Lessons Learned from Pilot Project using SNOMED-CT for ... · Lessons Learned from Pilot Project using SNOMED-CT for Clinical Observations Fall 2010 Infoway Partnership Conference

Information in the Service of Health

HIRI

MEdbASE Research

Lessons Learned from Pilot Project

using SNOMED-CT for

Clinical Observations

Fall 2010

Infoway Partnership Conference Vancouver, 16 Nov 2010

John B. Hughes, M.D., C.M., Associate professor, McGill University

Michel A. Lortie, ing.


HIRI

16-Nov-2010 MEdbASE Research

• Health Informatics Research Institute of St-Mary’s Hospital Center

– NPO for research into health informatics and clinician adoption

– Core funding from St-Mary’s Hospital Foundation

– Resultant of a review of the “state of the art” of EMRs done in preparation for McGill accreditation by the College of Family Physicians of Canada


HIRI


• HiRES – Health Informatics for Research, Education and Service; a project to – Research the ‘computable’ patient record needed for

teaching, research and service in the academic environment

– Design a clinician defined “clinical content specification” mechanism for Primary Care Teaching Facilities

– Create a curated Pan Canadian “clinical content standards library” through endorsement by the College of Family Practice of Canada and the Royal College of Physicians and Surgeons of Canada.


HIRI


• Pilot 2008 – Description

– In 2008, the principals at HIRI undertook a 6 month pilot project to investigate the use of SNOMED-CT as a coding standard for the ‘computable’ medical record

– Physicians in a poly-clinic in Westmount and in a retirement home in East-end Montréal were provided with a software tool that captured SNOMED-CT coded findings, observations and diagnoses


HIRI


• Pilot 2008 – Description (cont)

– Intent was to link findings, observations and diagnoses to a differential diagnoses engine (i.e. DxPlain) to create a ‘computable’ target for investigation


HIRI


• Pilot 2008 - Description (cont)

EMR User I/F

Observations,

Findings

Diagnoses

SNOMED-CT

Coding

Bowser

SNOMED-CT

Current obs,

Finding and Diagnoses

Patient

Medical records

Query based on

Obs, findings and

Diagnoses

Candidate coding of

Obs, Findings and

Diagnoses

Candidate coding of

Obs, Findings and

Diagnoses

Selected coding of

Obs, Findings and

Diagnoses

Selected coding of

Obs, Findings and

Diagnoses

SNOMED /

DxPlain

transcoder

DxPlain

Differentials database

DxPlain

Advisor

Selected coding of

Obs, Findings and

Diagnoses

New and historic

Obs, Findings and

Diagnoses – DxPlain coded

Query based on

Obs, findings and

Diagnoses

Candidate differentials

Candidate coding of

Obs, Findings and

Diagnoses

Candidate

Differentials

Prior obs, finding

and Diagnoses

Candidate differentials

SNOMED coded

Candidate

Differentials


HIRI



– The acquisition / coding tool was modeled after the Clue browser and operated ‘in process’ to an EMR system in use at both sites

– The paradigm used for the acquisition was one of composing findings, observations and diagnoses into a prose SOAP note by providing ‘hints’ to the browser then selecting the appropriate concept and qualifiers as presented by the browser


HIRI




HIRI


• Pilot 2008 – Outcomes

– Most participating physicians opted out of project

– Poly-clinic users abandoned the system ahead of the retirement home physicians

– Bridging of SNOMED-CT coding to DxPlain coding proved highly problematic

– The use of a structured prose approach to data acquisition was deemed to be sub-optimal


HIRI


• Pilot 2008 – Findings

– Initial search speed of browser was considered inadequate for production environments.

• In spite of subsequent significant enhancements to the search speed; project never recovered from initial ‘poor’ perception

– Vocabulary of the search was felt to be too formal and restrictive; the resulting prose note not acceptable.


HIRI


• Pilot 2008 – Findings (cont)

– Coding of diagnoses and extant bridge to ICD 9 was considered very valuable with respect to billing

– Difficulties with the coding of findings and observations coupled to the bridging to DxPlain made assessment of a ‘computable’ feature impossible


HIRI


• Pilot 2008 – Preferred direction

– Physicians proposed that a simpler browser aimed at collecting coded diagnoses would fit better within their practice

– Physicians felt that pre-coded acquisition templates, structured according to subject (e.g. diabetes, COPD, etc), would be an improvement over the stilted prose the browser produced


HIRI


• Post-Pilot 2008 direction

– After investigation of experiences in the UK and, in recognizing the problem of physician uptake with respect to any EHR, let alone a ‘computable’ record, it was felt that establishing a pan-Canadian effort to collect the ‘practice knowledge’ of health care professionals would better serve the physician community

– Archetypes and Templates were selected to serve as this new collection tool


HIRI


• Canadian Archetype Initiative

– Derived from work done elsewhere, notably in the UK.

