use the NHS preferred clinical terminology, SNOMED CT.Users/suppliers are advised not to develop new Read Code based systems from April 2003” • Building the Information CoreSection 4.8 • See: http://www.snomed.org/snomedct_txt.html

  8. Example: SNOMED RT (Reference Terminology) Breadth of Coverage - Multiple Root Hierarchies • Findings, Conclusions and/or Assessments • Procedures • Body Structures • Biological Functions • Living Organisms • Substances (Chemicals & Drugs) • Physical Agents, Activities and/or Forces • Occupations • Social Context • Modifiers*/Linkage Terms and/or Qualifiers** * Modifier: A string which when added to a term changes the meaning of the term in a clinical sense, e.g., clinical stage or severity of illness ** Qualifier: A string which when added to a term changes the meaning of the term in a temporal or administrative sense, e.g., “history of” or “recurrent” Source: http://www.snomed.org/benefits/RTCoverage_txt.html

  9. What Does a Clinical Terminology Do? • The most comprehensive terminologies, SNOMED CT, Clinical Terms Version 3 (Read Codes) and SNOMED RT, are used to populate computerised electronic patient records. • They allow computer systems to be created which use clinical data in a consistent way and thus promote a standard “language of health” for use in healthcare systems. • The terms enable computer systems firstly to capture and then retrieve on demand patient information using a natural clinical language interface. They also ensure that systems can “talk to each other” behind the scenes (system interoperability). • Computer systems using such terminologies enable decision support, e.g., in checking drug allergies for a patient, and also allow research and clinical management based on aggregated patient data. Source: http://www.nhsia.nhs.uk/terms/pages/snomedct/sno_faqp1.asp

  10. What a Clinical Terminology Doesn’t Do? • A clinical terminology is not a clinical classification. Classifications such as ICD-9, ICD-10 and OPCS-4* are used to summarise the incidence of diseases and operations on a national or worldwide level. • Other classifications such as CPT4** or ICD-9CM*** manage the process of billing patients for treatment they have received (US). • Cross-maps from SNOMED Clinical Terms to both ICD-10 and OPCS-4 will be supplied for auditing purposes. Source: http://www.nhsia.nhs.uk/terms/pages/snomedct/sno_faqp1.asp * Office of Population, Censuses and Surveys - Classification of Surgical Operations and Procedures - 4th Revision** Current Procedure Terminology*** International Classification of Diseases, ninth revision, Clinical Modification

  11. What are the Real Benefits of Using a Standard Clinical Terminology? - 1 • If clinical information is to be transferred and exchanged electronically, a standard clinical vocabulary is a necessary installation in clinical systems. There would be problems in exchange of information for clinical or managerial purposes if multiple vocabularies were used within the NHS. • Clinical information stored in a coded form (rather than free text) ensures that the information in the clinical record may be analysed for audit, research or decision support purposes. Source: http://www.nhsia.nhs.uk/terms/pages/snomedct/sno_faqp1.asp

  12. What are the Real Benefits of Using a Standard Clinical Terminology? - 2 • For instance, a patient’s record could be automatically checked for conditions which contraindicate the use of a particular drug; or a population of patients could be audited to compare the efficacy of different treatments for a particular condition. • A clinical terminology may be used to represent a standard language of health, which contributes to consistency in communication of patients’ clinical records. • Mapping to classifications such as ICD and OPCS can be done for epidemiological purposes. Source: http://www.nhsia.nhs.uk/terms/pages/snomedct/sno_faqp1.asp See also: http://www.nhsia.nhs.uk/dataquality/

  13. What Specific Benefits Can SNOMED Clinical Terms Bring? - 1 • SNOMED Clinical Terms creates a single unified terminology to underpin the development of the integrated electronic patient record by providing an essential building block for a common computerised language for use across the world. • The goal is that SNOMED CT should become the accepted international terminological resource for healthcare. It must therefore be capable of supporting multi-lingual terminological expressions for common concepts. This objective will enable unprecedented sharing and exchange of clinical information. See: http://www.snomed.org/snomedrt_txt.html#BENEFITS

  14. What Specific Benefits Can SNOMED Clinical Terms Bring? - 2 • By enabling consistent coding of clinical concepts, with clear relationships between terms and concepts, SNOMED CT helps ensure comparability of data recorded by multiple practitioners across diverse and often incompatible platforms and systems. • For example, an internist in New York can communicate SNOMED CT-encoded patient data to a radiologist in France, and the radiologist can immediately understand and apply the information - even if using a completely different language and software system. Source: http://www.snomed.org/snomedrt_txt.html#BENEFITS

