Toward Standardization of Terminology in Anesthesia Information

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Toward Standardization of Terminology in Anesthesia Information Management Systems Dr. Terri Monk, Dr. Martin Hurrell, Dr. Andrew Norton Data Dictionary Task Force International Organization for Terminology in Anesthesia Representing Anesthesia Patient Safety Foundation – USA Royal College of Anaesthetists - UK ι 4/23/2008 1 Anesthesia Patient Safety Foundation • 1984 - APSF founded • President - Dr. Ellison C. Pierce • Patient-centered safety foundation approved by the ASA • Mission: ―To assure that no patient shall be harmed by the effects of anesthesia‖ • Emphasis on education and research • Instrumental in making pulse oximetry & ι capnography a standard of care 4/23/2008 2 APSF Commitment to AIMS Systems “ The APSF endorses and advocates the use of automated record keeping in the perioperative period and the subsequent retrieval and analysis of that data to improve patient safety ” APSF Board of Directors October 2001 4/23/2008 3 ι A minor issue … ι “We have lots of information technology we just don’t have any information” 4/23/2008 4 IOTA‘s Modus Operandi • • • Data Dictionary Task Force (DDTF) organized by APSF in 2001 In 2002, the DDTF accepted UK members and changed name to International Organization for Terminology in Anesthesia (IOTA) Current work of IOTA — Model terms for anesthesia information systems using corps of international experts — Reference storage of resources on a versioning control system, with web access — Anesthesia Extension Group at SNOMED – controls all new anesthesia terminology in SNOMED CT ι — Special Interest Group for the Generation of Anesthesia Standards (SIGGAS) in HL7 to develop anesthesia record compliant with the CDA 4/23/2008 5 DDTF/IOTA Organization APSF Executive Board • Financial control • Guidance and direction Task Force Chair Dr. Terri Monk • Organizational control • Project reporting Content Director Dr. Andrew Norton • Content direction • Term submission Terming Group • Clinical review • Minimum data set 4/23/2008 U.S. Content Adviser Dr. David Reich Technical Director Dr. Martin Hurrell • Technical direction • Tools construction Ontology/Schema Group • Clinical review • Modelling 6 ι IOTA‘s International Work Group ι 4/23/2008 7 Why a Formal Terminology? • To provide effective database analysis • To enable the effective pooling of data • To allow predictive modeling • To allow any sort of deductive reasoning • Essential for the use of intelligent software agents ι A prerequisite for the progress of the specialty and industry into enhanced uses of AIMS. 4/23/2008 8 Anesthesiology: what are the drivers ? • The anesthetic record — Medico-legal — ‗On-line‘ document — Audit & research The common model is an ontology and it requires the use of newer, more expressive and more powerful languages to capture the richness of the domain • Data sharing — Common record structure — Common terminology — Common model : to identify clinical context : for aggregation and analysis : to enable AI applications, reasoning and decision support ι 4/23/2008 9 Foundations for future AIMS Terminology:T ext elements Schema: record structure Ontology: domain model ι 4/23/2008 10 Scope of the reference set • All clinically descriptive terms — Procedure notes, Equipment, Positioning, Emergencies, Outcomes • • • Business and Administrative terms — HCFA notes, Demographic terms, Insurers, Procedures, Diagnoses Drug formulary — Agreed abbreviations, totaling units, (suggested doses?) Monitored data — Agreed monitored data descriptors, abbreviations ι • Data Exchange — HL7, Devices etc Any text element in an AIMS GUI, database or data transaction where you might otherwise have to invent a term to make it work. 11 4/23/2008 Relevance of a Data Dictionary SNOMED CT The terms are mapped/linked to an existing wider body of work … which is adopted by the medical community Anesthesia Subset DDTF DDTF Reference Reference set set ι Used by APSF Corporate partners 4/23/2008 12 Terminology and Ontology Work in Protégé + OWL Why use Protégé Has a large international user community Supports OWL (Web Ontology Language) – W3C recommendation Has rich support for properties and description logics (OWL DL) Has visualisation, versioning plugins + reasoners ι Protégé is free 4/23/2008 13 Protégé + OWL ‗front end‘ ι 4/23/2008 14 The Schema Defines the Structure for WellFormed Anesthesia XML Documents Anesthesia Technique: spinal Position: sitting The Terminology defines the terms that can go in the structure Needle: blunt bevel Approach: midline Drug: bupivacaine 4/23/2008 Type: whitacre Gauge: 22G ι 15 Vital Signs modeled in CDA Act classCode*: <= x_ActClassDocumentEntryAct moodCode*: <= x_DocumentActMood id: SET [0..*] code*: CD CWE [1..1] <= ActCode negationInd: BL [0..1] text: ED [0..1] statusCode: CS CNE [0..1] <= ActStatus effectiveTime: IVL [0..1] priorityCode: CE CWE [0..1] <= ActPriority languageCode: CS CNE [0..1] <= HumanLanguage 0..* act entry ι typeCode*: <= x_ActRelationshipEntry contextConductionInd*: BL [1..1] "true" 4/23/2008 16 The Promise - Sharing of Information • • • Portability of records Outcomes research ―Knowledge‖ — The pre-emptive use of Information ι 4/23/2008 17 How Should Future Standardization of Anesthesia Information Progress? • 2 options 1. Continue to work on the terminology with SNOMED and the record schema in HL7 Bring the completed (or near completed work) to the appropriate ISO group and ask it to adopt the work as a standard. 2. Join an ISO technical committee? If so, which one? ι 4/23/2008 18 ι 4/23/2008 19

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