– Unique characteristics include:

• Mandatory coding, compliant with Infoway guidelines

• Use of a ‘richer’ constraint language

• Enhanced user interface

– Secure network linking contributors to the repository managed by St-Mary’s for the CFPC


HIRI


Outline

• IT standards have had a major positive impact on many facets of health data capture, communication and analysis.

• Certainly, this led to better research with faster results.

• The question is whether current e-Health standardization efforts around semantic interoperability are equally beneficial.

• We believe, as is now recognized internationally, it is because of too much focus on business aspects and not enough meaningful involvement of different the types of clinicians, educators and researchers


HIRI


Some ‘dissident’ voices

• ‘Do we want industry writing the nation’s health IT standards? CCHIT’s “standards” are, in fact, mainly approvals of whatever industry is doing’. – Dana Blankenhorn. Who will control the coming health IT standards? ZDNet. February

27th, 2009 (http://healthcare.zdnet.com/?p=1905)

• ‘Kush and others had asked the AHIC earlier this year to form a federally sponsored workgroup to help integrate clinical research data needs into EHRs, but the panel did not grant the request. It was dominated by representatives of the health care delivery and payer communities.’ – Nancy Ferris. Post-AHIC health IT standards process gets under way.

http://govhealthit.com/articles/2008/11/postahic-health-it-standards-process-gets-under-way.aspx

http://healthcare.zdnet.com/?p=1905


HIRI


A widespread misconception

• ‘A variety of clinical terminology standards exist in the health care system, giving meaning to raw data and allowing for semantic interoperability.

• The Systemized Nomenclature of Medicine (SNOMED) + Clinical Terms (CT) is one example of a clinical reference terminology that provides for

semantic interoperability.’


HIRI


The sad consequences …

• Misunderstanding ‘concepts’, and excessive focus on information models, data models, etc.

• Leads to the many mistakes in concept-based terminologies;

• and many ambiguities in electronic patient records in which such terminologies are used.


HIRI


5572 04/07/1990 26442006 closed fracture of shaft of femur

5572 04/07/1990 81134009 Fracture, closed, spiral


5572 12/07/1990 9001224 Accident in public building (supermarket)

5572

04/07/1990

79001 Essential hypertension

0939 24/12/1991 255174002 benign polyp of biliary tract

2309 21/03/1992

26442006

closed fracture of shaft of femur


47804 03/04/1993 58298795 Other lesion on other specified region

5572 17/05/1993 79001 Essential hypertension

298 22/08/1993 2909872 Closed fracture of radial head



5572 01/04/1997 79001 Essential hypertension

PtID Date ObsCode Narrative

0939 20/12/1998 255087006 malignant polyp of biliary tract

Three references of hypertension for the same patient denote three times the same disease.

If two different fracture codes

are used in relation to

observations made on the same

day for the same patient, they

might refer to the same fracture

The same type of location code used in relation to three different events might or might not refer to the same location.

If the same fracture code is used for the same patient on different dates, then

these codes might or might not refer to the same

fracture.

The same fracture code used in relation to two different patients can not refer to the same fracure.

If two different tumor codes are used in relation to observations made on different dates for the same patient, they may still refer to the same tumor.

Using codes does not prevent ambiguities as to what is described: how many disorders are listed?


HIRI


Realism vs. Concept

A Little Philosophy


HIRI


Desiderata for Controlled Medical Vocabularies in the Twenty-First Century James J. Cimino 1998

Department of Medical Informatics, Columbia University, New York, USA

• Builders of medical informatics applications need controlled medical vocabularies to support their applications

• Vocabulary content, • concept orientation, • concept permanence, • Non-semantic concept identifiers, • Poly-hierarchy, • formal definitions, • Rejection of "not elsewhere classified" terms, • multiple granularities, • multiple consistent views, • context representation, • Graceful evolution, and • recognized redundancy.


HIRI


From Concepts to Clinical Reality: An Essay on the Benchmarking of Biomedical Terminologies

Barry Smith 2004 Department of Philosophy and National Center for Biomedical Ontology, University at Buffalo,

Buffalo, NY 14260, USA

Institute for Formal Ontology and Medical Information Science, Saarland

• The orthodox approach rests on the view that the fixation of meanings is best brought about through the alignment of terminologies on what are called ‘concepts’.

• ‘concept orientation’ was in some respects an important step forward in terminology development,


HIRI


Four loose families of “concepts” can be distinguished,

Linguistic view, concepts are general terms whose meanings have been somehow regimented (or, as in some variants of the view, they are these meanings themselves).

