The Belgian Bilingual Biclassified Thesaurus Michel De Jonghe University of Brussels Department of General Practice

Introduction

The thesaurus In 2001, the Ministery of Health asked two universities (Ghent and Brussels) to make a thesaurus. Obligations : Bilingual : Dutch / French Must include 2 classifications : ICD-10 ICPC-2 Information integrity in case of communication of medical information between two praticians.

(combined in one tool: ICPC2-ICD10 thesaurus) Why biclassified ? In general practice, the patient’s electronic record requires : The possibility to analyse the activity in general practice: ICPC-2 diagnosis specificity: ICD-10 (combined in one tool: ICPC2-ICD10 thesaurus)

At the same moment : The labellisation of the medical software Obligation of structuration (SOAP and EPR architecture) Use of ICPC and ICD-10 Use of a medication data bank Exportation of personal information : security and confidentiality

Why a medical software ? For the patient For the GP For micro-epidemiology For macro-epidemiology The aim = quality of health

First point The structuration

The contact (SOAP) Subjective : Reason for encounter Objective : Medical examination, laboratories, referrals, … Assessment : Clinical labelling Plan : Process, terms

Proposal for Belgian EPR architecture 7 Basic concepts per patient record

Integration of all classical concepts in a simple format Chronological registration of all services and diagnoses (hospitalization record) SOAP List of the problems and list of the episodes Episodes registration

Second point Important concepts

4 fundamentals definitions Classification Définition de critères d ’inclusion Ordonner des objets d ’après une structure et avec un objectif e Jargon professionnel, termes, mots Nomenclature Terminologie L ’ICPC peut être considérée comme une classification, une nomenclature abrégée, relevant de la nosographie, de la taxinomie, construite avec des règles de lexicographie. Toutes les entrées et synonymes avec un ou plusieurs codes Thesaurus

The Belgian thesaurus

At the beginning Amsterdam (Henk Lamberts) 125 000 lines Translation from Dutch to French but no link between the two languages DOS (A1 = A2 ; A1 = B+C ; A2 = C+B) “Lobular pneumonia” = lobular + pneumonia “Lobular pneumonia” = pneumonia +lobular

The thesaurus structure IBUI = Unique number for identification for each line of the thesaurus (8 characters) Clinical labelling_FR = FR_CLINICA Clinical labelling_NL = NL_CLINICA ICPC_code ICPC_labelling ICD-10_code ICD-10_labelling FR_REF_IBUI NL_REF_IBUI + Search-terms (= relevant words of all the labellings) = other file

Difficulties Perfect translation from Dutch into French with respect of the two languages Clinical label management of double Correlation between the clinical labelling and the ICD-10 labelling Correlation between ICD-10 and ICPC-2 (mapping : WICC)

Specificity of the Belgian thesaurus The REF_IBUI : Makes it possible to respect the specificity of each language (Dutch / FR) : Fr_CLINICA Nl_CLINICA Fr_REF_IBUI Nl_REF_IBUI IBUI shigellose à Shigella sonnei Sonne 10091295 infectie, Shigella, sonnei 10116328

The validation The validation of the clinical labelling’s wording Via UNINE (http://taurus.unine.ch:8080/icd10?term=&select=0#select) The validation of the choice of the ICD-10 code Via UNINE 2005 T4 thésau\double non identss manif etio.mdb

The validation of the correlation between ICD-10 and ICPC-2 « Traitement de l’information médicale par la classification internationale des Soins Primaires CISP-2 (deuxième version) » “International classification of Primary Care ICPC-2-R (revised second edition)” Revision from CISP-Club’s members

Exemple 1 Myocardite thyphique : ICPC-2 : K70 (remplace D70) ICD-10 : I41.0 (remplace A01.1)

Exemple 2 Intoxication alimentaire par crustacés : ICD-10 : T61.2 (remplace A05.9). Il faut noter que aussi bien dans l’intitulé français que néerlandais, il n’est pas fait allusion à une infection bactérienne).

The search terms Words of the FR_CLINICA Words of the ICPC label Words of the ICD label Synonymous terms acronyms

Application in a medical software PRICARE

Thank you for your attention