A presentation for the Dental Informatics

1. Standards & Coding Systems
in Biomedical and Health Informatics
นพ.นวนรรน ธีระอัมพรพันธุ์
บรรยาย ณ สถาบันทันตกรรม ในหลักสูตรทันตสารสนเทศศาสตร์
24 กุมภาพันธ์ 2555

2. A Few Words About Me...
2003 M.D. (1st-Class Honors) Ramathibodi
2009 M.S. (Health Informatics) University of Minnesota
2011 Ph.D. (Health Informatics) University of Minnesota
Currently
• Medical Systems Analyst, Health Informatics Division, Ramathibodi
Contacts
ranta@mahidol.ac.th
SlideShare.net/Nawanan
www.tc.umn.edu/~theer002
groups.google.com/group/ThaiHealthIT

3. Manufacturing
Image Source: Guardian.co.uk

4. Banking
Image Source: Cablephet.com

5. Healthcare
ER - Image Source: nj.com

6. Why Healthcare Isn’t Like Any Others?
 Life-or-Death
 Many & varied stakeholders
 Strong professional values
 Evolving standards of care
 Fragmented, poorly-coordinated systems
 Large, ever-growing & changing body of
knowledge
 High volume, low resources, little time

7. Why Healthcare Isn’t Like Any Others?
 Large variations & contextual dependence
Input Process Output
Patient Decision- Biological
Presentation Making Responses

8. But...Are We That Different?
Banking
Input Process Output
Transfer
Location A Location B
Value-Add
- Security
- Convenience
- Customer Service

9. But...Are We That Different?
Manufacturing
Input Process Output
Raw Materials Assembling Finished
Goods
Value-Add
- Innovation
- Design
- QC

10. But...Are We That Different?
Healthcare
Input Process Output
Sick Patient Patient Care Well Patient
Value-Add
- Technology & medications
- Clinical knowledge & skills
- Quality of care; process improvement
- Information

11. Information is Everywhere

12. Types of Healthcare Information
 Clinical Information
 Demographics, History, Physical Exam
 Laboratory tests & Other Investigations (e.g. ECG), Imaging
 Diagnoses, Medications, Treatments
 Genomics
 Information about Healthcare Organizations & Operations
 Public Health Information - Epidemiology, Environmental
 Research Information - Basic Science, Clinical Research, Public Health
 Generic Health Information (e.g. Patient education materials)
 Knowledge Bases (e.g. PubMed) & Professional Education Materials

13. Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records Picture Archiving and
(EHRs) Communication System
(PACS)

14. Still Many Other Forms of Health IT
Health Information
Exchange (HIE)
m-Health
Biosurveillance
Personal Health Records
(PHRs)
Telemedicine &
Information Retrieval Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.

15. Health IT: What’s In A Word?
Goal
Value-Add
Tools

16. Recap
 Healthcare is complex and information-rich
 Healthcare information is heterogeneous
 Health IT is a tool to add value to care delivery
 Health IT comes in many different shapes and
forms, many must integrate with one another
 Yet healthcare is highly fragmented...
 That’s why we need “STANDARDS”

17. Standards Are Everywhere

18. Standards: Why?
 The Large N Problem
N = 2, Interface = 1
N = 3, Interface = 3
N = 5, Interface = 10
# Interfaces = N(N-1)/2
N = 100, Interface = 4,950

19. Health Information Exchange (HIE)
Government
Hospital A Hospital B
Clinic C
Lab Patient at Home

20. The Goal Is...
 Interoperability
 Inter-operable systems

21. Types of Standards
 De facto (informal/in practice) standards
 Dominant custom, convention, product, system
 e.g. Microsoft Word, QWERTY keyboard
 De jure (formal) standards
 Developed by recognized standard developing
organizations
 Maybe obligatory/regulatory, or voluntary

22. Standard-Developing Organizations (SDOs)
 Develops, coordinates, revises, interprets &
maintains standards that address interests outside its
own organization
 Clear scope
 Formal standards development process
 International, regional, national authorities
 Examples: ISO, IEC, ITU, IEEE, IETF, W3C, ANSI, NIST,
HL7, ASTM

23. Sample Standards Development Process
Public
Working Group
Draft Proposal Comment/
Consideration
Balloting
(Additional
Working Group
Test/Trial Use Balloting or
Amendment
Approval)
(Enforcement/ Evaluation/
Deployment
Certification) Maintenance

24. Various Kinds of Standards
 Unique Identifiers
 Standard Data Sets
 Vocabularies & Terminologies
 Exchange Standards
 Message Exchange
 Document Exchange
 Functional Standards
 Technical Standards: Data Communications, Encryption