Psychological view, concepts are mental entities, analogous to ideas or beliefs.

Epistemological view, concepts are units of knowledge (as the latter term is used in phrases such as ‘knowledge representation’, ‘knowledge modeling’, ‘knowledge-based systems’, and the like

Ontological view, concepts are universals, kinds, attributes or properties (i.e. they are something like general invariant patterns) on the side of entities in the world.


HIRI


• Each one of these views might, in and of itself, be in a position to sustain a coherent methodology for the fixation of meanings in terminologies.

• However, elements of all four views are to be found mixed together in different combinations in the standard literature, in ways which provide strong evidence for the thesis that no single reading of the term ‘concept’ can sustain all of the expectations which have become associated with its use


HIRI


‘‘When I use a word,’’ Humpty Dumpty said in a rather scornful tone, ‘‘it means just what I choose it to mean—neither more nor less.’’

‘‘The question is,’’ said Alice, ‘‘whether you can make

words mean so many different things.’’ ‘‘The question is,’’ said Humpty Dumpty, ‘‘which is to

be master—that is all.’’ Lewis Carroll


HIRI


MODELS

“Man tries to make for himself in the way that suits him best a simplified and intelligible picture of the world and thus to over come (sig. understand) the world of experience, for which he tries to some extent to substitute this cosmos (sig. picture) of his. This is what the painter, the poet, the speculative philosopher and the natural scientist do, each in his own fashion... one might suppose that there are any number of possible systems... all with an equal amount to be said for them; and this opinion is no doubt correct, theoretically. But evolution has shown that at any given moment out of all conceivable constructions one has always proved itself absolutely superior to all the rest.”

Einstein, A. “The World as I See It” (1931)


HIRI


The Ogden and Richards (1923) semiotic triangle


HIRI


Three levels of reality From Werner CEUSTERShttp://www.org.buffalo.edu/RTU 1. The world exists ‘as it is’ prior to a cognitive agent’s

perception thereof;


HIRI

16-Nov-2010 MEdbASE Research Werner Ceusters

Reality exist before any observation; From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

R


HIRI


Reality exist before any observation From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

• Humans had a brain well before they knew

they had one.

• Trees were green before humans started to use the word “green”.

R

And also most structures in reality are there in advance.


HIRI


Three levels of reality

From Werner CEUSTERShttp://www.org.buffalo.edu/RTU 1. The world exists ‘as it is’ prior to a cognitive agent’s

perception thereof;

2. Cognitive agents build up ‘in their minds’ cognitive representations of the world;


HIRI


From Werner CEUSTERS http://www.org.buffalo.edu/RTU

The ontology author acknowledges the existence of some Portion Of Reality (POR)

R

B


HIRI


From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

R

B

Some portions of reality escape his attention.


HIRI


Three levels of reality From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

1. The world exists ‘as it is’ prior to a cognitive agent’s perception thereof;

2. Cognitive agents build up ‘in their minds’ cognitive representations of the world;

3. To make these representations publicly accessible in some enduring fashion, they create representational artifacts that are fixed in some medium.


HIRI


He represents only what he considers relevant; From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

R

O

B

#1

RU1B1

RU1O1

R

O

B

#1

RU1B1

RU1O1

• Both RU1B1 and RU1

O1 are representational units referring to #1;

• RU1O1 is NOT a representation

of RU1B1;

• RU1O1 is created through

concretization of RU1B1 in some

medium.


HIRI


THUS

• These concretizations are NOT supposed to be the representations of the cognitive representations;

• We should not be in the business of concept representation

• Or should we?


HIRI


• Purpose:

– explicit reference to the concrete individual entities relevant to the accurate description of each patient’s condition, therapies, outcomes, ...

Proposed Solution: Referent Tracking ! From Werner CEUSTERShttp://www.org.buffalo.edu/RTU


HIRI


78

Numbers instead of words From Werner CEUSTERShttp://www.org.buffalo.edu/RTU • Method:

– Introduce an Instance Unique Identifier (IUI) for each relevant particular (individual) entity


HIRI


‘John Doe’s ‘John Smith’s liver liver tumor tumor was treated was treated with with RPCI’s RPCI’s irradiation device’ irradiation device’

‘John Doe’s liver tumor was treated with RPCI’s irradiation device’

The principle of Referent Tracking From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

#1

#3

#2

#4

#5

#6

treating

person

liver

tumor

clinic

device

instance-of at t1

instance-of at t1

instance-of at t1

instance-of at t1

instance-of at t1

#10

#30

#20

#40

#5

#6

inst-of at t2

inst-of at t2

inst-of at t2

inst-of at t2

inst-of at t2


HIRI


In defense of the Desiderata James J. Cimino * 2005

Departments of Biomedical Informatics and Medicine, Columbia University, New York, NY 10032, USA

“I suggest a path that acknowledges the importance of representing reality, as best we can know it,

but accepts the need for concepts to help us, among

other things, reason under uncertainty. I consider this the

realistic path.”


