1. Julie M. Green, MS, DVM Veterinary Medical Informatics VMRCVM – Virginia Tech Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine The Changing Face of Terminology How to Keep Up

2. Why does terminology change? Terminologies are incomplete  Medicine covers a large body of knowledge  Missing content is inevitable  Veterinary content is low priority Errors are made Medicine evolves Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

3. Why does terminology change? Terminologies are incomplete Errors are made  ‘To Err Is Human’…to correct is inevitable Medicine evolves Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

4. Why does terminology change? Terminologies are incomplete Errors are made Medicine evolves  Medical advancements  Expanding knowledge  Reevaluation of current thinking Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

5. How does terminology change? Minor changes Concept additions Concept retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

6. How does terminology change? Minor changes  Considered “minor” if changes do NOT affect the meaning of the concept  Ex. Spelling corrections Concept additions Concept retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

7. How does terminology change? Minor changes Concept additions  New content, self-explanatory Concept retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

8. How does terminology change? Minor changes Concept additions Concept retirements  Concepts should NEVER be DELETED  Mark content as retired or inactive  Relationships between retired content and potential replacements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

9. What does this mean? Change is a comin’… Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine Is your system ready?

10. What does this mean? Depends on type of implementation –Direct implementation –Mapping or translation Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

11. Direct Implementation Use content in the interface Users directly interact with terminology Practicality requires subsets Must be kept “in synch” with changes Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus Sample from a “Findings” Subset

12. Direct Implementation Minor changes Text changes Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus Sample “Findings” Subset Correct Subcutaneus

13. Direct Implementation Minor changes Text changes Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus Sample “Findings” Subset ComponentidChangetypeReleaseDate 95325000220090131 SCT_componenthistory table row Correct Subcutaneus

14. Direct Implementation Minor changes Text changes –Replace text of term used Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneous nodule 73211009Diabetes mellitus Sample “Findings” Subset ComponentidChangetypeReleaseDate 95325000220090131 SCT_componenthistory table row

15. Direct Implementation Additions (to subsets) User need drives additions to subsets –System should accept new content requests –Centralized content requests desirable Experts should decide appropriateness Central authority can then submit request to SNOMED –Temporary code for storage until concept is added to SNOMED Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

16. Direct Implementation Additions (to SNOMED) New terms become available in the standard Review based on –User requests –Subject Matter Expertise Choose additions based on review Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

17. Direct Implementation Additions Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus TempcodeElbow arthritis Sample “Findings” Subset User requested: Elbow arthritis (added to subset)

18. Direct Implementation Additions Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine Sample “Findings” Subset ComponentidChangetypeReleaseDate 439656005020090131 SCT_componenthistory table row New term added: (to SNOMED) Elbow arthritis 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus TempcodeElbow arthritis

19. Direct Implementation Additions If temporary “placeholder” codes were created in the subset, these need to be updated with new SCTID Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus 439656005Arthritis of elbow Sample “Findings” Subset ComponentidChangetypeReleaseDate 439656005020090131 SCT_componenthistory table row

20. Direct Implementation Retirements Retirement = inactivate term in standard –Ambiguous, Duplicate, Knowledge changed Must be replaced in subsets Record of “referrals” must be kept –Used for legacy data retrieval/analysis Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

21. Direct Implementation Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus 439656005Arthritis of elbow (disorder) Sample “Findings” Subset ComponentidChangetypeReleaseDateStatus 244480071200901312 SCT_componenthistory table row Retired as duplicate

22. Direct Implementation Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus 439656005Arthritis of elbow (disorder) Sample “Findings” Subset ComponentidChangetypeReleaseDateStatus 244480071200901312 SCT_componenthistory table row Retired as duplicate

23. relationshipidConceptid1Relationshiptypeconceptid2Characteristic type 354487902124448007168666000 (Same As) 1864350042 Direct Implementation Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 24448007Bacterial infection due to Klebsiella pneumoniae 95325000Subcutaneus nodule 73211009Diabetes mellitus 439656005Arthritis of elbow (disorder) Sample “Findings” Subset SCT_relationships table row Replace with 186435004 Friedlander’s bacillus infection

24. relationshipidConceptid1Relationshiptypeconceptid2Characteristic type 354487902124448007168666000 (Same As) 1864350042 Direct Implementation Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 186435004Friedlander’s bacillus infection 95325000Subcutaneus nodule 73211009Diabetes mellitus 439656005Arthritis of elbow (disorder) Sample “Findings” Subset SCT_relationships table row Replace with 186435004 Friedlander’s bacillus infection

