1. Coping with Changing Controlled Vocabularies James J. Cimino, M.D. Paul D. Clayton, Ph.D. Department of Medical Informatics Columbia University

2. Changes in ICD9-CM l Additions l Deletions l Minor Name Changes l Major Name Changes l Refinements

3. Additions 070.44: CHRONIC HEPATITIS C WITH HEPATIC COMA 333.92: NEUROLEPTIC MALIGNANT SYNDROME 512.1: IATROGENIC PNEUMOTHORAX 677: LATE EFFECTS OF COMPLICATION OF PREGNANCY, CHILDBIRTH, THE PUERPERUM 759.83: FRAGILE X SYNDROME

4. More Additions 789.6: ABDOMINAL TENDERNESS V50.4: PROPHYLACTIC ORGAN REMOVAL E869.4: ACCIDENTAL POISONING BY SECOND-HAND TOBACCO SMOKE 34.05: AUTOLOGOUS HEMATOPOETIC STEM CELL TRANSPLANT

5. Deletions 043.0: ACQUIRED IMMUNODEFICIENCY SYNDROME, UNSPECIFIED 305.13: TOBACCO USE DISORDER, IN REMISSION

6. Minor Name Changes 070.41: HEPATITIS C WITH HEPATIC COMA ACUTE OR UNSPECIFIED HEPATITIS C WITH HEPATIC COMA 440.2: ATHEROSCLEROSIS OF ARTERIES OF THE EXTREMITIES ATHEROSCLEROSIS OF NATIVE ARTERIES OR EXTREMITIES 770.1: MASSIVE ASPIRATION SYNDROME OF NEWBORN MECONIUM ASPIRATION SYNDROME

7. Major Name Changes 344.0: HEMIPLEGIA HEMIPLEGIA AND HEMIPARESIS V45.0: POSTSURGICAL CARDIAC PACEMAKER IN SITU CARDIAC DEVICE IN SITU

8. Refinements 441.0: DISSECTING ANEURYSM (ANY PART) 441.0: DISSECTING AORTIC ANEURYSM 441.00: DISSECTING AORTIC ANEURYSM OF UNSPECIFIED SITE 441.01: DISSECTING THORACIC AORTIC ANEURYSM 441.02: DISSECTING ABDOMINAL AORTIC ANEURYSM 441.03: DISSECTING THORACOABDOMINAL AORTIC ANEURYSM

9. Code Change Removed 795.8: POSITIVE SEROLOGICAL OR VIRAL CULTURE FINDING FOR HUMAN IMMUNODEFICIENCY VIRUS (HIV) ASSOCIATED VIRUS (HTLV-III/LAV) Added 795.71: NONSPECIFIC SEROLOGIC EVIDENCE OF HUMAN IMMUNODEFICIENCY VIRUS (HIV)

10. Volatile Vocabulary/Persistent Data 99.71 MERCURY-ZINC PACEMAKER99.71 THERAPEUTIC PLASMAPHERESIS 19801992 Patient Database 99.71 ?? ?

11. Historical Vocabulary l Store the code l Keep track of when the code changes l Look up the meaning of the code based on date it was used

12. Retrieval Using Historical Vocabulary IF (Code=75.22 and Year<1990) OR (Code=76.2 and Year=1991) OR ((Code=76.20 or Code=76.21) AND Year=1992)...

13. CPMC Approach: Encode the Meaning l Each code corresponds with one meaning (concept) l Each concept may or may not have an ICD9 Code l If ICD9 term changes meaning, it is no longer associated with the concept

14. Deletion Concept Code:10101 Concept Name:Tobacco Use Disorder, in Remission ICD9 Code:305.13 ICD9 Entry Code: Old ICD9 Code: Concept Code:10101 Concept Name:Tobacco Use Disorder, in Remission ICD9 Code: ICD9 Entry Code: 305.1 Old ICD9 Code: 305.13

15. Concept Code:31313 Concept Name:Massive Aspiration Syndrome of Newborn ICD9 Code:770.1 ICD9 Entry Code: Old ICD9 Code: Minor Name Change Concept Code:31313 Concept Name:Meconium Aspiration Syndrome ICD9 Code:770.1 ICD9 Entry Code: Old ICD9 Code:

16. Major Name Change Code:21212 Name:Mercury-Zinc Pacemaker ICD9:99.71 Entry: Old: Code:21212 Name:Mercury-Zinc Pacemaker ICD9: Entry: Old:99.71 Code:44444 Name:Therapeutic Plasmapheresis ICD9:99.71 Entry: Old:

17. Volatile Vocabulary/Persistent Data 99.71 MERCURY-ZINC PACEMAKER 19801992 Patient Database 21212 MERCURY-ZINC PACEMAKER (Old Code 99.71)

18. Additional Situations l New redundancy l Discovering old redundancy l Ambiguity l Disambiguation l Obsolescence l Precoordination

19. Advantages of Concept-Based Approach l Database contains original meaning l Concept-oriented retrieval is easier

20. Conclusions l Vocabulary changes are inevitable l Store what the clinician means l Map the vocabulary to the meanings, not the reverse

21. Definitions l Users: attendings, nurses, residents, respiratory care technicians, dieticians, social workers, students l Knowledge: textbooks, bibliographic databases, guidelines (passive), algorithms (active) l Point of care: clinic, emergency room, in-patient floors, ICU’s, recovery rooms

22. Access to Information Sources ??? “Electronic Library”

23. Integrated Access to Information ??? Clinical Information System Context Concepts Data

24. “Medline Button” Design l Application-specific questions (Mad Libs) l Coded clinical information to fill in the blanks l Medical Entities Dictionary of concepts l Translation using the UMLS l Scripts for accessing on-line resources

25. Implementations l 3270 Admission/Discharge Profile: ICD9 -> MeSH -> Medline l X-Windows Laboratory Summary: Lab terms -> MeSH -> Medline, DXplain, HSTAT l Mosaic clinical information system

26. Challenges l What questions arise in different contexts? l What information source is right for each? l How are the concepts translated? l How are complex retrievals performed? l How is the knowledge presented?