1. The Medical Entities Dictionary - © 2002 - James J. Cimino Intelligent Terminologies to Support System Interfaces: The Medical Entities Dictionary Presentation to Guidant Corporation April 15, 2002

2. The Medical Entities Dictionary - © 2002 - James J. Cimino Overview What is the MED? Support for Clinical Information Systems Support for Data Reuse MED Tools Knowledge-based Maintenance

3. The Medical Entities Dictionary - © 2002 - James J. Cimino New York Presbyterian Hospital Clinical Information Systems Architecture Clinical Database Medical Entities Dictionary Database Monitor Medical Logic Modules Database Interface Research Administrative Alerts & Reminders Results Review... Radiology Laboratory Discharge Summaries Reformatter

4. The Medical Entities Dictionary - © 2002 - James J. Cimino Medical Entities Dictionary: A Central Terminology Repository

5. The Medical Entities Dictionary - © 2002 - James J. Cimino K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 Communicating Terminology Changes K#1 K#2 K#3 = 2.6 K#3

6. The Medical Entities Dictionary - © 2002 - James J. Cimino K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 Solution: Hierarchical Integration K#1 K#2 K K#3 K#3 = 2.6

7. The Medical Entities Dictionary - © 2002 - James J. Cimino MED Structure Medical Entity Laboratory Procedure CHEM-7 Plasma Glucose Laboratory Specimen Plasma Specimen Substance Sampled Part of Has Specimen Event Laboratory Test Diagnostic Procedure Substance Measured Glucose Plasma Anatomic Substance Bioactive Substance Chemical Carbo- hydrate

8. The Medical Entities Dictionary - © 2002 - James J. Cimino The MED Today Concept-based (70,000) Multiple hierarchy (90,000) Synonyms (170,000) Translations (120,000) Semantic links (130,000) Attributes (160,000)

9. The Medical Entities Dictionary - © 2002 - James J. Cimino Support for Data Reuse Generated by one system, used by another Different granularities (lumpers and splitters) Different semantics (impedance mismatch)

10. The Medical Entities Dictionary - © 2002 - James J. Cimino Translations with the MED Gentamicin Injectable Gentamicin Gentamicn Sensitivity Test Serum Gentamicin Level Gentamicin Toxicity Etiology Measures Sensitivity Substance Measured Has ingredient is-a Intravascular Gentamicin Tests Summary Reports Decision Rule Expert System Drug Information

11. The Medical Entities Dictionary - © 2002 - James J. Cimino Summary Reporting Plasma Glucose Test Serum Glucose TestFingerstick Glucose Test Lab Test Intravascular Glucose Test Chem20 Display Lab Display

12. The Medical Entities Dictionary - © 2002 - James J. Cimino DOP Summary

13. The Medical Entities Dictionary - © 2002 - James J. Cimino WebCIS Summary

14. The Medical Entities Dictionary - © 2002 - James J. Cimino Supporting Clinical Research Epidemiology - symptoms, incidence, natural history of disease Outcomes - effectiveness of therapy, ideal length of stay Recruitment - identifying eligible participants

15. The Medical Entities Dictionary - © 2002 - James J. Cimino Patient Recruitment Study of bisphosphonates in hypercalcemia Potential subjects treated before enrollment Alert checked for elevated calcium and sent message to research fellow Enrollment was complete in two months

16. Linking to Expert Systems

19. The Medical Entities Dictionary - © 2002 - James J. Cimino 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

20. The Medical Entities Dictionary - © 2002 - James J. Cimino 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?

21. The Medical Entities Dictionary - © 2002 - James J. Cimino 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.

22. The Medical Entities Dictionary - © 2002 - James J. Cimino How We Outsmarted the Lab (Before) No Growth Medical Logic Module No Growth to Date

23. The Medical Entities Dictionary - © 2002 - James J. Cimino 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

24. The Medical Entities Dictionary - © 2002 - James J. Cimino Smarter Retrievals from the Record Repository stores events and results Clinical problems at a different level of granularity Re-use knowledge to map from problems to clinical data Produce problem-specific views of the medical record

25. Chest X ray Congestive Heart Failure Intravascular CK Test Creatine Kinase Chest X ray 2 View Cardiac Enzyme Angina Lab :1/1/99 Cardiac Enzyme Test Radiology :2/23/99 Chest X Ray Radiology :2/28/96 Head CT Lab :12/28/96 Sickle Cell Test Admission :3/14/96 Stroke Admission :2/14/98 Angina Lab :1/1/99 Blood Type Test Radiology :2/1/97 Knee X Ray Concept-oriented (Heart) Heart Disease Chest Discharge :1/15/99 CHF CHF Discharge :1/15/99 CHF CHF Admission :2/14/98 Angina Lab :1/1/99 Cardiac Enzyme Test Radiology :2/23/99 Chest X Ray

26. The Medical Entities Dictionary - © 2002 - James J. Cimino

29. Linking to On-line Resources with Terminology Reviewing reports will generate information needs On-line information sources can satisfy that need Data from report can be used to automate the query

30. The Medical Entities Dictionary - © 2002 - James J. Cimino

33. Linking Text Reports to On-line Information Sources Natural Language Processing Data representation to support reuse Codification of information needs

41. The Medical Entities Dictionary - © 2002 - James J. Cimino MED Tools MUMPS MED Editor qrymed accessmed Web Browsers

42. The Medical Entities Dictionary - © 2002 - James J. Cimino

43. MED Browsers

44. The Medical Entities Dictionary - © 2002 - James J. Cimino

45. Vocabulary Construction Issues Understanding Modeling Creation Maintenance

46. The Medical Entities Dictionary - © 2002 - James J. Cimino Knowledge-based Maintenance Theory: "A knowledge-based approach to vocabulary representation will improve maintenance and utility."