25. relationshipidConceptid1Relationshiptypeconceptid2Characteristic type 354487902124448007168666000 (Same As) 1864350042 Direct Implementation Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine Previous Subset ConceptReplacement Concept 24448007 (Bacterial infection due to Klebsiella pneumoniae) 186435004 (Friedlander’s bacillus infection) Subset Replacement History SCT_relationships table row Keep Local History Of Replacements

26. Mapping Proprietary interface lists –Familiar “pick lists” Interface lists are “transformed” in the background Users “insulated” from standard terminology Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine CODEPick List TermSCTID [Provided for demo only, not stored] KLEBKlebsiella infection 24448007 Bacterial infection due to Klebsiella pneumoniae NODSNodule, SQ95325000 Subcutaneus nodule DIBMDiabetes mellitus73211009 Diabetes mellitus Sample Mapping table

27. Mapping When changes occur… Mappings must be reviewed and updated As users create new local terms, maps must be created If mappings are used to drive queries, retirement history must be utilized. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

28. Mapping Minor changes Text changes only affect the standard terminology Mapping is still accurate. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine CODEPick List TermSCTID KLEBKlebsiella infection 24448007 Bacterial infection due to Klebsiella pneumoniae NODSNodule, SQ95325000 Subcutaneus nodule DIBMDiabetes mellitus73211009 Diabetes mellitus Sample Mapping table Correct Subcutaneus

29. Mapping Additions Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine User requested: Elbow arthritis CODEPick List TermSCTID KLEBKlebsiella infection 24448007 Bacterial infection due to Klebsiella pneumoniae NODSNodule, SQ95325000 Subcutaneous nodule DIBMDiabetes mellitus73211009 Diabetes mellitus ARTEArthritis, Elbow Sample Mapping table

30. Mapping Additions Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine CODEPick List TermSCTID KLEBKlebsiella infection 24448007 Bacterial infection due to Klebsiella pneumoniae NODSNodule, SQ95325000 Subcutaneous nodule DIBMDiabetes mellitus73211009 Diabetes mellitus ARTEArthritis, Elbow Sample Mapping table ComponentidChangetypeReleaseDate 439656005020090131 SCT_componenthistory table row New term added: Elbow arthritis

31. Mapping Additions Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine CODEPick List TermSCTID KLEBKlebsiella infection 24448007 Bacterial infection due to Klebsiella pneumoniae NODSNodule, SQ95325000 Subcutaneous nodule DIBMDiabetes mellitus73211009 Diabetes mellitus ARTEArthritis, Elbow439656005 Arthritis of elbow (disorder) Sample Mapping table ComponentidChangetypeReleaseDate 439656005020090131 SCT_componenthistory table row New mapping: Elbow arthritis

32. ComponentidChangetypeReleaseDateStatus 244480071200901312 Mapping Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine CODEPick List TermSCTID KLEBKlebsiella infection 24448007 Bacterial infection due to Klebsiella pneumoniae NODSNodule, SQ95325000 Subcutaneous nodule DIBMDiabetes mellitus73211009 Diabetes mellitus ARTEArthritis, Elbow439656005 Arthritis of elbow (disorder) Sample Mapping table SCT_componenthistory table row Retired as duplicate

33. Mapping Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine CODEPick List TermSCTID KLEBKlebsiella infection 186435004 Friedlander’s bacillus infection NODSNodule, SQ95325000 Subcutaneous nodule DIBMDiabetes mellitus73211009 Diabetes mellitus ARTEArthritis, Elbow439656005 Arthritis of elbow (disorder) Sample Mapping table relationshipidConceptid1Relationshiptypeconceptid2Characteristic type 354487902124448007168666000 (Same As) 1864350042 SCT_relationships table row Replace with 186435004 Friedlander’s bacillus infection

34. relationshipidConceptid1Relationshiptypeconceptid2Characteristic type 354487902124448007168666000 (Same As) 1864350042 Mapping Retirements Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine Previous Mapping ConceptReplacement Concept 24448007 (Bacterial infection due to Klebsiella pneumoniae) 186435004 (Friedlander’s bacillus infection) Mapping Replacement History SCT_relationships table row Keep Local History Of Replacements

35. Legacy…Querying…Reporting Assumption: standard terminology is the basis for queries –Relationships in terminology used to determine what codes to search for Ex: Retrieve all cases of Enterobacter infections (Enterobacteriaceae) Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

36. Legacy…Querying…Reporting Retrieve all cases of Enterobacter infections (Enterobacteriaceae) Step 1: Determine all diagnosis codes that “fit the bill”. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

37. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. Is there a single code that is equivalent to your criteria? –Infection due to Enterobacteriaceae (disorder) [128945009] Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

38. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. What about cases that are coded with specific bacteria? –Descendents of Infection due to Enterobacteriaceae (disorder) [128945009] Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

39. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 128945009Infection due to Enterobacteriaceae (disorder) 300985007Coliform septicemia (disorder) 186435004Friedlander's bacillus infection (disorder) 71057007Infection due to Escherichia coli (disorder) 302231008Salmonella infection (disorder) … * Sample of 5 displayed out of 135 descendents

40. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 128945009Infection due to Enterobacteriaceae (disorder) 300985007Coliform septicemia (disorder) 186435004Friedlander's bacillus infection (disorder) 71057007Infection due to Escherichia coli (disorder) 302231008Salmonella infection (disorder) … * Sample of 5 displayed out of 135 descendents Was a replacement

41. Legacy…Querying…Reporting Retrieve all cases of Enterobacter infections (Enterobacteriaceae) Step 1: Determine all diagnosis codes that “fit the bill”. Step 2: Determine all LEGACY codes that “fit the bill”. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

42. Legacy…Querying…Reporting Step 2: Determine all LEGACY codes that “fit the bill”. Query your current list of diagnosis codes for those with replacement history in your system. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 186435004Friedlander's bacillus infection (disorder) Previous Subset ConceptReplacement Concept 24448007 (Bacterial infection due to Klebsiella pneumoniae) 186435004 (Friedlander’s bacillus infection)

43. Legacy…Querying…Reporting Step 2: Determine all LEGACY codes that “fit the bill”. Add previous Concepts to the list of codes. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 128945009Infection due to Enterobacteriaceae (disorder) 300985007Coliform septicemia (disorder) 186435004Friedlander's bacillus infection (disorder) 71057007Infection due to Escherichia coli (disorder) 302231008Salmonella infection (disorder) … * Sample of 5 displayed out of 135 descendents 24448007Bacterial infection due to Klebsiella pneumoniae

44. Legacy…Querying…Reporting Retrieve all cases of Enterobacter infections (Enterobacteriaceae) Step 1: Determine all diagnosis codes that “fit the bill”. Step 2: Determine all LEGACY codes that “fit the bill”. Step 3: Query database for records stored using the codes found. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

45. Legacy…Querying…Reporting New content additions can also affect quality of querying. Ex: Retrieve cases diagnosed with Elbow arthritis Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

46. Legacy…Querying…Reporting Retrieve cases diagnosed with Elbow arthritis Step 1: Determine all diagnosis codes that “fit the bill”. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

47. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. Is there a single code that is equivalent to your criteria? –Arthritis of elbow (disorder) [439656005] Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

48. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. Arthritis of elbow (disorder) [439656005] and all descendents Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 439656005Arthritis of elbow (disorder) 431263002Bacterial arthritis of elbow (disorder) 201561002Reactive arthropathy of elbow (disorder) …* Sample of 3 displayed out of 12 descendents

49. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. What about BEFORE the addition? Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine 439656005Arthritis of elbow (disorder) 431263002Bacterial arthritis of elbow (disorder) 201561002Reactive arthropathy of elbow (disorder) …* Sample of 3 displayed out of 12 descendents Was an addition

50. Legacy…Querying…Reporting Step 1: Determine all diagnosis codes that “fit the bill”. Cases stored BEFORE the addition may have been coded in a different way. –Elbow joint inflamed? –Arthropathy of elbow? Epidemiologist/clinician should be aware –They decide what “other” codes to add (or not) Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

51. Legacy…Querying…Reporting Retrieve cases diagnosed with Elbow arthritis Step 1: Determine all diagnosis codes that “fit the bill”. Step 2: Check for Additions, note the date, and consult Epidemiologist/clinician. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

52. Legacy…Querying…Reporting Retrieve cases diagnosed with Elbow arthritis Step 1: Determine all diagnosis codes. Step 2: Check for Additions, note the date, and consult Epidemiologist/clinician. Step 3: Determine all LEGACY codes. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

53. Legacy…Querying…Reporting Retrieve cases diagnosed with Elbow arthritis Step 1: Determine all diagnosis codes. Step 2: Check for Additions, note the date, and consult Epidemiologist/clinician. Step 3: Determine all LEGACY codes. Step 4: Query database for records stored using the codes found. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

54. Legacy…Querying…Reporting Both implementations need HISTORY –Difference - where the final queries are run –Mapping determine applicable SNOMED concepts query translation table to retrieve local codes query records database to retrieve cases –Direct Implementation determine applicable SNOMED concepts query records database to retrieve cases Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

55. Legacy…Querying…Reporting Retirements –Need to have replacements stored Additions –Need to record date of addition Query/Reporting functions MUST account for changes made. Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine

56. Changing Terminology SUMMARY: Changes WILL happen Systems MUST be designed for terminology change History of changes are important to accurate retrieval and analysis Veterinary Medical Informatics – Va-Md Regional College of Veterinary Medicine