1. Efficient Remediation of Terms Inactivated by Dictionary Updates
AMIA Symposium – November 8, 2017
Benjamin J. Gross, MD, MMSc,1
David H. Dubois, MBA, PMP,2
Mark H. Twelves MSW, LICSW,2
Roberto A. Rocha, MD, PhD2,3,4
1InterSystems Corporation
2Clinical Informatics, Partners eCare, Partners Healthcare System 3Brigham and Women’s Hospital
4Harvard Medical School, Boston, MA

2. Abstract
Ongoing maintenance of a diagnosis dictionary in an electronic health record includes replacing inactivated terms with clinically equivalent terms in configuration and data records
Partners Healthcare has developed an efficient process that relies on
Detailed reports to suggest active replacement terms
Clinical review by subject matter experts
Replacements which are made manually or with the help of system tools
Learning Objectives:
Recognize dependencies of terms inactivated by dictionary updates
Formulate an approach towards remediation

3. Background Partners Healthcare System (PHS) 800,000+ clinical terms
Commercial EHR
Third party diagnosis dictionary
800,000+ clinical terms
Mapped to ICD-10-CM codes, SNOMED CT concepts
Hundreds of terms inactivated with each periodic update + PHS customization

4. Implications of inactivating terms
Providers can usually find desired terms despite inactivations thanks to significant redundancy
After >2 years, 7% of terms accounted for 99% of usage
However, certain inactivated terms must be replaced with active terms:
Terms with “configuration dependencies” – linked to other system elements
Terms with “process dependencies” – appear in patients’ records and can be used downstream

5. Diagnosis terms with dependencies
Configuration dependencies
Examples: questions on a form, triggers for decision support
Inactive terms cause runtime errors and functionality gaps
Terms must be replaced in advance
Process dependencies
Examples: patient’s problems, future orders
Inactive terms hinder workflows, especially billing
Providers may make replacements themselves
EHR system offers alternative terms when available
Replacing terms in advance reduces workflow interruptions and saves providers time

6. Finding appropriate replacement terms
Mapping requires clinical expertise and each replacement requires approval
To improve efficiency, PHS developed reports to suggest multiple options for each inactivated term
Number of suggested terms for each inactive term (recent update)
Suggestions ranked by likelihood of semantic equivalence
Terminology engineers select a single optimal replacement term
Clinical subject matter experts review proposed replacements
Report type
Median
Mean
Configuration dependencies 17 36
Process dependencies 20 41

7. Suggestion reports Criteria for suggesting alternative terms Rank1
Previously approved mapping 2
Suggested by the dictionary vendor 3
Textual match + SNOMED CT concepts + ICD-10-CM codes 4
Textual match + SNOMED CT concepts only 5
Textual match + ICD-10-CM codes only 6
Textual match only (similarity function) 7
Textual match only 8
Matching SNOMED CT concepts + ICD-10-CM codes only 9
Matching SNOMED CT concepts only 10
Matching ICD-10-CM codes only

8. Configuration dependency – Protocol Chemical conjunctivitis ICD-10-CM:
Configuration dependency – Protocol Chemical conjunctivitis ICD-10-CM: H Acute toxic conjunctivitis, unspecified eye SNOMED CT: Toxic conjunctivitis (disorder)
Term name
ICD-10-CM
SNOMED CT
Matching criteria
ACUTE CHEMICAL CONJUNCTIVITIS
H10.219
SNO + ICD
ACUTE CHEMICAL CONJUNCTIVITIS, UNSPECIFIED LATERALITY
CHEMICAL CONJUNCTIVITIS, BILATERAL
H10.213
SNO
CHEMICAL CONJUNCTIVITIS, RIGHT
H10.211
CHEMICAL CONJUNCTIVITIS, LEFT
H10.212
TOXIC CONJUNCTIVITIS, LEFT
TOXIC CONJUNCTIVITIS, RIGHT
TOXIC CONJUNCTIVITIS, BILATERAL
DRUG-INDUCED TOXIC CONJUNCTIVITIS
ICD
DRUG-INDUCED TOXIC CONJUNCTIVITIS, UNSPECIFIED LATERALITY

