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James J. Cimino
Columbia UniversityMIE ‘02
Budapest, Hungary
August 27, 2002
The Challenge of Reuse of Information
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Information Reuse
InformationResearch
OtherClinicians
Summary
HospitalAdministration
Government
DecisionSupport
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Information Mismatch: Version
Patient has hantavirus infection
“Virus, NEC”
2001 ICD: - Smallpox - Cowpox - Virus, NEC
2002 ICD: - Smallpox - Cowpox - Hantavirus - Virus, NEC
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Terminology Solutions: Standards
• Advantages– Less duplication of work– “Plug and play” compatibility
• Disadvantages– Cost of adoption– Unresponsive to change– Developers Users
Terminology Solutions: Distribution
• Media– 9-track tape– Floppy disks– CD-ROM– Web
• Models– ICD: annual– UMLS: change files– HL7: server
Terminology Solutions: Semantic Representation
• Concept oriented
• Concept permanence
• True is-a hierarchies
• Multiple hierarchies (heterarchy)
• Semantic relationships
• Inheritance
Terminology Solutions: Semantic Representation
Goodpasture’sSyndrome
Kidney Disease
Hemoptysis Hematuria
Finding
Lung Kidney
Organ
has-site
Lung Disease
is-a
has-finding
Semantic Representation: Galen
• Structured Meta Knowledge from Pen&Pad
• Common Reference Terminology
• Requires terminology server
• Automated classification
• Open source terminology
Semantic Representation: GalenFracture which <
hasLocation BonehasCause Condition>
Fracture which <hasLocation (AnatomicalNeck which isDivisionOf Femur)hasCause (Osteoporosis which hasCause
PostMenopausalChange)>
Can be classified as:FractureFracture which hasLocation LongBone.Fracture which hasLocation (AnatomicalNeck which
isDivisionOf LongBone).Fracture which hasLocation Thigh.Fracture which hasLocation Hip.Lesion which isCausedBy Osteoporosis.Lesion which isCausedBy PostmenopausalChange.
Semantic Representation:SNOMED-CT
• Merger of SNOMED and Read Clinical Terms
• Reference terminology
• Many domains
• Heterarchy
• Semantic relations (roles)
• Postcoordination
• >300,000 concepts
Semantic Representation:SNOMED-CT
is-a
BacterialPneumoniaTularemia
PulmonaryTularemia
has-causative-agent
Francisellatularensis
LungStructure
has-finding-site
Inflammation
associated-morphology
Semantic Representation: LOINC
• Logical Observations, Identifiers, Names and Codes
• Codes for observations in HL7 messages
• Fully-specified names
• Codes for orderable observations
• Codes for results
Semantic Representation: LOINC
24356-8 | URINALYSIS PANEL
5778-6 | COLOR | COLOR | PT | UR | NOM
22705-8 | GLUCOSE | SCNC | PT | UR | QN | TEST STRIP
YellowRedColorless…
Semantic Representation: Drugs
• Food and Drug Administration
• Veterans Administration
• National Library of Medicine
• Drug knowledge base vendors
• Common model for Clinical Drug
• RxNorm
Semantic Representation: Drugs
Clinical Drug
Ingredient Class
Ingredient
is-a
ChemicalsDrug Class
Not-Fully-Specified Drug
is-a
is-a
Medications
International Package Identifiers
Country-Specific Packaged Product
is-a
Packages
Trademark Drug
Manufactured Components
is-a
is-a
Composite Clinical Drug
is-a
Composite Trademark Drug
is-a
Semantic Representation: MED
• Medical Entities Dictionary
• Data dictionary and controlled terminology
• Columbia-Presbyterian Medical Center
• Heterarchy
• Semantic network
• Multiple domains
• >70,000 concepts
Semantic Representation: MED
LaboratoryProcedure
CHEM-7PlasmaGlucose
Test
