Introduction to Medical Informatics Standards

Dr Tan Yung Ming

Learning Objectives
Understand the importance of standards in healthcare Gain an overview of the various informatics standards Appreciate the differences between terminology standards and their uses Gain a better appreciation of SNOMED CT

Examples of standards through history

Internet protocol WiFi Power plugs

Benefits and limitations of standards

Benefits Interoperability May allow innovation based on common foundation
Limitations Dominance by one segment of industry May stifle innovation May be a mixed bag Microsoft standards, e.g., Windows, Office, etc. One of best things about standards is that there are so many of them

The Healthcare Data Standards Solar System

Read UML

LRA
SNOMED

V3

HL7 V2

ICD10
CDS

DS&P

OPCS

Data Dictionary

openEHR

EHR

IHE

ISO Data Types

What is the Main Purpose of Data Standards?

Exchange of Data & Meaning
(Data & Semantic interoperability)
enables

Effective Work Processes

(Social/process interoperability)

Data Communications Simplified

THINK about the traditional snail mail. To send a friend a letter, you need to specify: Your friends and your name (Identifiers) Words written in a language he/she understands (Terminology/vocabulary) Write in on paper and place it into an envelope with a stamp & address of destination. (Message exchange format)

Postal service will deliver it (Infrastructure/Network)

Standards covered here

Identifiers (Sender & Receivers names) Terminology (Written Content) Message Exchange (Envelope)
Note: the hardware infrastructure/networks (Postal service) are fairly standardised internationally and will not be covered here.

Identifiers
Unique identifiers needed for: Patients: eg. NRIC, FIN, passport no. Providers: OID (ISO/ITU), Unique Entity No. (Spore) Businesses/Employers: OID, UEN - CDA Document headings eg. OID

What is OID?
An OID (object identifier) is a numeric string that is used to uniquely identify an object Eg. MOH OID - 2.16.840.1.113883.3.115 ISO and ITU manage & assign OIDs to organizations (root OIDs) eg. MOH These organizations (eg. MOH) can then assign OIDs to objects or further delegate to other institutions under their charge. (branches or arcs)

For eg. MOH can create OIDs for healthcare institutions by adding the UEN to their root id.
No limit to the number of digits scalable Needed in HL7 RIM v3, CDA message formats

What is UEN?
UEN = Unique Entity Number is the standard unique identification number of an entity. Example - the UEN for a company could be T09LL0001B.

Usually 9-10 digits

From 1 Jan 09, all entities that are registered in Singapore, such as businesses, societies, healthcare institutions and trade unions, will have a UEN as its identification number. The UEN shall be used for your interaction with government agencies.

More info - http://www.uen.gov.sg

Medical informatics standards covered here

Identifiers Terminology (Written message content) Message exchange

Terminology (Message content)

Why do clinicians record data? What are the various types of terminology? How do we classify them? DRG ICD SNOMED CT LOINC

Why do Clinicians record patients data?

Primary Uses:
Memory aid

Legally document what they heard, saw, thought and done ( recall S.O.A.P in clinical notes.)
Communicate to other members of a team Required by protocols & policies

Secondary Uses of Data

Financial & Billing : eg. discharge summary diagnoses used for reimbursement. Primary purpose for clinicians more for documentation +/communication, (not reimbursement secondary use).
Reporting/ Surveillance: Communicable disease reports can be derived from routine lab culture reports. Primary purpose: communication to the ordering physician, (not epidemic detection)

Analytics/Decision support

Terminology Classification by Domain

Diagnosisrelated groups (DRG)

Original intent was to aggregate ICD9 codes into groups for health services research.
Now used for billing & govt funding purposes in some countries

Less granular & specific: One DRG code can represent many ICD codes.
For example if the govt decides to fund chronic diseases diabetes, hypertension, All lumped into one DRG code even though they are stroke different diagnoses with different ICD codes

International Classification of Diseases (ICD)

Originated in 1893 as International List of Causes of Death Initial primary purpose was to compile mortality statistics Eventually taken over by WHO
Now called International Classification of Diseases (ICD) Has evolved as means to code diseases for more than just cause of death

