Controlled Terminology in Clinical Practice James J. Cimino, M.D. Department of Medical Informatics Columbia University

Definition Terminology: A finite, enumerated set of terms intended to convey information unambiguously

Some General Classes of Terms Diagnostic Procedures Therapeutic Procedures Medications Diagnoses Findings Organisms Anatomy

Uses of Terminology Storing in database Querying database Transfering data Billing Monitoring data

Term - Basic Features Unique Identifier (Code) Official Name aspirin Synonyms ASA Translations NDC: 5502; UMLS: C

Term - Advanced Features Classes antipyretic, anti-inflammatory, analgesic Semantic Links CAUSES: gastritis TREATS: arthritis Attributes UNITS: mg

Desiderata for Terminology Content Concept Orientation Nonredundant Nonambiguous Permanent Nonsemantic Concept Identifiers Polyhierarchy Semantic relationships

Strict Hierarchy disease heart diseaselung disease heart attackarrhythmiapneumonia

Polyhierarchy disease heart attackarrhythmia heart diseaselung diseaseinfectious disease pneumonia

Semantic Network serum potassium test testspecimensubstance is_a serumpotassium has_specimenmeasures_substance

ICD-9/10 and -CM 9th International Classification of Diseases WHO for collecting health statistics Clinical Modifications added 10th edition Clinical modifications under construction Strict hierarchy Synonyms and “index” terms Code determines place in hierarchy

ICD9-CM Examples Diseases----- OTHER SALMONELLA INFECTIONS SALMONELLA GASTROENTERITIS LOCALIZED SALMONELLA INFECTIONS LOCALIZED SALMONELLA INFECTION, UNSPECIFIED SALMONELLA MENINGITIS OTHER LOCALIZED SALMONELLA INFECTIONS Procedures----- INCISION AND EXCISION OF SKULL, BRAIN,... CRANIAL PUNCTURE CISTERNAL PUNCTURE OTHER CRANIAL PUNCTURE

SNOMED Systematized Nomenclature of Medicine College of American Pathologists Organized into axes Synonyms Assemble complex terms from axes SNOMED-RT (Reference Terminology) under development

SNOMED - Axes D - Diseases C - Drugs F - Function L - Living Organisms X - Manufacturers G - Modifiers M - Morphology J - Occupations A - Physical Agents P - Procedures S - Social Context T - Topography

SNOMED - Examples "D " "01" "Myocardial infarction, NOS" "(T-32020) (M-54700)" "D " "02" "Infarction of heart, NOS" "(T-32020) (M-54700)" "D " "02" "Cardiac infarction, NOS" "(T-32020) (M-54700)” "D " "02" "Heart attack, NOS” "(T-32020) (M-54700)" "D " "01" "Microinfarct of heart” "(T-32000) (M-54701)” "C-C137A" "01" "Bufferin Analgesic Tablets" "C-C137B" "01" "Bufferin Analgesic Caplets" "M-54700" "01" "Infarct, NOS" “M-54700" "02" "Infarction, NOS" "M-54700" "05" "Infarcted" "M-54701" "01" "Focal infarct" "M-54701" "02" "Microscopic infarct" "S-10120" "01" "Mother, NOS"

MeSH Medical Subject Headings National Library of Medicine Indexing the medical literature Multiple hierarchy Synonyms

MeSH Example D011014: Pneumonia D018410: Pneumonia, Bacterial D007877: Legionnaires' Disease D011018: Pneumonia, Pneumococcal D011019: Pneumonia, Mycoplasma D009175: Mycoplasma Infections D011002: Pleuropneumonia, Contagious D011022: Pneumonia, Rickettsial D011023: Pneumonia, Staphylococcal D001996: Bronchopneumonia D009956: Ornithosis D011001: Pleuropneumonia D011015: Pneumonia, Aspiration D011017: Pneumonia, Lipid D011020: Pneumonia, Pneumocystis carinii D011024: Pneumonia, Viral

Nursing Terminologies

UMLS Unified Medical Language System National Library of Medicine Metathesaurus groups terms under single concept id No new hierarchy Translation of terms

Metathesaurus 80+ sources 1,358,891 strings 626,893 concepts Strings have attributes Concepts have attributes, including Relations

Metathesaurus String Lexical group Concept String Lexical group String Lexical group Concept String Lexical group

Metathesaurus - MRCON C |ENG|P|L |PF|S |benign neoplasm of heart C |ENG|P|L |VC|S |Benign neoplasm of heart C |ENG|P|L |VO|S |Benign neoplasm of heart, NOS C |ENG|S|L |PF|S |Benign tumor of heart C |ENG|S|L |PF|S |Benign tumour of heart C |ENG|s|L |PF|S |Heart C |ENG|s|L |VO|S |Heart C |GER|P|L |PF|S |Gutartige Neubildung: Herz

