1. The Role of Standard Terminologies in Facilitating Integration James J. Cimino, M.D. Departments of Biomedical Informatics and Medicine Columbia University

2. Integration of… …data with each other …systems that exchange data …data with decision support systems …data with health information resources

3. The Re-Use of Clinical Data l Have to query a longitudinal database l Want to collect data from multiple sources l Need automated alerts l Should link to on-line information resources

4. The Format of Information

5. Re-Use of Nonstandard Information 21 22 23 24 25 26 27 28 29 76543217654321

6. Blobs and Symbols Text Numeric SignalStructuredCodedStandard Coded NLP Interpretation Image Blobs Symbols

7. The Strange Case of MRSA l Database with 15 years of laboratory results l Medical knowledge changes over time l Information systems change over time l Institutions merge their data

8. Multiple Representations of MRSA 1) Culture: Specimen: Blood Organism: S. aureus Sensitivity test: Methicillin Result: Resistant 2) Blood Culture: Organism: S. aureus Sensitivity test: Methicillin Result: Resistant 3) Blood Culture: Result: “MRSA” 4) Blood Culture: Organism: Methicillin-Resistant-Staph-Aureus 5) MRSA Culture: Positive

9. Result Table Result Code Value 1 1 1 Culture 3 3 S. aureus MRSA Positive: Solution 1 Terminology Table Term Code Term Name 4 Methicillin 4 5 Resistant 5 2 2 Blood Spec.

10. Terminology Table Term Code Term Name Result Table Result Code Value 6 6 Blood Cult 3 3 S. aureus MRSA Positive: Solution 2 4 4 Methicillin 5 5 Resistant

11. Terminology Table Term Code Term Name Result Table Result Code Value “MRSA” 6 6 Blood Cult MRSA Positive: Solution 3

12. 6 Terminology Table Term Code Term Name Result Table Result Code Value 6 Blood Cult 7 7 MRSA MRSA Positive: Solution 4

13. Terminology Table Term Code Term Name Result Table Result Code Value 8 8 MRSA Cult 9 9 Positive MRSA Positive: Solution 5

14. Longitudinal Database Terminology Table Term Code Term Name 1 Culture 2 Blood Spec. 3 S. aureus 4 Methicillin 5 Resistant 6 Blood Culture 7 MRSA 8 MRSA Cult. 9 Positive Result Table Result Code Value 1 2 1 3 4 5 6 3 4 5 6 “MRSA” 6 7 8 9

15. Coding with Standards: Gender l Data element - gender l Controlled terminology: Male, Female, Unknown l Representation: M,F,U; 0,1,2 l What about other values? – Genotypic – Phenotypic – Administrative

16. What Standards are Out There? l ICD9-CM – Strict hierarchy – Coarse granularity – “Not Elsewhere Classified” l CPT – Procedures for billing – No hierarchy l NDC – Products-oriented – No classification – Codes reused – Revisions in progress l UMLS

17. What Standards are Out There? l UMLS – Subsumes many standards – Provides extensive synonymy – No hierarchy – Near-synonymy l RxNorm – Cooperation of NLM, FDA and VA – Defines clinical drugs – Mapping to pharmacy knowledge bases

18. What Standards are Out There? l LOINC – Good domain coverage of laboratory – Principled design – Working on hierarchy – Extending to all observations l SNOMED-CT – Merger of SNOMED and Read Clinical Terms – Rich semantics – Principled design – Public domain – Coordination with other terminologies

19. What Could We Do With Standards? l Summary data reporting

20. Lab Summary 1995

21. Lab Summary 1998

22. What Could We Do With Standards? l Summary data reporting l Exchange of information l Automated decision support l Integration with of health information resources

26. Take Home Message l Standards are hard to do l Not much out there l Can do neat things if standardized

27. Learning More SNOMED: http://www.snomed.org/http://www.snomed.org/ UMLS: http://www.nlm.nih.gov/research/umlshttp://www.nlm.nih.gov/research/umls LOINC: http://www.regenstrief.org/loinc/loinc.htmhttp://www.regenstrief.org/loinc/loinc.htm MED: http://www.cpmc.columbia.edu/homepages/ciminoj/med.htmlhttp://www.cpmc.columbia.edu/homepages/ciminoj/med.html Standards: http://www.hl7.org/standards/developer.htmhttp://www.hl7.org/standards/developer.htm