ICD9 and its variants

ICD9 approved by WHO in 1975 ICD9 has fourdigit codes
ICD9CM (clinical modifications) is a U.S. variant with more detailed terms and fivedigit codes Most reimbursement entities require health care provider to assign ICD9CM codes

Has additional set of V codes for encounters related to prevention and screening G codes document provision of specific services, such as quality measures

Example of ICD9CM
Diseases of the circulatory system (390459)
Ischemic heart disease (410414) (410) Acute myocardial infarction (410.0) MI, acute, anterolateral (410.1) MI, acute, anterior, NOS (410.2) MI, acute, inferolateral (410.3) MI, acute, inferoposterior (410.4) MI, acute, other inferior wall, NOS (410.5) MI, acute, other lateral wall (410.6) MI, acute, true posterior (410.7) MI, acute, subendocardial (410.9) MI, acute, unspecified (414) Other forms of chronic ischemic heart disease + (414.01) Coronary atherosclerosis, native coronary artery + (414.02) Coronary atherosclerosis, autologous vein bypass graft + (414.04) Coronary atherosclerosis, artery bypass graft

ICD10
http://www.who.int/classifications/icd/en/ http://www.cms.hhs.gov/ICD10/ Adopted by WHO in 1990, now used by most developed countries except US

Singapore planning a migration from ICD9CM to ICD 10 in 2010

Significant changes in structure from ICD9

Augmentation of ICD10 includes (CMS, 2008) ICD10CM for diagnosis codes 37 digits ICD10PCS for procedure codes 7 digits, alphanumeric General Equivalence Mappings (GEM) for translation from ICD9

Problems with ICD

(1) ICD is enumerative, leading to scalability issues Attempts to list down every possible term or phrase for use within a domain. Can result in very detailed phrases: ICD-10-AM code 'X24.24' 'Contact with centipedes and venomous millipedes (tropical), school, other institution and public administrative area, while resting, sleeping, eating or engaging in other vital activities' Scale problems: Despite running up to > 250,000 discrete phrases, users still complain that they cant find a particular phrase they want Users often have to use a one high level code for most cancers.

'not otherwise specified', 'not elsewhere classified' and 'other codes good for statistical grouping & data analysis. But bad for capturing clinical details for health records.

Problems with ICD

(2) ICD is Uni-axial - meaning that any specific code is restricted to having one and only one parent code Leads to Organisational problems: For example, in ICD10, the code: A15.2 Tuberculosis of lung, confirmed histologically ...is classified ONLY in: Chapter I Certain infectious and parasitic diseases and is NOT classified below:

Chapter X Diseases of the respiratory system

...even though tuberculosis of the lung is clearly a kind of both types.

Problems with ICD

(3) ICD codes are restricted to a fixed length.

Any single ICD code can have a maximum of 10 children (numbered 0-9 after the original parent code stub),
You are unable to add 11 or more related terms underneath the parent in the hierarchy. (4) The organisational hierarchy does not clearly specify the relationships between terms/phrases. Eg. modifiers for location, severity, casual
relationships

Anatomy -Cardiovascular Anatomy --Blood Vessel --Heart ---Heart Valve ----Pulmonary Valve ----Aortic Valve -----Cusp of Aortic Valve

Heart Valve is a part of the Heart

Aortic valve is a kind of Heart Valve

SNOMED CT = Systematised Nomenclature of Medicine Clinical Terms

Rich vocabulary for describing clinical observations and findings vs. ICD which is more suitable for classification & statistical groupings.

Originally developed by College of American Pathologists (CAP). Now Managed by IHTSDO. (www.ihtsdo.org) Merger of READ codes and SNOMED

About SNOMED CT
Support one concept - multiple languages
Multiaxial hierarchy - each concept can have more than one parent as well as more than one child. Enumerative & Compositional hybrid terminology The old enumerative READ code schemes are merged into the compositional structure of SNOMED

Allows primitive terms to be combined, e.g., lung + inflammation

Allows qualifiers/modifiers to be added explicitly, e.g., severe, worsening

Clearly defined relationships between concepts

SNOMED Browsers
Cliniclue browser (rich client) www.Cliniclue.com SnowFlake (web based) browser http://www.snoflake.co.uk/

Comparing ICD vs SNOMED

ICD
Used for Diagnosis coding & Disease Classification

SNOMED
Used for documenting clinical observations with rich vocabulary

Enumerative design: concepts are Enumerative-Compositional: added and numbered in a long and beyond just the listing of concepts, big list. Compositional design involves creating primitive terms that can be combined into composite expressions. Uni-Axial: each concept has one and only parent. Each parent has a fixed no. of children Code has a fixed length of digits Multi-axial: each concept can have more than one parent as well as more than one child. Code has no fixed length.