Metathesaurus - MRSO C |L |S |ICD10|PS|D15.1|3| C |L |S |MTH|MM|U003158|0| C |L |S |ICD10|PX|D15.1|3| C |L |S |ICD99|PT|212.7|0| C |L |S |RCD98|SY|B727.|3| C |L |S |MTH|PN|U001287|0| C |L |S |SNMI98|PT|D3- F0100|3| C |L |S |RCDAE|PT|B727.|3| C |L |S |RCD98|PT|B727.|3| C |L |S |DMDICD|PT|D15.1|1 |

Metathesaurus - MRSTY C |T191|Neoplastic Process|

Metathesaurus - MRREL C |CHD|C |isa|MSH99|MTH|| C |CHD|C ||CSP98||| C |CHD|C ||RCD98||| C |RB|C ||MTH|MTH|| C |RL|C |mapped_to|SNMI98 |SNMI98||

MED Medical Entities Dictionary CPMC Multiple hierarchy Synonyms Translations Semantic links Attributes 60,000 concepts

Central Controlled Vocabulary

MED Structure Medical Entity Laboratory Procedure CHEM-7 Plasma Glucose Laboratory Specimen Plasma Specimen Substance Sampled Part of Has Specimen Substance Measured Event Laboratory Test Diagnostic Procedure Plasma Anatomic Substance Bioactive Substance Glucose Chemical Carbo- hydrate

What do we want to do with these data? Primary use Other patient care reuse Financial Management Information transfer (messaging) Clinical research Expert systems Information retrieval Vocabulary discovery

Primary Use of Data Spit back the reports

Other Patient Care Reuse Summaries Comparability of data Trending of data Time representation

K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 K#3 = 2.6 Retrieving Results Individually K#1 K#2 K#3

K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 K#3 = 2.6 Retrieving Results by Class K#1 K#2 K#3 K

Case Study: Summaries in the MED Plasma Glucose Test Serum Glucose TestFingerstick Glucose Test Lab Test Intravascular Glucose Test Chem20 Display Lab Display

DOP Summary

WebCIS Summary

Financial Reporting Accounting Inventory

Case Study: Orderable Tests HCFA won’t pay for lab batteries Individual tests now treated as orderable procedures Need to appear in database as procedures and as tests

Case Study: Orderable Tests Lab Procedure Chem 7 Lab Test Intravascular Glucose Test Plasma Glucose Test Serum Glucose TestFingerstick Glucose Test

Case Study: Orderable Tests Lab Procedure Chem 7 Lab Test Intravascular Glucose Test Plasma Glucose Test Serum Glucose TestFingerstick Glucose Test Orderable Test

Management Quality assurance Case management

Information Transfer (messaging) Transfer to repository State reporting

Clinical Research Epidemiology - symptoms, incidence, history of disease Outcomes - effectiveness of therapy, ideal length of stay

Expert systems Knowledge base construction Case abstraction Automated decision support

Terminology and Automated Decision Support Data monitor checks for triggering conditions Medical Logic Modules decide if warning conditions are present Message sent to appropriate channel Example: Tuberculosis culture result

Decision Support Example: TB Monitors for delayed culture results Sends message if result not equal to the code “No growth” One day, dozens of alerts about positive results but no organism was reported What happened?

How the Lab Fooled the Alert Alert looked for results = “No Growth” Lab started reporting “No Growth to Date” “No Growth to Date” = “No Growth” Solution: Use the controlled terminology to map all No-Growth-like lab terms into a single class, and have the alert logic refer to the class.

How We Outsmarted the Lab (Before) No Growth Medical Logic Module No Growth to Date

No Growth after... How We Outsmarted the Lab (After) No Growth No Growth after 48 Hours No Growth after 72 Hours “No Growth” Results No Growth after 24 Hours No Growth to Date Medical Logic Module

Linking to On-line Resources with Terminology Clinician reviewing reports will have information needs On-line information sources can satisfy that need Data from report can be used to automate the query

Laboratory Test Medical Entities Dictionary Has Ingredient Measures Chemical Aminoglycoside Antibiotic Gentamicin Serum Gentamicin Test Drug Injectable Gentamicin Trade-Name: Garamycin" Has-Ingredient: Gentamicin Measures Random Gentamicin Level Main-MeSH: Supplementary-MeSH: "Gentamicin/bl" Measures: Gentamicin