47. The Medical Entities Dictionary - © 2002 - James J. Cimino Adding New Terms Identify redundant terms Put new terms into existing classes Create new classes where appropriate

48. The Medical Entities Dictionary - © 2002 - James J. Cimino Put Terms into Existing Classes Theory: The attributes of new terms can be used to identify classes Practice: "Pushing" Terms

49. The Medical Entities Dictionary - © 2002 - James J. Cimino “Pushing” a Term Medical Entity Laboratory Test Plasma Glucose Test Bioactive Substance Glucose Carbo- hydrate Chemistry Test Chem-7 Glucose Test Chem-20 Glucose Test Stat Glucose Test Chemical

50. The Medical Entities Dictionary - © 2002 - James J. Cimino “Pushing” a Term Medical Entity Laboratory Test Plasma Glucose Test Bioactive Substance Glucose Carbo- hydrate Chemistry Test Chem-7 Glucose Test Chem-20 Glucose Test Stat Glucose Test Stat Glucose Test Chemical

51. The Medical Entities Dictionary - © 2002 - James J. Cimino “Pushing” a Term Medical Entity Laboratory Test Plasma Glucose Test Bioactive Substance Glucose Carbo- hydrate Chemistry Test Chem-7 Glucose Test Stat Glucose Test Chem-20 Glucose Test Stat Glucose Test Stat Glucose Test Chemical

52. The Medical Entities Dictionary - © 2002 - James J. Cimino Create New Classes Theory: Attribute patterns can be detected which identify potential classes Practice: Recursive partitioning of existing classes

53. The Medical Entities Dictionary - © 2002 - James J. Cimino Finding a New Class Medical Entity Laboratory Test Hepatitis B Core Antigen Chemical Chemistry Test Core Antigen HBC Antigen

54. The Medical Entities Dictionary - © 2002 - James J. Cimino Finding a New Class Medical Entity Laboratory Test Hepatitis B Core Antigen Chemical Chemistry Test Core Antigen Hepatitis B Core Antigen Test HBC Antigen Medical Entity Laboratory Test Hepatitis B Core Antigen Chemical Chemistry Test Core Antigen HBC Antigen

55. The Medical Entities Dictionary - © 2002 - James J. Cimino Maintenance Tasks New Vocabularies (Laboratory) Changing Vocabularies (Pharmacy)

56. The Medical Entities Dictionary - © 2002 - James J. Cimino New Vocabulary: Laboratory Original lab: 2533 terms New lab: 5291 terms Vocabulary delivered: June 15, 1994 “Go live” date: July 24, 1994

57. The Medical Entities Dictionary - © 2002 - James J. Cimino Changing Vocabulary: Pharmacy Started with 2091 drugs In two years, added 1827 drugs Classification by: –Ingredients –AHFS Class –Allergy –DEA –Form

58. The Medical Entities Dictionary - © 2002 - James J. Cimino Automated Classification Medical Entity Drug Pharmacologic Substance Sulfameth- oxizole Chemical Antibiotic Bactrim "S1", "65" Trimethoprim/ Sulfamethoxizole Preparations Trimeth- oprim Septra "S1" Sulfa Allergy "S1" Allergy Class Trimethoprim Allergy "65"

59. The Medical Entities Dictionary - © 2002 - James J. Cimino Formulary Correction Statistics Among original 2091 drugs: –334 unclassified drugs assigned classes –289 drugs assigned multiple classes –173 drugs discovered to be missing allergy codes Among additional 1827 drugs added: –25 unclassified drugs assigned classes –121 drugs assigned multiple classes –38 drugs discovered to be missing allergy codes

60. The Medical Entities Dictionary - © 2002 - James J. Cimino Semi-Automated Maintenance Read formulary file Identify new drugs Link new drug to ingredient(s) Suggest classifying in “preparation” class Add new drug as per human reviewer

61. The Medical Entities Dictionary - © 2002 - James J. Cimino Interactive Classification Adding "LASIX 20MG TAB" Generic Ingredient "FUROSEMIDE" AHFS Class "DIURETICS" Add to "FUROSEMIDE PREPARATION"?y Adding "ZAROXOLYN 5MG CAP" Generic Ingredient "METOLAZONE" AHFS Class "DIURETICS" Add to "DIURETICS"? n Create METOLAZONE PREPARATION" Class? y

62. The Medical Entities Dictionary - © 2002 - James J. Cimino Impact of "Theory into Practice": Better management Easier to merge new vocabularies Easier to automate change management Higher quality through better modeling

63. The Medical Entities Dictionary - © 2002 - James J. Cimino Impact of Better Management: More Useful Vocabulary MED is up-to-date for ancillary systems Easier to find terms in the MED Support for multiple conceptual levels More accurate database queries

64. The Medical Entities Dictionary - © 2002 - James J. Cimino Knowledge-Based Terminology Maintenance Forcing explicit definitions elicits meaning Explicit definitions force consistency Inferencing possible to: –automate classification –identify new classes But: –Modeling is hard –Agreement on definitions is hard

65. The Medical Entities Dictionary - © 2002 - James J. Cimino The Columbia Experience Capturing data from ancillary systems Natural language processing Reusable data summaries Merging data across systems Support for clinical research Linking to expert systems Automated decision support Smarter retrievals from the record Linking to on-line resources Terminology management