Terminologies, informatique et soins primaires. Belgique
Contents
1. les pick list et les relations ontologiques ex SNOMED CT L apparition des nouvelles techniques informatique tel que le langage OWL et le web s mantique permet le d veloppement d outil terminologique nouveaux puissants et utilisable avec les technique de Natural Language Processing On pourra les appeler terminologies de troisieme g nb ration 1 2 Enqu te Prorec pour SEMINOP L enqu te men e aupr s de douze producteurs d applications m dicales membres de Prorec be par le groupe SEMINOP du Ministere de la Sant a montr la grande variation d utilisation terminologique par les logiciels belges On voit que seulement 6 sur 1 utilise 3BT un n utilise que la version 1987 de ICPC et 5 utilisent des dictionnaires propri traires Le tableau ci dessous montre cette vari t Terminologies Diag RFE 3BT Direct ICPC 1 proprietaire ICPC 1 ICPC 2 Indirect ICD9 CM ICDIO SNOMED l ABLE 1 1 Enqu te men e dans le cadre de PROREC BE sur l exploitation de terminologies et de leur mode directement ou indirectement par l industrie en Belgique et pr sent e lors du SEMINOP du 24 juin 1 3 Les dictionnaires propri taires Sauf reproduire des copies d cran il est quasi impossible d obtenir des soci t s de soft des d tails sur leur dictionnaire qu elles semblent consid rer comme des secrets industriels Elles ne r pondent m me pas aux mails envoy s ce sujet 3 Piette Ph Celis MT De Clercq E Devlies J Jamoul2. 0051 PROBLEME ECONOMIQUE 202 0011 PROBLEME D EAU 202 0021 PROBLEME DE NOURRITURE 203 0011 PROBLEME DE CHAUFFAGE 203 0021 PROBLEME D HABITAT 203 0031 PROBLEME DE RELATION DE VOISINAGE 203 0041 VAGABONDAGE Z03 0051 SANS DOMICILE FIXE Z04 0011 DISCRIMINATION ETHNIQUE Z04 0021 DISCRIMINATION LIEE A UNE GROSSESSE ILLEGITIME Z04 0031 DISCRIMINATION Z04 0041 DISCRIMINATION LIEE A LA RELIGION Z04 005 1 DISCRIMINATION LIEE AU SEXE Z04 0061 PERSECUTION Z04 0071 PROBLEME LIE A UNE CROYANCE Z04 0081 PROBLEME CULTUREL Z04 0091 PROBLEME LIE A LIMMIGRATION Z04 0101 PROBLEME LIE A UNE PRATIQUE SOCIALE Z04 0111 PROBLEME LIE A LA RELIGION Z04 0121 PROBLEME DE SOLITUDE Z04 0131 PROBLEME DE SOCIETE Z04 0141 PROBLEME LIE A UNE EXCLUSION SOCIALE Z04 0151 PROBLEME D HYGIENE Z05 0011 PROBLEME OCCUPATIONNEL Z05 0021 PROBLEME D ORIENTATION PROFESSIONNELLE Z05 0031 PROBLEME LIE AU TRAVAIL Tableau 3 Extrait de LOCAS Ouverture des codes CISP 2 Z01 a Z05 Michel Roland Marc Jamoulle amp Bernard Dendeau LOCAS 2 logiciel de codage et d acquisition de synonyme bas sur la CISP version 2 Care Editions asbl 2000 7 Michel Roland Marc Jamoulle amp Bernard Dendeau Approche Taxinomique en M decine de Famille Care Editions asbl 1996 Le LOCAS comprend 4610 termes et syntagmes d usage courant en m decine g n rale cod s syst matiquement sur la CISP 2 De nombreux m decins des Maisons M dicales belges dont le logiciel
3. a attribute Gastrointestinal ulcer clinical finding machine 397825006 116680003 40845000 Figure 14 SNOMED CT Concepts and relations expressed in readable and coded form 3 7 Pre and post coordination SNOMED CT is compositional allowing concept expressions to be pre coordinated within the terminology or post coordinated within the medical record 25 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 Pre coordinated concepts 2474726011 pan retinal photocoagulation for diabetes 2533101018 attended diabetes structured education program 125663012 lipodystrophic diabetes with partial lipoatrophy 356077018 malnutrition related diabetes mellitus fibrocalculous 408810010 DTSQ Diabetes treatment satisfaction questionnaire Figure 15 Five of the 877 occurrences of the chain diabet in Cliniclue browser SNOMED CT International Edition 2010 01 31 These are typical example of pre coordinated concepts Post coordination of concepts SNOMED CT enables complex descriptions For example there might not be an explicit concept for a burn between the toes But it could be described as 284196006 Burn of skin 246112005 Severity 24484000 severe 363698007 Finding Site 113185004 Structure of skin between fourth and fifth toes 272741003 Laterality 7771000 left Figure 16 SOMED interpretation of burn between the toes Example of post coordination Methods have been develope
