The high functional demands for a terminology system for primary care

in a trilingual country and in a globalising world

Robert Vander Stichele, MD, PhDHeymans Institute of Pharmacology , Ghent University

Conference Terminologie.be, Belgian Medical Informatics Association Tuesday June 4, 2013, 19.00 – 20.30h

Federal Department of Public Health, Brussels, Room 0D10-0D11

Conflict of interest statement

The author - is a general practitioner and a clinical

pharmacologist at Ghent University - was a member of the Belgian Working Group on Terminology SEMINOP (2010 – 2011)- is a member of the research consortium

MERITERM (UGENT, CETIC, FBK), keeper of intellectual property rights on terminology, under Common Creative Licence

With special thanks to Meriterm members : Joseph Roumier, Elena Cardillo, Marc Jamoulle

OVERVIEW

What is a terminology system ?

What are the functional demands for an interface terminology ?

How far are we and are we on the right track ?

How are we going to test this ?

Perspective of Primary Health Care Professionals

What is a terminology system ?

Terminology system

• Terminological resources• With a structure • With a content • With functionalities

• Terminological applications • To produce the resources • To maintain the resources • To use be able to use the resources in practical programs

• Terminology server • To provide access to resources and applications for practical

programs • Terminology Center

• To keep resources, applications, and server up-to-date and operational

• To follow up on governance instructions

GOVERNANCE

Terminology Center

Server

Public health

e-Health

Business users End-users

Academic expertise

What are the functional demands for an

interface terminologie ?

Demands for terminology resources in Primary Care

• Geared to 3 basic functionalities • High quality medical registration of daily practice activities

• Intermittent summaries in a SUMEHR• Permanent Episode-oriënted registration • Multidisciplinairy registration of care targets

• Retrieval of bibliographic or EBM information and decision Support• Continuous Quality Assurance and epidemiological research

• => imperative use of GP classifications (ICP and ICD)

• Suitable for communication with other health care providers• In primary care • In secundary and tertiary care (30 specialist disciplines)

• Suitable for communication with patients

• Suitable for semantic interoperability (language, info systems)

Definition of Semantic Interoperability

is the ability to automatically interpret

the information exchanged

meaningfully and accurately

in order to produce useful results

as defined by the end users of both systems.

Is a quest to bridge between

the wealth and versatility of human language,

on the one hand, and

the rigidity and precision of registration and classification

systems, on the other hand

In diferrent languages, in different contexts

GP in Primary Care / Health Care /

Patient – Physician Communication

Semantische interoperabiliteit

Language Machine language

Word

Sense 1

Sense 2

Synonym

Synonym

Concept

Preferred term

Synonym

Language Machine language

Word

Sense 1

Sense 2

Synonym

Synonym

Concept

Preferred term

Synonym

String Match

Language Machine language

Word

Sense 1

Sense 2

Synonym

Synonym

Concept

Preferred term

Synonym

Semantic Match

Recommendation 1 of the SEMINOP Report

Our terminological resources within an interface terminology should respect the specific international standards for language resources and for machine language resources.

For language : The ISO-standard LMF (Lexical Markup Framework)

For machine language : The ISO-standard TMF(Terminological Markup Framework)

Interface terminology

End-userTerminology

ISO-LMF

Unilingual

ReferenceTerminology

ISO- TMF

Multilingual

Natural Language Processingresources

Classifications

Thesauri

Nomen-claturesCore Set of 15.000 concepts

Recommendation 2 of the SEMINOP ReportBuild pragmatic hybrid terminological resources

Further recommendations in the SEMINOP Report

• Limit in a pragmatic way the number of concepts (to approx; 15.000) and invest in postcoordination

• Do not limit yourself to SNOMED alone, but also link to other relevant international classifications

• Assure continuity with past registration by maintaining the existing terminology for primary care (3BT), with legacy conversion

• Make sure that your information format in the terminological resources allows applications for semantic web (RDF)

• Use the linguistic expertise present in academic departments for translation technology, computer linguistics and medical informatics.

• Pay attention to the language of the patiënt (lay language)

How far are we and are we on the right track ?

Governance beslissingen • No plenum meetings of SEMINOP since 2 years

• Round Table ICT in Health : Working group Terminology • Ambiguous outcomes (3 contradictory texts) • No sign of starting a supervising working group

• Builiding of a terminological resource (in excel) according to an explicit methodology, with terms from different Belgian sources (VUB, 2BT, RIZIV nomenclagure, ICD translations) around diagnoses and procedures, with linking to SNOMED (already running up to 30.000 terms for diagnoses).

• A national licence for snomed was subscriberd (a political decision between regional / federal government / Public Health / RIZIV)

• No public tender for a Terminology Center or Terminology Server

Follow up on SEMINOP Recommendations

• No use of terminological ISO-standards • No use of semantic web technology• No contacts with academic centers with linguistic expertice• No budget for maintenance of 3BT • No budget for attendance of international meetings of

primary care classification committees • No budget for legacy conversion of registrations in 3BT / ICD• No budget for experiments with alternative approach • Uncontrolled growth of the number of terms (words) to be

managed• Only attention to SNOMED• Hospitalo-centristic approach, little attention to

classifications in primary care • No projects to handle lay language and communicataion

with patients

How are we going to test this ?

Use cases 1. How does the general practitioner evaluates the value of the automatically

exported SUMERH from the EMD of a specific patient ? If the quality is not good, is it because registration activity was not good, or is the underlying terminology system to blame ?

(see the little encouraging results of the REGM-I project)

2. How user-friendly and accurate is the terminological support evaluated by the general practitioner, when he/she manually corrects the automatacally exported SUMERH to a document that he/she is ready to sign and put on the eHealth platform ?

3. How easy is it to update the SUMERH to new events registered in the journal notes or coming from a discharge letter of a recent hospitalisation ?

4. Does the patient understand the SUMEHR or its lqy lqnguqge version ?

5. Does a French speaking physician from Brussels or Wallonia understands the SUMEHR ? Does an American physician working with openEHR en HL7 understand the SUMEHR ?

Methods for testing

Process evaluation

How much time was needed ?How much effort was needed ?Where did it went wrong ?

Outcome evaluatie

How much misundertanding ? How much painfull and dangereous misunderstanding ?

Satisfaction of the sender of the reciever

Which methodological approach in testing will save us from this results ?

The new cloths of the emperorHans Christian Andersen, 1837.

The emperor is wearing cloths, made by clever tailors, who say that only intelligent people are able to see them.

Conclusion

Conclusion

Everybody agrees that it is urgent that something happens.

If a sense of urgency brings us to choose one and only solution, then we have a problem :

« If you only have a hammer, everything looks like a nail »

There will be a really big problem if after some time the chosen solution turns out to be not as adequate as thought.

The ROADMAP for ICT – eHEALTH in Belgium tells us what should be ready in 2014 and in 2015.

But are the conditions for success present and do we give sufficient attention to alternative, more long-term approaches.

Epilogue

EPILOGUE

SAMOURAI RULE 176

EPILOGUE

SAMOURAI RULE 176

• Matters of great importance must be taken lightly

EPILOGUE

SAMOURAI RULE 176

• Matters of great importance must be taken lightly

SAMOURAI RULE 177

EPILOGUE

SAMOURAI RULE 176

• Matters of great importance must be taken lightly

SAMOURAI RULE 177

• Matters of small importance must be taken seriously