  15. What Specific Benefits Can SNOMED Clinical Terms Bring? - 3 • This terminological resource can be implemented in software applications to represent clinically relevant information, consistently and reliably. Through the use of this information, SNOMED CT- enabled applications will support effective delivery of high quality healthcare to individuals and populations in the following ways: • Structured data entry • Decision support • Communication of clinical data between healthcare workers and their systems, e.g., Discharge summaries, referrals, ordering and requests, etc. • Identifying and monitoring the health needs of a population • Reducing bureaucracy while managing and funding care delivery • Enabling reporting of externally specified health statistics • Effective and efficient resource planning and allocation, and healthcare management • SNOMED Clinical Terms is a multidisciplinary electronic vocabulary designed by clinicians for clinicians. Source: http://www.nhsia.nhs.uk/terms/pages/snomedct/sno_faqp1.asp

  16. What Specific Benefits Can SNOMED Clinical Terms Bring? - 4 • SNOMED CT enables tagging of reference databases and patient education materials for easy access targeted to the particular needs of a client. • Literature search and retrieval: SNOMED CT can link clinical documentation via SNOMED-encoded literature references, education materials, treatment guidelines and other practice enhancers, and can link to MeSH-coded literature references via SNOMED links in the UMLS* Metathesaurus. Source: http://www.snomed.org/benefits/softwareproviders_txt.html http://www.snomed.org/benefits/patients_txt.html WWW * Unified Medical Language System - http://www.nlm.nih.gov/research/umls/

  17. Source: http://www.snomed.org/reuters.pdf

  18. Clinical Classifications and Groupings

  19. What are Clinical Classifications? - 1 • Clinical classifications are the translation of a diagnostic or procedural term, as written by the clinician in the clinical record, into an alphanumeric code(s). • The categories and codes within the classification are structured in such a way that enables easy storage, retrieval and analysis of the data collected in different areas and time or even, if international, across different countries. See: http://www.nhsia.nhs.uk/dataquality/Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  20. What are Clinical Classifications? - 2 • A classification can be defined as, “a list of all the concepts belonging to a well defined group (e.g., of diagnoses, etc.) compiled in accordance with criteria enabling them to be arranged systematically, and permitting the establishment of a hierarchy based on the natural or logical relationship between them.” Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  21. What are ICD & OPCS-4? • The International Classification of Diseases and Related Health Problems (ICD) and the Office of Population Censuses and Survey Classification of Surgical Operations and Procedures, 4th revision (OPCS-4) are statistical classifications of diseases and surgical procedures respectively. • They allow the logical translation of clinical statements into codes in a way that facilitates the retrieval of data in a consistent manner and comparative analysis of aggregated datasets compiled from multiple sources. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  22. Uses of ICD & OPCS-4 • ICD and OPCS-4 are designed for statistical analysis of data to study the incidence of disease and treatment, and to support and assist in the management of healthcare services at international, national and local levels. • ICD and OPCS-4 codes are also used as the basis for deriving Healthcare Resource Groups (HRGs). Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  23. How ICD & OPCS-4 are Structured? - 1 • Both ICD and OPCS-4 are mainly divided into body system based chapters, using a system of categories and subcategories within the chapters. • For example, in ICD-10 Chapter IX, Diseases of the Circulatory System, the 3 character category I21, Acute myocardial infarction, is further subdivided into the following 4th character categories: I21.0 Acute transmural myocardial infarction of anterior wall I21.1 Acute transmural myocardial infarction of inferior wall I21.2 Acute transmural myocardial infarction of other sites I21.3 Acute transmural myocardial infarction of unspecified site I21.4 Acute subendocardial myocardial infarction I21.9 Acute myocardial infarction, unspecified Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  24. How ICD & OPCS-4 are Structured? - 2 • Similarly, in OPCS-4, in the ear chapter (D), the category D04 for Drainage of external ear is further subdivided as follows: D04.1 Drainage of haematoma of external ear D04.2 Drainage of abscess of external ear D04.3 Other specified D04.9 Unspecified Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  25. How has ICD been Developed? • The International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10), published in 1993 has evolved from versions of international classifications revised since the 17th Century*. • ICD-9 had been in use in the NHS since 1979. • Supplementary classifications, compatible with ICD have been developed for some specialties, to enable clinicians to record greater detail than available in the main ICD. • The tenth revision (ICD-10) became mandatory in contract minimum data sets and central returns in the NHS in England on 1 April 1995 (Wales: 1 April 1995; Scotland and Northern Ireland: 1 April 1996). • The Classification is maintained and published by WHO (World Health Organisation). Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2* http://www.standards.nhsia.nhs.uk/isotc215/wg3/docs/chv-0005.doc