25. DIKW Pyramid
Wisdom
Knowledge
Information
Data

26. Levels of Interoperability
Functional
Semantic
Syntactic

27. Unique Identifiers
 A unique convention to identify a class of objects
 E.g. serial numbers, national citizen ID, HN (MRN), NDC
 Unique within scope of intended operations e.g. a hospital, a
company, a city, a country, or globally
 May or may not be “smart numbers” (digits with meaning).
Smart numbers are bad practices.
 May or may not have “check digits” (digits used to prevent
data entry errors)
 In general, not supposed to be confidential (except U.S.
Social Security Numbers, credit card numbers)

28. Standard Data Sets
 Sometimes called minimum data sets
 Data structure (fields, formats, meanings) for a specific
purpose
 E.g. Ministry of Public Health’s 12-file or 18-file reports

29. Vocabularies & Terminologies
 Controlled Vocabulary
 A set of terms used in a specific area where the use of each term is predefined, and the set
maintained by the responsible party
 Taxonomy
 A hierarchical system to classify objects in a specific area
 Terminology
 A system or study of terms used to label concepts and their meanings in a specific area
 Ontology
 “A formal representation of knowledge as a set of concepts within a domain, and the
relationships between those concepts.” (Wikipedia)
 Coding System
 A system to identify how to represent an object or concept

30. Examples
 ICD-10, ICD-9
 Classification System
 Coding System
 Taxonomy
 CPT (Current Procedural Terminology)
 Classification System
 Coding System
 Taxonomy
 SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms)
 Controlled Vocabulary
 Terminology
 LOINC (Logical Observation Identifiers Names and Codes)
 Coding System
 ICNP, ICPC

31. Exchange Standards
Message
Message
Government
Message
Hospital A Hospital B
Clinic C
Lab Message Patient at Home
Message

32. Exchange Standards
 Message Exchange
 Goal: Specify format for exchange of data
 Internal vs. external messages
 HL7 v.2, HL7 v.3 Messaging, DICOM, NCPDP
 Document Exchange
 Goal: Specify format for exchange of “documents”
 HL7 v.3 Clinical Document Architecture (CDA), ASTM
Continuity of Care Record (CCR), HL7 Continuity of Care
Document (CCD)

33. Documents vs. Messages
 Clinical Documents
 Human Readable
 (Ideally) Machine Processable
 Messages
 Human UnReadable
 Machine Processable

34. Sample HL7 v.2 Message (Lab Result)
OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml|
0-1.3|H||H|F|19980309…

35. Sample HL7 v.3 Message (Pt. Regist.)
<?xml version="1.0" encoding="UTF-8"?>
<PRPA_IN101311UV02 xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
ITSVersion="XML_1.0" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/PRPA_IN101311UV02.xsd">
...
<name use="SYL" >
<given>นวนรรน</given>
<family>ธีระอัมพรพันธุ์</family>
</name>
<name use="ABC">
<given>Nawanan</given>
<family>Theera-Ampornpunt</family>
</name>
<administrativeGenderCode code="M"/>
...
</PRPA_IN101311UV02>
Message source adapted from Ramathibodi HL7 Project by Supachai Parchariyanon, Kavin Asavanant, Sireerat Srisiriratanakul
& Chaiwiwat Tongtaweechaikit

36. Functional Standards
 Aims for functional interoperability
 Example Scenario: Two systems are expected to behave in the same
way with the same trigger event (e.g. once received an electronic
message)
 Real-world Example: PDF file viewing by two different viewers
 Informatics Example: HL7 EHR Functional Specifications

37. How Standards Support Interoperability
Functional Standards (HL7 EHR
Functional Functional Specifications)
Vocabularies, Terminologies, Coding
Systems (ICD-10, ICD-9, CPT,
SNOMED CT, LOINC)
Semantic Information Models (HL7 v.3 RIM,
ASTM CCR, HL7 CCD)
Standard Data Sets
Unique ID
Syntactic Exchange Standards (HL7 v.2, HL7
v.3 Messaging, HL7 CDA, DICOM)
Technical Standards
(TCP/IP, encryption)
Some may be hybrid: e.g. HL7 v.3, HL7 CCD

38. More Standards for Self-Study
 Medications & Pharmaceutical
 RxNorm (U.S. National Library of Medicine)
 U.S. National Drug Code (U.S. FDA)
 Labs (& Others)
 LOINC (Regenstrief Institute)
 Clinical Terminologies
 SNOMED CT
 Organizational/Business
 ISO 27799 (Information Security Management in Health)
 Integration
 IHE (Integrating the Healthcare Enterprise)
 OpenEHR (a hybrid of standards for health information in EHRs)
 And many more!