9. Configuration dependency – Preference list High myopia, bilateral ICD-10-CM: H52.13 Myopia, bilateral SNOMED CT: Severe myopia (disorder)
Term name
ICD-10-CM
SNOMED CT
Matching criteria
SEVERE MYOPIA OF BOTH EYES
H52.13 s
Suggested by vendor
SEVERE MYOPIA, UNSPECIFIED LATERALITY
H52.10
SNO
HIGH MYOPIA
SEVERE MYOPIA
… [2 more] …
MYOPIA OF BOTH EYES s
ICD
CONGENITAL AXIAL MYOPIA OF BOTH EYES s
SIMPLE MYOPIA s
MYOPIC RETINOPATHY OF BOTH EYES s

10. Process dependency – Future order Dry eye syndrome, bilateral ICD-10-CM: H Dry eye syndrome of bilateral lacrimal glands SNOMED CT: Tear film insufficiency of bilateral eyes (disorder) Tear film insufficiency (disorder)
Term name
ICD-10-CM
SNOMED CT
Matching criteria
INSUFFICIENCY OF TEAR FILM OF BOTH EYES
H04.123
Suggested by vendor
BILATERAL DRY EYES
Textual match + ICD
DRY EYES
ICD
DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS
INSUFFICIENCY OF BOTH LACRIMAL SACS
CHRONIC DRYNESS OF BOTH EYES
DRYNESS OF BOTH EYES DUE TO DECREASED TEAR PRODUCTION

11. Textual match + SNO + ICD
Process dependency – Future order Hepatic cirrhosis, unspecified hepatic cirrhosis type ICD-10-CM: K74.60 Unspecified cirrhosis of liver SNOMED CT: Cirrhosis of liver (disorder)
Term name
ICD-10-CM
SNOMED CT
Matching criteria
HEPATIC CIRRHOSIS
K74.60 s
Suggested by vendor
CIRRHOSIS OF LIVER
Textual match + SNO + ICD
OTHER CIRRHOSIS OF LIVER
K74.69
Textual match + SNO
CIRRHOSIS
SNO + ICD
CIRRHOSIS OF LIVER WITHOUT ASCITES
… [2 more] …
CONGENITAL CIRRHOSIS
P78.81
SNO
NON-ALCOHOLIC CIRRHOSIS s
ICD
… [5 more]

12. Results of recent updates
Jun 2017
Oct 2017
Inactive terms queued for replacement
847
778
Replacement terms identified
743 (88%)
658 (85%)
Elements impacted by replacements:
When replacements were not made
Configuration dependencies
402
662
Configuration dependencies were otherwise changed or removed
Process dependencies
Future orders
163,279
107,903
Terms associated with < 50 orders were left to providers
Problem lists
23,749
41,940
Terms associated with < 50 problems were left to providers
Active treatment protocols
682
339
All inactive terms were replaced
Total elements impacted
188,112
150,844

13. Effort required Initial report design and development
1 x Clinical Informatician (report design)
1 x Software Engineer (report development)
Single dictionary update (x4/year):
Approximately 75 hours
12-13 people with complementary roles and expertise
1 x Terminology Team Lead (project management)
1 x Clinical Informatician (project management)
1 x Software Engineer (report delivery)
2-3 x Terminology Engineers (selection of optimal replacement terms)
6 x Clinical Subject Matter Experts (review of proposed replacements)
1 x Application Coordinator (implementation)

14. Summary
This is the PHS approach for replacing terms inactivated by periodic updates of the diagnosis dictionary
Terms with “configuration dependencies” – to avoid runtime errors and functionality gaps
Terms with “process dependencies” – to reduce workflow interruptions and save providers time

15. Conclusions
Just one example of overall effort to maintain system configuration and data integrity
Costs and expertise required may be the “Achilles heel” of complex EHR systems
EHR vendor offers few tools for knowledge management
Data integrity is only one consideration of content vendors. Others include term availability, term “friendliness”, matching multiple terminologies simultaneously
Responsibilities split between EHR vendor (search) and content vendor (content), and available solutions are limited to single domains (diagnoses, meds, procedures)
PHS has large quantities of configured content and patient data to consider
PHS has dedicated resources for knowledge management and necessary expertise. Not available at every institution

16. Thank you
Ben Gross, MD, MMSc