2. Nomenclatures in e-Health
Drs. Sven Van Laere
Nomenclatures in e-Health

3. Personal Sven VAN LAERE 4rd year PhD Previous
Research in nomenclatures in eHealth systems in Belgium related to pharmacy
Promotor: Prof. Dr. M. Nyssen
Previous
MSc in Engineering: Computer Science (2013)
Professional Bachelor in Applied Informatics (2010)

4. Content Table Definition Clinical ideas History
Nomenclatures in e-health
“Coding”

5. Definition Nomenclature Definition Nomen - name Calare - to call
A system of names used in a science, as of  anatomical structures or biological organisms

6. Clinical idea
Clinical idea comprise everything we think we know about health, illness, prevention, investigation, and treatment
Clinical ideas are the building blocks of a personal health record
Connected clinical ideas are essential for a connected health service

7. Clinical idea? Diseases Organisms Operations Procedures Devices Drugs
Part of the body …

8. Working with clinical ideas
Anyone involved in delivering healthcare
Recognition, manipulation and interconnection of clinical ideas is a necessary part of the practice of any clinical discipline
Growth of knowledge requires new clinical ideas to be developed, expressed and tested
Effective delivery of high-quality health care requires clinical ideas to be shared in ways that…
Enhance the quality of the patient care
Facilitate the growth of clinical knowledge
Demonstrably deliver value to money
Avoid errors of commision or ommission
Clinical decision support

9. Problem It seems very simple Clinical ideas are important
We need to share them
What’s the problem?
Hasn’t this problem already been solved?
Can coding help to this?

10. Background Example: coronary heart disease Coding is needed
Variety of representing a clinical concept
Example: coronary heart disease
Diagnosis of myocardial infarction
Raised cardiac enzymes
Myocardial ischaemia
Tripple vessel coronary artery disease …
Coronary heart disease is the name given to the disease process called artherosclerosis that causes the smooth inside lining of the coronary arteries to become narrowed by fatty deposits, sometimes called 'plaques' or 'artheroma'.

11. Why Need for a uniform way of expressing Audit
NLP has not reached the point where free text can be automatically turned into codes
Scientific research
Clinical decision support …

12. History – Text based records
1970 – floppy disk invented
IBM introduced a pilot system in GP practice in Exeter, UK
1976 – inktjet printer invented, VHS video tape introduced
ICL launched GP system in Otterly St Mary, Exeter, UK
1980: Text based patient records stored on mainframe computer
expensive pilot project
Patient records linked by landlines
Free text allowed users to express clinical ideas
Easy for data entry
Problem with retrieval

13. History – Flags to indicate clinical ideas
1982 – compact disks first released
New Abies computer system
System allowed each practice to specify a set of 96 important clinical ideas and link them to a patient record
Shared codes for each practice?

14. History – Coding clinical ideas
1983 – Lotus spreadsheet arrived
Memory got a bit cheaper
Dated coded entries are added to the system
The codes are symple mnemonics with no structure
Links between similar ideas?
=> Still hard to query the data

15. History – Organising clinical ideas
1984
Read Codes released (named after James Read)
Hierarchical set of codes
Retriaval based on hierarchy

16. History – Organising clinical ideas
1986 – late 1990’s there was a wider use of clinical systems using coded data
Read codes in the UK, SNOMED in the US, ICD-9 classification codes in several countries
The scope of coverage was broadening according to scientific improvements
Codes served a useful purpose and continued to be used
However growing awareness of limitations in simple approaches to codes and hierarchies

17. History – Organising clinical ideas
1986 – late 1990’s there was a wider use of clinical systems using coded data
Read codes in the UK, SNOMED in the US, ICD-9 classification codes in several countries
The scope of coverage was broadening according to scientific improvements
Codes served a useful purpose and continued to be used
However growing awareness of limitations in simple approaches to codes and hierarchies