Note: SNOMED is not superior to ICD. They are used in different ways and cannot be compared as apples to oranges.

Logical observations, identifiers, and numerical codes (LOINC)

http://www.regenstrief.org/loinc/ (Stark, 2006)
For each test, specify Property e.g., mass concentration, numeric fraction Time point in time Specimen e.g., blood, cerebrospinal fluid Method e.g., qualitative, quantitative

LOINC Examples

Blood glucose GLUCOSE:MCNC:PT:BLD:QN: Serum glucose GLUCOSE:MCNC:PT:SER:QN: Urine glucose concentration GLUCOSE:MCNC:PT:UR:QN: Urine glucose by dip stick GLUCOSE:MCNC:PT:UR:SQ:TEST STRIP Ionized whole blood calcium CALCIUM.FREE:SCNC:PT:BLD:QN: 24 hour calcium excretion CALCIUM.TOTAL:MRAT:24H:UR:QN: Automated hematocrit HEMATOCRIT:NFR:PT:BLD:QN:AUTOMATED COUNT Manual spun hematocrit HEMATOCRIT:NFR:PT:BLD:QN:SPUN Erythrocyte MCV ERYTHROCYTE MEAN CORPUSCULAR VOLUME:ENTVOL:PT:RBC:QN:AUTOMATED COUNT ESR by Westergren method ERYTHROCYTE SEDIMENTATION RATE:VEL:PT:BLD:QN:WESTERGREN

Terminology in Summary
Purpose

Resource & Funding Purposes

Epidemiology analysis & management purposes Record & retrieve dayday clinical details & information

Grouping Terminology

Terminology DRG

>1k of codes
Classification Terminology >10k of codes EMRs Working (Reference) Terminology SNOMED, LOINC ICD

> 300k concepts

Medical informatics standards covered here

Identifiers Terminology Message exchange (the envelope)

Message exchange standards

Allow data and application interoperability
Major standards include: Health Level 7 (HL7) v2, v3 RIM, CDA Digital Imaging and Communications (DICOM) for radiology Continuity of Care Record (CCR) and Continuity of Care Document (CCD)

Health Level 7 (HL7, www.hl7.org)

Version 2 is a syntax for health data exchange Current version (2.5) is Supported by most vendors for interchange of data Implemented by bardelimited ASCII files Limited by no semantics, i.e, no definition of terms or how messages are used

What does HL7 stand for?

A domain-specific, common protocol for the exchange of health care information.

Function

Communication

7 6 5 4 3 2 1

Application Presentation Session Transport Network Data Link Physical

ISO-OSI Communication Architecture Model

HL7 version 2.5 example

MSH|^~&\|DHIS|OR|TMR|SICU|199212071425|password|ADT|16603529|P|2.1<c> EVN|A02|199212071425||<cr> PID|||Z99999^5^M11||GUNCH^MODINE^SUE|RILEY|19430704 |F||C|RT. 1, BOX 97^ZIRCONIA^NC^27401 |HEND|(704)9821234|(704)9831822||S|C||24533 9999<cr> PV1|1|I|N22^2204|||OR^03|0940^DOCTOR^HOSPITAL^A|||SUR|||||A3<cr> OBR|7|||93000^EKG REPORT|R|199401111000|199401111330|||RMT||||19940111 11330|?|P030||||||199401120930||||||88126666|A111|VIRANYI^ANDREW<cr> OBX|1|ST|93000.1^VENTRICULAR RATE(EKG)||91|/MIN|60100<cr> OBX|2|ST|93000.2^ATRIAL RATE(EKG)||150|/MIN|60100<cr> ... OBX|8|ST|93000&IMP^EKG DIAGNOSIS|1|^ATRIAL FIBRILATION<cr>