Substance
Sampled
Part of
Has S
pecimen
Substance Measured
MedicalEntity
Event
LaboratoryTest
DiagnosticProcedure
Substance
BioactiveSubstance
Glucose
Chemical
Carbo-hydrate
LaboratorySpecimen
PlasmaSpecimen
Plasma
AnatomicSubstance
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Matching Granularity and Semantics
Gentamicin
InjectableGentamicin
Gentamicin Sensitivity
Test
SerumGentamicin
Level
is-a
IntravascularGentamicin
Tests
GentamicinToxicity
EtiologyMeasures
Sensitivity
Substance Measured Has ingredient
SummaryReports
DecisionRule
ExpertSystem
DrugInformation
Example of Reuse:Summary Reporting
• Spreadsheets for trends in lab data
• Defined as concepts in the MED
• Linked to test classes
Example of Reuse:Summary Reporting
Plasma Glucose Test
Serum Glucose TestFingerstick Glucose Test
Lab Test
Intravascular Glucose Test Chem20 Display
Lab Display
Example of Reuse: Merging Data
• Merger between Presbyterian Hospital and New York Hospital
• Separate departmental systems
• Common repository
• Merger of terms in MED allows cross-institution data aggregation
Example of Reuse: Merging Data
45748 - Diazepam 5 mg Tablet
28727 - CPMC Drug: Diazepam 5 mg Tab29952 - CPMC Drug: UD Diazepam 5 mg Tab34734 - CPMC Drug: UD Diazepam 5mg Tab35346 - CPMC Drug: UD Diazepam 5 mg Tab.62523 - Cerner Drug: Diazepam Tab 5 mg
46888 - Diazepam Tablets
31136 - Diazepam Preparations
24015 - Benzodiazepine Preparations28107 - Drug Enforcement Administration (DEA)
Class IV - Drug with Low Abuse Potential 28129 - Drug Allergy Class: Benzodiazepines
28203 - Tablet
Example of Reuse: Merging Data
2478 - Plasma Glucose Measurement
32308 - Intravascular Glucose Test 32101 - Plasma Chemistry Test
35836 - CPMC Laboratory Test: Glucose Tolerance, 6hr35836 - CPMC Laboratory Test: Glucose Tolerance, 6hr35837 - CPMC Laboratory Test: Glucose Tolerance, Fasting35838 - CPMC Laboratory Test: Glucose, 1/2 Hour36337 - CPMC Laboratory Test: Glucose, Fasting 250005 - NYH Lab Procedure: Glucose, Plasma50078 - NYH Lab Procedure: Glucose, 0 H50079 - NYH Lab Procedure: Glucose, 2 PP50080 - NYH Lab Procedure: Glucose, 0.5 H50081 - NYH Lab Procedure: Glucose, 1 H50082 - NYH Lab Procedure: Glucose, 2 H50084 - NYH Lab Procedure: Glucose, 3 H50107 - NYH Lab Procedure: Glucose, 1.5 H50108 - NYH Lab Procedure: Glucose, 4 H50109 - NYH Lab Procedure: Glucose, 5 H50110 - NYH Lab Procedure: Glucose, 6 H50111 - NYH Lab Procedure: Ogtt,Gest Screen,(50g)
1523 - Presbyterian Plasma Glucose Test 1601 - Presbyterian Plasma Glucose Measurement 1652 - Allen Plasma Glucose Measurement33807 - New CHEM-7 Plasma Glucose Measurement35454 - CPMC Laboratory Test: Old Plasma Glucose
Measurement35815 - CPMC Laboratory Test: Glucose, Challenge35816 - CPMC Laboratory Test: Glucose, Fasting35817 - CPMC Laboratory Test: Glucose, 1hr Post Prandial35818 - CPMC Laboratory Test: Glucose, 2hr Post Prandial35819 - CPMC Laboratory Test: Glucose, Random35821 - CPMC Laboratory Test: Glucose35831 - CPMC Laboratory Test: Glucose Tolerance, 1hr35832 - CPMC Laboratory Test: Glucose Tolerance, 2hr35833 - CPMC Laboratory Test: Glucose Tolerance, 3hr35834 - CPMC Laboratory Test: Glucose Tolerance, 4hr35835 - CPMC Laboratory Test: Glucose Tolerance, 5hr
Example of Reuse:Automated Decision Support
• Data stored in repository reviewed in real time
• Arden Syntax rules triggered by data
• Generation of alerts and reminders
• High-level concepts in rules map to low-level concepts in database
Automated Decision Support: Tuberculosis
• 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?