18. Limitations to code-based hierarchies
In a code-based hierarchy errors cannot be corrected without changing the code
Either the hierarchy stays “wrong” or the code must change
For example
The read code hierarchy suggest that otis media is a type of “nervous system and sense organ disease”
F: Nervous system and sense organ disease
F5: Ear disease
F52: Suppurative and unspecified otitis media

19. Limitations to code-based hierarchies
Suppurative otitis media (middle ear infection) is not a disorder of the nervous system
The condition is not a disorder of the nerves or sensors of the ear
The middle ear belongs anatomically to the respiratory tract
Logically middle ear infections are a type of respiratory tract infection
F: Nervous system and sense organ disease
F5: Ear disease
F52: Suppurative and unspecified otitis media

20. Limitations to code-based hierarchies
Idea of polyhierarchy popped up
A simple hierarchy is a tree
Every node has one parent node
Exception: Most upper parent node (concept)
Example
Suppurative acute otitis is… (POLYHIERARCHY)
An ear disease
An infectious disease
F: Nervous system and sense organ disease
F5: Ear disease
F52: Suppurative and unspecified otitis media

21. Limitations to code-based hierarchies
Need for non-hierarchical relations
Suppurative otitis media
Is caused by “bacteria” but … is not a type of bacteria
Occurs in the “middle ear” but … is not a type of middle ear
F: Nervous system and sense organ disease
F5: Ear disease
F52: Suppurative and unspecified otitis media

22. ICPC International Classification of Primary Care
Author: WONCA Int. Class. Committee
Two versions:
1987: ICPC-1
1998: WHO
(accepted within WHO)

23. ICPC structure bi-axial
One axis: 17 chapters with an alpha code based on body systems/problem areas
Second axis: 7 identical components, with rubrics bearing a two-digit numeric code

24. ICPC’s 17 chapters A General and unspecified
B Blood, blood forming organs, lymphatics, spleen
D Digestive
F Eye
H Ear
K Circulatory
L Musculoskeletal
N Neurological
P Psychological
R Respiratory
S Skin
T Endocrine, metabolic and nutritional
U Urology
W Pregnancy, childbirth, family planning
X Female genital system and breast
Y Male genital system
Z Social problems

25. ICPC’s components
Symptoms and complaints 1-29 Diagnostic and preventive procedures Treatment procedures, medication Test results Administrative 62 Referral and other reasons for encounter Diseases: infectious diseases - neoplasms - injuries - congenital anomalies - other specific diseases

26. ICPC example
Heartburn Code: D03 Chapter D: Digestive Component 1: Symptom / Complaint
Pneumonia Code: R81 Chapter R: Respiratory Component 7: Disease

27. Read Codes
Set of clinical codes designed for Primary Care to record the every day care of a Patient
Used in United Kingdom
Developed by Dr James Read (GP, Loughborough)
Recognized standard for General Practice
Hierarchical structure

28. Key aspects of Read Codes
Sorted into categories and chapters
Hierarchical structure
Combination of letters and numbers
CaSe-SeNsItIve
Version 1: Maximum of 4 characters (1983) Version 2: Maximum of 5 characters (1985)

29. Read Code chapters Diagnoses Processes of Care Medication
Codes all begin with a capital letter
e.g. H33 (Asthma), C10E (Type 1 diabetes mellitus)
Processes of Care
Codes all begin with a number
Used to record history, symptoms, examinations, tests, screening, operations and patient administration, etc
e.g. 44P (Serum cholesterol), 65E (Influenza vaccination)
Medication
Codes all begin with a small case letter
Automatically entered into the patient record when any treatment is prescribed
e.g. bu25 (Aspirin 75mg tablets)

30. Read Code chapters Example:
C Endocrine, nutritional, metabolic and immunity disorders
C Other endocrine gland diseases
C Diabetes mellitus
C10E Type 1 diabetes mellitus
C10E7 Type 1 diabetes mellitus with retinopathy
Could refer to these as “families” of codes – Parent and Child Codes
C10 is a parent code to C10E. It is also a child code to C1
Each code begins the same way as the one before but contains an extra layer of detail
This pattern repeats across all chapters
Enables data to be entered at the required level of detail

