A Roadmap for EHR-Coding Systems

Pieter E Zanstra

Radboud University Nijmegen Medical CenterCo-ordinator EU SemanticHEALTH Specific Support Action:Semantic Interoperability Deployment and

Research Roadmap

Eurorec Conference; Geneve 20061010

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Presentation Overview

• Clinical perspective• Coding practice• Why it is so hard• The challenge

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Reviewed. Primip FT No ANC probsF/D at 08:45Needed synto for contractions about 7cmDecent progress since.Epidural in-situNo urges to push really according to patientContractions 4:10 but poor duration & strength (on 60 u/s /synto)

PA: Ceph 0/5VE: Head at +1

Caput +1 No ???OA positionCx F/D NO DESCENT

Tried pushing – poor maternal effort despite instructionAlthough epidural working well, doesn’t stop longstandingspasmodic hip pain.Very problematicFHR CTG

No descent with attempts at pushing – poor effort.Plan… a) Push synto

b) Need really try to push & work on techniquec) reassess at interval 15 mins & D/W consultant

Would not be happy to have to exert traction withForceps when no effort & no descent

Where are we coming from..

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A bit of Archeology

• SESAME Committee (1990)

– Medical Semantics Advisory Task (Mesat) – Establish national standardisation organisations for

semantical aspects in medicine – European medical termbank (Eumet) – European Model of Health Care (Euromodel) – European Classification of Medical Procedures (Euclamep) – Harmonization of validation and coding rules for ICD

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Competing demands on recording

Record

Categorise

ICD, ICPM

DRG

Documentation

Referral letters?

Grouper

ClassifierReimburse

Manage

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What kind of business logic do we need?

Record

ICD, ICPM

DRG

Documentation

Grouper

Classifier

MediationService

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What binds Records, Interface, Reporting, Knowledge…?

Interface Terminology

Reporting Terminology

(ICD)

MediationService

Health Record

DischargeReferral..

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Record architecture terminology (mediation)

Name, Context and Content

physical examinationbreast

palpationlump

present CONTENT

NAME

CONTEXT

©Angelo Rossi Mori

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Sound semantics underpinning continuity in care

status of lump by palpation of breast

observation by palpation of breast

observation by physical examination of breast

observation by physical examination

restore the terminological CONTINUUMbetween Content

present

presence

and Structure

of lump by palpation of breast©Angelo Rossi Mori

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National Institutefor Public Health andthe Environment

Classification & the Law

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Codes, codes everywhere...

SNOMED-3READ-2MeSHICD-9ICD-9-CMICD-ONCSPICPMOXMIS ECRI-UMDNSSNOPHCFAACR-NEMAIUPAC-NPULOINCDICOM-SDMMCTGECDAMNGAP ICPC OPCS-4CPT-4 NDCNANDAICNP AIDSLINEMED80MED66AIDSDRUGS

AIDSTRIALSChemIDCHEMLINEGENE-TOXHISTLINESDLINETOXLINETOXLINE65TOXLITPDQAVLINEBIOETHICSCANCERLITCATLINEDENTALPROJMEDLINEPOPLINESERLINEDOCUSERDxplainAI/RHEUMIliadGenBankOMSPSYTRIFACTSNIOSHNPIRSNEDRESMED85

MED75HSTATHDAMED90HealthSTARACR92AIR93BRMP96NICULTBRMS96COSTARCPMCRISPCOSTARTDMDDSM III & IVDORHHCINSLCHMCMMIMNeuronamesWHOARTCTV3

CCHI (Canada)MBS-E (Australia)ICD-10-PCS (USA)ICPM-NL (Netherlands)NCSP (Swedish Version)NCSP (Finnish Version)ICPM-DE (Germany)CCAM (France)

SNOMED-CT (USA-UK)OPCS-5 (UK)SKS (Denmark)ICIDH (WHO)Digital Anatomist (UW)Nomina Anatomica

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And there is more to come……

• Official Inventory on IT systems– 52 ‘exotic’ patient record systems– 1 ‘undiscovered summary-system’ used by 250

physicians of which 70 daily containing 20.000 patients

• Inventory by students– Estimated 200 ‘exotic’ systems– At least 200 shortlists for diagnosis, treatment– Only some terminologies properly

documented/maintained

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Maintenance dynamics

System Major Update

ICD 10-20 years Annual

Procedures 10+ years Quarterly

Snomed ? Quaterly

Genome ? Daily

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Do you recognise this?

• Airbus 380 delay on delay on delay…• Software project over budget, over time,

under-performing• Railroad development 3-fold budget increase• Gulf wars• Fight bioterrorism• ….• <your own favourite>

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Tame versus Wicked Problems

• Well defined stable problem statement• Known when the solution is reached• Solution can be objectively assessed

right/wrong• Belongs to class of similar problems with

similar solutions

• Ill defined problem, ambiguous• Strong moral, political, professional issues• Strong stakeholder dependence

Rittel & Webber (1973)

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Observations

• Step to HL7 version 3 probably too big leap• Galen and probably Snomed CT too complex• Combination HL7v3 – SCT unpredictable• Many clinical projects too ambitious

Time to complete = Estimate * Outcome = Expectation /

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The New Economy effect

• Withdrawal of government from public domain– Tasks moving to market parties– Dynamic workforce– Globalisation

• Human factors– More career oriented labour force on short contracts– Government policies more driven by political agenda

• Effects– More effective services– Dramatic loss in corporate knowledge at gov. level– Investments horizon on next elections

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Dealing with Infrastructures

• Role in supply of Water, Electricity, Telephone?– Different response in gov withdrawal

• Role in railways?– Responsible for infrastructure?

• Role in road construction maintenance?– Withdrawal unthinkable (some public/private partnering)

• Role in maintenance of dikes waterways?– In NL withdrawal out of the question; life threatening!

• Role in national life threat alarm system?• Role in maintenance of healthcare infostructure

– Utter confusion

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Still many open questions

• Why do this at all

• What level of detail is required

• Revolutionairy/evolutionairy implementation

• How do we cope technically

• How do we cope in the business process

• How do users cope cognitively

• How do we cope with version control in the

new highly interdependent architectures

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Distinction of roles and collaborations

• National terminology centres (networked)• Standards bodies• Healthcare providers• Vendors• Governments• Universities

Challenge to let this orchestra play

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Recommendation: Establish the process

• Focus on real immediate needs, and realistic time scales

• Do not just select a single product, but join forces to redesign with best of breed

• Be prepared to throw away what you loved and cherised!

• Be aware and secure solutions for different cultures/ languages

• Involve and explain to those who have the burden of recording (registration dividend)

• Without a well managed network of compentent expertise centres, the process is likely to fail

• Governments develop & adhere to longer term visions– Value and maintain your corporate knowledge

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Acknowledgements

Specific Support Action co-funded by the European Commission SIXTH FRAMEWORK PROGRAMME

Communication & Technology Research, Germany

Radboud University Nijmegen Medical CenterDepartment of Medical Informatics (Co-ordinator)

World Health Organisation Dept. Measurements & Health Information Systems, Switzerland

Uppsala UniversityNordic Centre for Classifications in Health Care, Sweden

University of St. EtienneDepartment of Public Health & Medical Informatics, France

National Institute for Strategic Health ResearchHungary

University of Manchester Health and Bioinformatics Group, UK

University College LondonCentre for Health Informatics, UK

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Thank you for your attention!

Further information:

www.semanticHEALTH.orgsemantichealth@eski.hu

Pieter E ZanstraRadboud University Nijmegen Medical Center

P.Zanstra.mi@xs4all.nl www.OpenGALEN.org