HIRI


COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE

IMMEDIATE STEPS AND STRATEGIC DIRECTIONS

William W. Stead and Herbert S. Lin, Editors

Committee on Engaging the Computer Science Research Community in Health Care Informatics

Computer Science and Telecommunications Board

Division on Engineering and Physical Sciences

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS

Washington, D.C. www.nap.edu

2009

http://www.nap.edu/


HIRI


Principle 1:

Focus on Improvements in Care—Technology Is Secondary

• The most important principle for guiding evolutionary change in health care is to focus efforts on achieving the desired improvements in health care rather than on the adoption of health care IT as a goal in itself.


HIRI


Principle 2:

Seek Incremental Gain from Incremental Effort

• If programs can be structured so that small investments yield visible success, stakeholders and the relevant decision makers are more likely to be persuaded to continue along such a path.


HIRI


Principle 3: Record Available Data So That They Can Be

Used for Care, Process Improvement, and Research

• Systematic improvement of health care is data-driven.

• providers should aggregate as much data as feasible about people, processes, and outcomes from all sources,

• acknowledging the never-ending challenge of maintaining reasonable degrees of patient confidentiality in such a data collection effort.


HIRI


Principle 4:

Design for Human and Organization Factors • design systems to support people in doing the right

thing

• provide incentives for and eliminate barriers to doing those things.

• barriers and incentives can be sociological, psychological, emotional, cultural, legal, economic, or organizational.

• Human-centered design pays attention to all of these factors as they relate to technical function and form.


HIRI


Principle 5: Support the Cognitive Functions of All

Caregivers, Including Health Professionals, Patients, and Their Families

• cognitive support needs to center on high-level decision making (e.g., diagnosis) for populations, patients, or situations,

• cognitive support needs to span transactional tasks such as test ordering or prescribing.

• cognitive support is not well served by the task-specific automation systems that make up the majority of today’s health care IT.


HIRI


Principle 6:

Architect Information and Workflow Systems to Accommodate Disruptive Change

• architect health care IT for flexibility to support disruptive change rather than to optimize today’s ideas about health care.

• it is axiomatic that health care will change dramatically into the future.


HIRI


Principle 7:

Archive Data for Subsequent Re-interpretation • health care IT should provide the capability of

recording any data collected in their measured, un-interpreted, original form, archiving them as long as possible to enable subsequent retrospective views and analyses of those data.

• Advances in biomedical science and practice will change today’s interpretation of data.


HIRI


Principle 8: Seek and Develop Technologies That Identify

and Eliminate Ineffective Work Processes • develop technologies that allow identification and

elimination of ineffective work processes and implementation of new approaches to achieving their purpose.

• automation of work processes developed in an era when paper was the medium for communicating and archiving is fraught with cost and unintended consequences.


HIRI


Principle 9:

Seek and Develop Technologies That Clarify the Context of Data

• develop technologies that present new information in the context of other information available about the patient and relevant biomedical knowledge.

• the combination of new biomedical technologies, together with increased access to data through health care IT, is increasingly overwhelming health professionals’ ability to make sense of individual findings e.g. “Alert fatigue”

• New approaches are needed to present information in context so that patterns and choices stand out.


HIRI


Summary of EMR generations • First generation: The Collector - simple systems that provide a site-

specific solution for the need to access clinical data which is imported through scanning or other forms of aggregation

• Second generation: The Documenter - basic systems that clinicians use at the point of care to adequately document rather than merely access clinical data

• Third generation: The Helper - Systems that include episodic and encounter data and use decision support tools to assist clinicians, functional in at the minimum both ambulatory and inpatient settings

• Fourth generation: The Partner - Advanced systems that provide more decision support capabilities and that are operational and accessible across the continuum of care, and providing sufficient credibility as to become the patient's legal medical record

• Fifth generation: The Mentor - Complex and fully integrated systems that include all previous capabilities and that are a main source of decision support in guiding patient care for both clinicians and consumers


HIRI


13th International Congress on Medical Informatics September 2010

Cape Town, South Africa

Documents

Lessons Learned from Pilot Project using SNOMED-CT for ... · Lessons Learned from Pilot Project using SNOMED-CT for Clinical Observations Fall 2010 Infoway Partnership Conference