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					  ISO TC 215 Working Group 3
  Medical Concept Representation
   Working Group Summary
   ISO Working Groups’ Meeting
   Pretoria, South Africa


ISO Health Terminology             1
 Overview
  The Importance of Standards
  The Place of Terminology in the Stream

  Context as part of Information Content

  ISO TC 215 WG3




ISO Health Terminology                      2
 Health Care Is An Information Intensive
 Industry

 Controlof Health Care Costs ...
 Improved Quality of Care ...
 Improved Health Outcomes ...
 Appropriate Use of Health Technology...
 Compassionate Resource Management...
... depend upon information
… Ultimately Patient Data

ISO Health Terminology                      3
 Information Beyond Practice
 Secondary Re-use as Primary A Interest
  Data Collected for Clinical Care Forms the
   Basis for Patient Experience Repositories
  The Importance of a Well Characterized,
   High Quality Patient Experience
   Repository May Exceed the Value of the
   Primary Information Many Fold

ISO Health Terminology                          4
 Repositories of Patient Information
  Disease   Natural History
  Treatment Response (non-RCT)
  Basis for Guidelines, Clinical Paths, Best
   Practice
  “Just in Time” Source for Decision Support
    Have   we seen a patient just like this…
  Efficient   and Effective Care Delivery
ISO Health Terminology                          5
 Prospective Clinical Trials vs
 Patient Data Repository
  StillRequire Consistent and Comparable
   Information
  Most Reliable if Captured in and for the
   Process of Care
    Requires  Terminology Services Integrated
      into Record System
  Efficiencies   from Non Boutique Approach
ISO Health Terminology                           6
 Medical Concepts
 Events, Observations, Interventions
    How should we represent it? Language:
        Nuance, detail, unfettered combination
        Timely, current, never obsolete
        Natural, friendly, established
        [Ambiguous, imprecise, unpredictable]
    Codes:
      Concise, precise
     Structured, consistent, well formed
     Analyzable, manipulable
     [Rigid, tedious, high maintenance]
ISO Health Terminology                            7
 Medicine is[was] Mostly
 Folklore and Anecdote
 BasicPathophysiology
 Molecular Medicine        Clinically   Indirect

 Outcomes    Analyses
 Best Practices
  Evaluation (CQI)
                            No   Data
 Clinical Epidemiology

ISO Health Terminology                          8
 Clinical Data Needs
 Clinical Informatics and EMRs
 Electronic   Patient
  Records                  No Standards
 Structured Source of     No Conventions
  Patient Presentations    No Consistency
  and Recorded             Limited
  Outcomes                  Architectures
                            (epage turners)
ISO Health Terminology                    9
 Health Info. Standards Efforts Are Active!
 US and International
ANSI HISB
 HL/7
                           NO   CONTENT
 IEEE MIB

 DICOM

 ASTM

ISO TC 215
ISO Health Terminology                        10
 Content Standards Do Exist
 National Repositories (HCFA)
 ICD-9-CM
                          Clinically
 CPT
                          Impoverished
 DRGs



 HCFA   Datasets
                          Biased
 MIBs

ISO Health Terminology                   11
 Heritage of Continuous Improvement
 Central Role of Terminology
                  Clinical   Observational
                 Database       Data


      Patient                       Medical Knowledge
    Encounters
                    Terminology

                  Expert        Clinical
                 Systems       Guidelines

ISO Health Terminology                             12
 Clinical Process and Outcome
 Well-Established Traditions
   Practice Description
   Outcomes Research
   Continuous Quality Improvement
   Health Services Research
   Clinical Epidemiology
   Resource Management
   Guideline Development


ISO Health Terminology               13
 The Historical Center of the
 Health Data Universe Billable Diagnoses


    Clinical Data




ISO Health Terminology                 14
 Copernican Healthcare
   (Niklas Koppernigk)
                         Clinical Data

  Billable Diagnoses




ISO Health Terminology                   15
 Cycle of Longitudinal Care


               Presenting
                                       Evaluate Findings
               Conditions

Demographics


               Outcomes                      Working
                                            Diagnoses