31. Read version 3, Clinical Terms
1994: CTv3
Read version 3, clinical terms
Clinical Terms version 3
Intention: develop terminology that could include specialist practice
Used in small minority in UK
Merged with SNOMED => SNOMED CT

32. ICD
International Classification of Diseases (and Health Related Problems)
Long history and many revisions
Possibly suffixes
CM: Clinical Modifications (e.g. ICD-9-CM)
PCS: Procedure Classification System (e.g. ICD-10-PCS)
The ICD-9-CM is based on the ICD-9 but provides for additional morbidity detail and is annually updated on October 1
ICD-10-PCS was developed by CMS for use in the U.S. for inpatient hospital settings

33. ICD End 2014- begin 2015: step-over to ICD-10
Start in Belgium: January, 2015

34. SNOMED
In 1965
SNOP was developed by the College of American Pathologists (USA)
Next 50 years
several changes on …
… the number of concepts
… the covered domains
… the underlying representation formalism…
Result: Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) released in 2002

35. SNOMED CT
Controlled coded clinical terminology for use in Electronic Health Records
Helps in adding meaning to the EHR
SCT maintained and distributed by the IHTSDO since 2007

36. Fully Specified Name (FSN)
SNOMED CT
Concept components
Concepts
Descriptions
Relationships
CONCEPT
Fully Specified Name (FSN)
Identifier

37. SNOMED CT Concept Description types Own unique identifier
Numeric identifier of up to 18 digits
Used to refer between concepts
Description types
All concepts have …
At least one fully specified name
At least one synonym

38. CONCEPT
Language refsets
Preferred terms

39. SNOMED CT Relationships
Each concept is associated with other concepts by a set of relationships
Expressing the defining characteristics of a concept
CONCEPT
is a subtype of
CONCEPT
CONCEPT
[attribute] has value

40. SNOMED CT Relationships Subtype relationships
Create a hierarchy linking each concept to more general concepts
Enable retrieval of specific concepts in response to general concepts

41. All the supertypes of appendectomy

42. SNOMED CT Relationships Attribute relationships
Provide additional defining information about concepts
Why is it different from its supertype
E.g. sites, causative agents, …

43. SNOMED CT Pre- and post-coordination Pre-coordination 31978002
Terminology producer provides a single conceptid for the meaning
means “fracture of tibia”

44. SNOMED CT Pre- and post-coordination Post-coordination
A user composes a combination of conceptids to represent
the meaning
: =
(fracture of tibia : laterality = left)
In human readable form … “fracture of left tibia”

45. SNOMED CT
Which one is best to use? ?

46. SNOMED CT Which one is ‘best’ to use? Pre-coordination
Post-coordination
PRO’s
CON’s
- Single term use
- Short vocabulary: each concept once
- Terms are easier to understand
- Syntax is linked to semantics
- Overuse of terms
- Long uninterpretable strings
- Need for powerful engine (complex)

47. Relationship All included in UMLS ICD9 ICPC ICD10
UMLS: Unified Medical Language System
All crossed with Snomed-Ct

48. “Coding” Code… Classification… Nomenclature…
… is a representation applied to a term so that it can be more readily processed.
Classification…
… is an arrangement of all elements of a domain, into groups according to established criteria.
Nomenclature…
… is an arrangement of concepts, that can be combined according to specific rules to form more complex concepts.
2005, S. De Ludignan: Codes, classifications, terminologies and nomenclatures

49. + logical groupings (…is a… relationship)
“Coding”
Codes
+ logical groupings (…is a… relationship)
Classifications
+ polymorphism
+ characteristics
Nomenclatures

50. ICPC
Codes
Read
Classifications
ICD
Nomenclatures
SNOMED CT

51. Sources Papers Presentations Videos
2005, S. De Ludignan: Codes, classifications, terminologies and nomenclatures
2006, R. Cornet: A framework for characterizing terminological systems
Presentations
IHTSDO: Why Clinical Terminology Matters
Health Informatics: Terminology and classification
Videos
What is ICD 10?