Introduction to Coding and SNOMED-CT

11 October 2010Dr.F.Jahedi

iGENE - INFOVALLEY

Data

Information

Knowledge

Wisdom

Process

Process

Process

Coding

Data

Information

Knowledge

Wisdom

Relationships

Principles

Patterns

Reasons for storing medical data in a computer

Application area

• Patient care

• Quality control

– Uniform reports

– Comparing with other’s

– Protocol management

• Medical research

• Planning and management

Advantages of coding medical data

• Data reduction

• Standardized terminology

• Enabling statistical overviews & research

• Support of management and planning

• Coupling with DSS

Nomenclatures / Thesauri

Thesaurus

• A is a list of terms used for a certain application area or domain

• One of the problems of uniform registration in health care is the lack of a common terminology

Nomenclature

• Codes are assigned to medical concepts

• Medical concepts can be combined according to

specific rules

• Form more complex concepts.

Classification Systems

• ICD - International Classification of Diseases

• DSM-Diagnostic and Statistical Manual for Mental Disorders

• SNOMED-Systematized Nomenclature of Human and Veterinary Medicine

• ICD-0-International Classification of Diseases for Oncology

• RCC Read Clinical Classification

• ATC-Anatomic Therapeutic Chemical Code

Mapping

• An example of mapping RCC to ICD-9

UMLS

• UMLS Metathesaurus:

– Systematized Nomenclature of Medicine (SNOMED International)

– Read Thesaurus

– International Classification of Diseases - Clinical Modification (ICD9-CM)

– Universal Medical Device Nomenclature System

–WHO Adverse Drug Reaction Terminology

– Classification of Nursing Diagnoses (NANDA)

UMLS cont.

• UMLS Semantic Network

– links between the semantic types provide the structure for the Network

• SPECIALIST Lexicon (by NLP)

– From MEDLINE citation records

– A large set of terms from medical and general English dictionaries

• UMLS Information Sources Map

– Software tools are being developed

SNOMED-CT Building blocks

• Concepts

– The anchors for meaning

• Descriptions

– Terms (strings of readable characters) used to express the meanings of the concepts in human language

• Relationships

– Concept-to-concept links used to express information in computer-processable language

Codes, concepts, classes, instances

• Code:

– In general, any sequence of characters used to represent something in a coding system

– SNOMED Clinical Terms Identifier (SCTID):

– A sequence of 6 to 18 digits that identifies a component

• Concept:

– In general, an idea which has meaning. Through its meaning, a person can identify specific instances of the concept

• Class:

– An abstract category of things sharing common features

• Instance:

– A particular real member of a class

SCTID

Types of concepts

A SNOMED example

• Headache

– is-a ache: finding-site = head structure

– (and headache is marked as “defined”in concepts table).

• The class “headache” is sufficiently defined as the set of instances of the class “ache”

• which also have at least one finding-site relationship to an instance of the class “head structure”.

• And all instances of class “ache” with some finding-site relationship to an instance of “head structure” are instances of “headache”.

• Now, is that what you mean when you say “headache”?

Multimedia Patient/Dead Record• Many diagnostic techniques produce images and signals:

– X-ray equipment,

– CT scanning,

– Magnetic Resonance Imaging;

– endoscopy,

– Doppler ultrasound

– echocardiography;

– eIectrocardiograpy,

– electroencephalography,

– Electmyography,

– etc.

• At present it is time-consuming for a clinician to obtain non-textual data.

• Clinicians only use the final reports for their decision making

Benefits of Coding

• Data reduction

• Standardized terminology

• Enabling statistical overviews & research

• Support of management and planning

• Coupling with DSS

Any Question?

Thank you