                            Interventions
ISO Health Terminology                                  16
 Medical Event Representation
 Clinical Concept
    The Clinical Concept subsumes
     presenting  condition
     serial course
     subsequent outcomes
    Not restricted to patient condition at arbitrary
     point, e.g.:
     admitting diagnosis
     discharge diagnosis
     follow-up status


ISO Health Terminology                                  17
 Value Proposition

 “Those with more detailed, reliable and
   comparable data for cost and outcome
   studies, identification of best practices,
   guidelines development, and management
   will be more successful in the
   marketplace.”
            SP Cohn; Kaiser Permanente
ISO Health Terminology                      18
 Strategic Role of Vocabulary

  Interfaceto Knowledge Resources
   Guidelines, Critical Paths, Reminders
   Decision Support, Reference
  Support Practice Analysis
   Quality Improvement
   Clinical Epidemiology
   Outcomes Analyses


ISO Health Terminology                      19
 Terminology as Crucial Requirement
  Without  Terminology Standards...
  Health Data is non-comparable
  Health Systems cannot Interchange Data
  Secondary Uses (Research, Efficiency)
   are not possible
  Linkage to Decision Support Resources
   not Possible
ISO Health Terminology                      20
 Continuum from
 Nomenclature to Classification
  Patient   Data is Highly Detailed
    Modifiers: Anatomy, Stage, Severity, Extent
    Qualifiers: Probability, Temporal Status

  Aggregate      Uses Require Categorization
    Granularity   of Classifiers
        Focused Groups and Strata for CQI/Outcomes
        Broad Statistical/Fiscal Groups

ISO Health Terminology                                21
 Familiar Points Along Continuum
 Modern Health Vocabularies
  Nomenclature – Highly Detailed
   Descriptions (SNOMED)
  Classification – Organized Aggregation of
   Descriptions into a Rubric (ICDs)
  Groupings – High Level Categories of
   Rubrics (DRGs)
         Nomenclature    Classification Groups
  Detailed                                 Grouped
ISO Health Terminology                          22
 Terminology Systems Relationships
 Functional Role in Use

 Entry Terminology
    Humans                     Machines

                 Reference Terminology


                             Aggregate and
                             Administrative
                Applications Terminology
ISO Health Terminology                        23
                         Abstraction Layers
                         Narrow Boundary of Ideal, Human Recording
                                                             High Level Groups,
                           Machine Abstracted,               e.g. DRGs
Increasing Abstraction




                             Algorithmically
                                Derived              Clinical
                                                  Classifications
                             Classifications
                                                 Surveys, Scales,
                                                  and Datasets
                           Humanly         Clinical Observations and
                           Recorded       Patient Record Recording
                                          Molecular, Genomic, Cellular
                                                   Increasing Detail and Richness
      ISO Health Terminology                                                        24
 Information Model and Content
  Content Requires Context for Understanding
  Terminologic    Representation
    Maternal History Heart Disease
    Modifier Disease

  Information   Model Representation
    Enumerated  within “Family History: Maternal”
     Heart Disease
    Role of Heart Disease Implicit within Model

ISO Health Terminology                           25
 Content vs. Structure
 Contest or Synergy? Computer Equivalent?
  Family History of Breast Cancer
  Family History of Heart Disease
  Family History of Stroke
 vs.
          Family History
          Breast Cancer
          Heart Disease
          Stroke
ISO Health Terminology                  26
 Interaction of Standards
 Terminology and Information Model
  One Cannot Have Terminology Only
   Standards (Simple Naming Lists)
  One Cannot Have Information Model Only
   Standards (Pure Abstractions)
  Requires a Common Framework For
   Standards Development
  Roles of TC 215, HL7, CEN, …

ISO Health Terminology                  27
 ISO TC215 WG3
 History
  Formative    Meetings:
    Bermuda,  1996
    Kyoto, 1997