HL7 version 3 (Hinchley, 2005)

Attempts to introduce semantics (meaning or semantic interoperability) beyond syntax of version 2 Based on Reference Information Model (RIM), an object model of entities that pass messages (Mead, 2005) Implemented in eXtensible MarkUp Language (XML)
Thought by many to be complicated, by some overly So Some aspects have been called incoherent (Smith, 2006)

Overview of the RIM (Mead, 2005)

RIM uses objectoriented approach to define health care interactions based on five abstract classes: Entity things in world, e.g., people, organizations, other living subjects Role capability or capacity, e.g., patient, practitioner Participation role in context of an act, e.g., performer, target Act clinical or administrative definitions, e.g., observation, diagnosis, procedure Act relationship links between acts, e.g., diagnosis act All clinical, administrative, financial, etc. activities of health care can be expressed in model, as defined in v3 Normative Edition (HL7, 2005)

Participation = A Role in Context of an Act

An Entity (Person or Organization) plays zero-to-many Roles
0..* Entity 1 Role 1 0..* 1 1..* Healthcare Action

Participation

Staff

Doctor

Performer

Examines Patient

Minimise ambiguity: A Staff who is a doctor performs the physical examination of a patient Compare with HL7 V2 messages which do not clearly specify the context & relationships

Digital Imaging and Communications (DICOM)

Developed by American College of Radiology (ACR) and National Electrical Manufacturers Association (NEMA) Defines how images and associated data are moved between electronic devices, including information systems Used in most radiology picture and archiving systems (RIS-PACS: Radiology Information System picture archiving and communication systems)

Clinical Document Architecture (CDA; Dolin, 2001; Dolin, 2006)

Much health care information is in documents CDA defines XMLbased standard structure and metadata for clinical documents Unstructured documents can be wrapped in CDA framework Recent release of version 2 (Dolin, 2006) Specifications include characteristics of Persistence Stewardship Authentication Wholeness Readability

Continuity of Care Record (CCR)

CCR is a set of basic patient information consisting of the most relevant and timely facts about a patients condition http://www.medrecinst.com/pages/about.asp?id=54
To be used when patient is referred, transferred, or discharged among health care providers and/or facilities Contains basic or essential information for providing continuity of care

CCR is an XML document but fields are free text Concerns about lack of structured data that may prohibit interaction with rest of EHR and incompatibility with other standards, such as HL7 and CDA Standardization has been granted by ASTM E31

CCD
The HL7 Continuity of Care Document (CCD) is the result of a collaboration between HL7 and ASTM.
CCD harmonizes the data format between ASTMs Continuity of Care Record (CCR) and HL7s Clinical Document Architecture (CDA) specifications. With CCD, the CCR is represented and mapped into the HL7 CDA. These are structured XML standards for clinical information exchange.
Sample CCD

Summary
Informatics Standards are essential for Interoperability
Key standards are needed for Identifier data, Message exchange, Terminology. Important message exchange standards in healthcare include HL7, DICOM, CCR/CDA. Terminology considerations are important in the design of electronic medical record systems

Thank you.

More on SNOMED

SNOMED CT use in Spore

For the public health sector, MOHH has specified:
Clinical notes and diagnoses should be coded in SNOMED Billing & statistical reporting needs to be migrated to ICD10 AM

Power of a compositional terminology like SNOMED

The power of SNOMED lies in the ability to compose new concepts by combining primitive terms to meet future vocabulary needs.
Ways of doing this: Pre-coordination combine primitive concepts into one new concept with a new code, and releasing it into the systems for use Post-coordination combine primitive concepts real-time within systems and allow exchange of new compositional codes. Compositional grammar needed.

Problems with using compositional grammar

Compositional explosion billions of new concepts can be created on the fly, with possible duplication and contradictions. Are our systems ready to handle complex compositions of codes for one diagnosis? What are the breaking points? The idea of post coordination is still largely academic as not many systems are capable of handling such ideas yet. But something to think about in the future.