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.
No Growth after ...
How We Outsmarted the Lab
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
Example of Reuse:Information Retrieval
UnderstandInformation
Needs
1
Get InformationFrom EMR
2
AutomatedTranslation
5
ResourceTerminology
4
Presentation
7
Querying
6
ResourceSelection
3
Example of Reuse: Expert Systems
• Expert system has high-level concepts
• Database has quantitative results
• Semantic mismatch
• Translation through semantic net traversal
Example of Reuse: Expert Systems
1600 44 L
1600 Gluc
32703 SerumGlucose Tests
32308 IntravascularGlucose Tests
42485 ElevatedAbnormal Findingin Body Substance
42486 DecreasedAbnormal Findingin Body Substance
42541 Hyperglycemia 3286 Hypoglycemia
32412 IntravascularSpecimen
31987 Glucose
42527 AbnormalLevel of Blood
Glucose
3286 Hypoglycemia
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 :2/14/98Angina
Lab :1/1/99 Blood Type Test
Radiology :2/1/97 Knee X Ray
Discharge :1/15/99 CHF
MedicalRecord
Example of Reuse:Problem-Oriented Views
Chest X ray
IntravascularCK Test
CreatineKinase
Chest X ray 2 View
Cardiac Enzyme
CongestiveHeart Failure
Angina
Heart Disease
Chest
Admission :2/14/98Angina
Lab :1/1/99 Cardiac Enzyme Test
Radiology :2/23/99 Chest X Ray
Discharge :1/15/99 CHF
Heart MED
Experience with Information Reuse
• Summary reporting
• Merging data
• Automated decision support
• Information retrieval
• Expert systems
• Problem-oriented views
Overview
• Data types
• Information reuse
• Information mismatch
• Terminology solutions
• Experience
• Conclusions
Information, Then and Now
- Cimino JJ, Int J Biomed Comput. 1994; 34:185-194
DischargeDiagnoses
Radiology Reports
PhysicalExams
DischargeSummaries
PatientHistories
Medication Lists
Uncoded,Unstructured
Uncoded,Structured
LocallyCoded
UniversallyCoded
Then (1993)
Information, Then and Now
- Cimino JJ, Int J Biomed Comput. 1994; 34:185-194
DischargeDiagnoses
Radiology Reports
PhysicalExams
DischargeSummaries
PatientHistories
Medication Lists
Uncoded,Unstructured
Uncoded,Structured
LocallyCoded
UniversallyCoded
Near Future
Information, Then and Now
- Cimino JJ, Int J Biomed Comput. 1994; 34:185-194
DischargeDiagnoses
Radiology Reports
PhysicalExams
DischargeSummaries
PatientHistories
Medication Lists
Uncoded,Unstructured
Uncoded,Structured
LocallyCoded
UniversallyCoded
Far Future
Current Status
DischargeDiagnoses
Radiology Reports
PhysicalExams
DischargeSummaries
PatientHistories
Medication Lists
Uncoded,Unstructured
Uncoded,Structured
LocallyCoded
UniversallyCoded
Current Status
Uncoded,Structured
Standard Semantic
Terminology
Standard Code Set
DischargeDiagnoses
Radiology Reports
PhysicalExams
DischargeSummaries
PatientHistories
Medication Lists
Uncoded,Unstructured
Current Status
DischargeDiagnoses
LaboratoryReports
ProblemLists
TextReports
Text Reports
Medication Lists
Uncoded,Unstructured
Uncoded,Structured
Standard Semantic
Terminology
Standard Code Set