  26. How has OPCS-4 been Developed? • OPCS-4, published in 1987, has evolved from a series of classifications revised since the earliest classification of surgical operations published in Britain by the Medical Research Council in 1944. Subsequent updates have been made to the fourth revision in 1987, 1988 and 1989. • It is currently mandatory in contract minimum data sets and central returns in NHS England. • The classification is maintained and published by the NHS Information Authority (NHSIA). • The classification is no longer meeting the needs of the user as current practice has been significantly developed since the last revision of OPCS-4. NHSIA is currently in discussion with the Information Policy Unit on the need to take forward work on an OPCS-4 replacement. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  27. Guidelines for Applying a Classification • Classifications such as ICD and OPCS-4 contain specific rules and conventions which, when applied, provide the basis for consistent and comparable statistical data, thus facilitating the type of statistical analysis necessary for epidemiology, healthcare planning and management. • Because of the nature of the conventions, extensive training is needed in how to translate clinical statements in case notes into the most appropriate codes. Some software tools are available that can assist human clinical coders in doing this translation. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  28. How Can Hospitals Use Clinical Terms and Provide Data for Central Returns? • Clinical Terms (The Read Codes) and SNOMED CT provide cross maps to both ICD-10 and OPCS-4 classification codes, therefore hospitals are able to use Clinical Terms yet still provide mandatory data in both ICD-10 and OPCS-4 for Central Returns. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  29. Clinical Terms, Classifications, and Groupings: What are the Relationships? - 1 • There are three distinct processes in information handling: terming (SNOMED Clinical Terms), classifiying (ICD-10 and OPCS-4), and grouping (Healthcare Resource Groups). These are often described in terms of granularity. • The finest granularity offering the greatest detail for recording patient care is a natural clinical terminology, such as SNOMED Clinical Terms. This will underpin and populate the Electronic Patient Record by providing an essential building block of a common computerised language. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  30. Clinical Terms, Classifications, and Groupings: What are the Relationships? - 2 • A coarser granularity is found at classification level to support statistics and management. Statistical analysis depends on information being consistently recorded and comparable over time. The classification has to be static by nature in order to generate meaningful statistical data for example, even if the name of a concept may change it should not affect the place of the concept in the classification. • The coarsest granularity is found at grouping level to support aggregation for costing and other analysis. Grouping allows aggregation by common criteria to enable the study of mix of cases and the pattern of care delivery for different types of care. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  31. Clinical Terms, Classifications, and Groupings: What are the Relationships? - 3 • Each have very different design objectives relating to different purposes but compliment each other to support integrated care through NHS wide standards and infrastructure in the NHS Information Strategy – ‘Information for Health’ and NHS Plan. Source: http://www.nhsia.nhs.uk/dataquality/pages/class_faq.asp?om=m2

  32. References/Recommended Readings • Bechhofer SK, Goble CA, Rector AL, Solomon WD, and Nowlan WA. Terminologies and Terminology Servers for Information Environments. In: Proceedings of STEP '97 Software Technology and Engineering Practice, 1997. URI: http://citeseer.nj.nec.com/354766.html • Chute CG, Elkin PL, Sheretz DD and Tuttle MS. Desiderata for a Clinical Terminology Server. In: Proceedings of AMIA'99 Annual Symposium, 1999. URI: http://www.amia.org/pubs/symposia/D005782.PDF • Cimino JJ. Terminology Tools: State of the Art and Practical Lessons, Methods of Information in Medicine. 2001;40(4):272-361 • Elkin PL. Standard for Controlled Health Vocabularies. NHSIA, 2000. URI: http://www.standards.nhsia.nhs.uk/isotc215/wg3/docs/chv-0005.doc • Kamel Boulos MN. Hi1 Lecture on Terminologies, Classifications and Groupings. URI: http://vega.soi.city.ac.uk/~dk708/Lect/epr_coding_and_standards/coding2001.ppt • Rector AL. Clinical Terminology: Why Is it so Hard? Methods of Information in Medicine. 1999;38(4-5):239-52

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