  Formed,    January 1998
        Meeting – Orlando, August
    First

    WG3 one of the early work groups



ISO Health Terminology                  28
 Mission
    Standardization in the field of information for
     health, and Health Information and
     Communications Technology (ICT) to achieve
     compatibility and interoperability between
     independent systems. Also, to ensure
     compatibility of data for comparative statistical
     purposes (e.g. classifications), and to reduce
     duplication of effort and redundancies.
ISO Health Terminology                               29
 Standards Requirement from
 International Context
          of Health Data Interchange are
  Problems
   Compounded by National Boundaries
    Laws and Requirements
    Customs and Practices

    Languages and Dialects

         that Terminology must be
  Implies
   Concept-Based
ISO Health Terminology                     30
 Concept-Based Terminology
 International Context
  Catalog of Abstractions:
  Independent of any Language
  Linkable to Local “Synonyms”
    Practical   Attachment to National Language
  ReadilyExchangeable across National
   and Language Boundaries
  Commonly Accessible Knowledge Bases

ISO Health Terminology                             31
 ISO TC215 WG3
 Working Group Strategy
  Focus  on Meta-standards
  Will not Develop “Content”

  No Intention to create an ISO Terminology
   for Healthcare




ISO Health Terminology                     32
 WG3 NetMeeting Modality
 Global Portal to All WG3 Meetings
    Use MS NetMeeting as Platform
     FreeDownload from MS
     Mayo Provided Common Server

  Basis of Shared Document Viewing and
   Editing–Word and PowerPoint, Whiteboard
  Invoke Simultaneous Conventional
   Teleconference [Mayo Operator]
  Eschew Live Video

ISO Health Terminology                       33
 WG3 Current Work Items
 Quality Indicators for Terminology
  Standard Criteria for Well-Formed
   Terminologies
  Guideline to Terminology Developers and
   Users
  Present Emphasis on Nomenclature
  Competed, Balloted, Approved
    Submitted   for Publication

ISO Health Terminology                       34
 WG3 Current Work Items
 MetaVocabulary [CEN joint effort]
    Glossary of Terms used for Describing and
     Developing Terminologies
          Word, Concept, Code
     Term,

     Nomenclatures, Classification

     Compositional Terminology, Pre-Coordinated

  Based upon Existing ISO/CEN Documents
  Wide Participation  Committee Draft 2002


ISO Health Terminology                             35
 WG3 Current Work Items
 Integrated Nursing Models
  Coordinate  Terminology Models Among
   Major International Nursing Terminologies
  Build Upon Existing CEN Initiative
  Align with Emerging Health Information
   Models – HL7, CEN
  Become Prototype for Domain
   Independent, Common Terminology Model

ISO Health Terminology                     36
 Proposed Work Item [in preparation]
 Distribution Formats for Terminology
    Standard Format for Minimum Content
     Codes,  Terms, Synonyms, Translations
     Relationships, Coding Rules, Description Logic

    Coordinate Activity with CEN CLaML
     XLM   Syntax for Classification Interchange
    Anticipate Nomenclature and Classification
     Subsets

ISO Health Terminology                                 37
 Proposed Work Item [in preparation]
 Terminology Expressions in Clinical Data
  Terminology     Expressions in Clinical Data
    Recognize    that a Diagnosis not just Code
  Compositional     Expressions and Problem
   Nesting
    Primary   Application on Problem List
  Dave   Robinson, Interim Task Leader
    Work   Closely with WG2, HL7

ISO Health Terminology                             38
 Proposed Work Item [in preparation]
 Semantics of Terminology
  Part   of Original Work Plan
    Divided    Across Two WG3 Work Items–
      dropped
  Timely in face CEN Work – MOSE II
  Timely Given Metavocabulary Closure
  Plan to Coordinate with CEN at Their Next
   Meeting [Rodrigues/Thurin]

ISO Health Terminology                       39
 Recent Meetings
  November     5, Washington (AMIA)
    Plus   Global NetMeeting Participation
  In   Association with CEN [Rodrigues]
    Explore Semantic Models (MOSE II)
    Explore Distribution Formats (CLaML)




ISO Health Terminology                        40
 Next Meetings
  August,   2002, Melbourne




ISO Health Terminology         41

				
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