4. de 3BT la tendance internationale autour d un produit anglo saxon d nomm SNOMED CT et nous indiquons la voie qui nous parait la plus ad quate pour le d veloppement d une informatique m dicale plus fluide dans les ann es venir On peut grossi rement distinguer trois tapes dans l laboration des terminologies Les terminologies historiques construite au moyen des bases de donn es des ann es 80 fournissent des listes d occurrences selon le terme cherch par l utilisateurs On peut les appeler terminologie de premiere g n ration Ex 3BT 1 Fieschi M Un enjeux les terminologies m dicales sur http esante gouv fr pointsdevue marius fieschi un enjeu les terminologies medicales 2 Wuster E La th orie g n rale de la terminologie un domaine interdisciplinaire impliquant la linguistique la logique l ontologie l informatique et les sciences des objets dans DUPUIS H d Essai de d finition de la terminologie Actes du colloque international de terminologie Qu bec Manoir du lac Delage 5 8 octobre 1975 Qu bec R gie de la langue francaise p 49 57 1976 accessible sur http docpatient net onto doc wuster pdf L apparition dans les ann es 2000 de nouvelles techniques informatiques a premis d introduire dans le d veloppement terminologique des outils puissants de relation entre des concepts tout en gardant la structure de liste telle quelle On peut les appeler terminologie de deuxi me g n ration qui mixent
5. semantic interoperability This involves the ability of two or more computer systems to exchange information and have the meaning of that information accurately and automatically interpreted by the receiving system In the field of interoperability user s interface and consequently language is one of the main issue of the relationship with the computer Basic information about SNOMED CT is difficult to find material available lacks complete understandability by other than experts in formal terminology Moreover SNOMED CT is a complex product being the meeting point of medicine computer sciences and computational linguistics SNOMED CT a mix between US and UK terminologies represents also a move from the terminological field to the ontological one and it is not so easy to understand the concept of ontology One view of ontology is that it is a formal specification of a conceptualization for the purpose of enabling knowledge sharing and reuse This implies that relations between concepts are as important as the concept themselves Understanding the domain of terminologies ontologies and their relationships particularly of SNOMED CT represents a challenge for the general or family practitioner who is progressively facing the charge to gather in his EMR all the information generated by the health system for a particular patient One can say that Information is to general practice family medicine as technology is to medical specialties M
6. traduction du n erlandais en francais et concepts compos s 12 Filtre selon mot s DEPR 7 Mot s pr sent s dans la phrase Recherche mot dans la liste DEPR E ABATTEMENT 10063659 ABETISSEMENT 10003988 AFFECTION MANIACO DEPRESSIVE 15002514 ANXIO DEPRESSION 10006831 APATHIE 10007851 AUTRE TROUBLE AFFECTIF PERSISTANT 15004879 AUTRE TROUBLE PERSISTANT DE L HUMEUR 15004878 CHAGRIN 10104070 CHAGRIN DU A LA PERTE D UN AMI 20000009 COURTE RECIDIVE D UN TROUBLE DEPRESSIF 10085907 DECOURAGEMENT 10063660 DEMENCE SENILE AVEC SYPTOMES DE DEPRESSION ET DE PARANOIDE 10115912 DEPISTAGE D UNE DEPRESSION 10025262 DEPRESSION 10025204 DEPRESSION AIGUE 10002449 DEPRESSION ATYPIQUE 10009920 DEPRESSION AVEC AGITATION 10025235 DEPRESSION CEREBRALE 10017751 DEPRESSION CEREBROVASCULAIRE 10025223 DEPRESSION CLIMATERIQUE 10019328 DEPRESSION CONGENITALE DE LA VOUTE PLANTAIRE 10115933 DEPRESSION DANS SA PHASE INVOLUTIVE 10047516 DEPRESSION DE LA MOELLE OSSEUSE 10010630 DEPRESSION DU CENTRE RESPIRATOIRE 10002638 DEPRESSION DU POST NATALE 10025251 DEPRESSION DU POST PARTUM 10025250 DEPRESSION ENDOGENE 10025226 DEPRESSION ENDOGENE AVEC SYMPTOMES PSYCHOTIQUES 10025227 DEPRESSION HYSTERIQUE 10025240 DEPRESSION LIEE A LA MENOPAUSE 10025244 DEPRESSION MAJEURE 10030843 DEPRESSION MASOUFF 10025238 Figure 4 3BT dans Epicure V14 recherche sur les digits depr L image montre une trentaine des 97 occurrences propos es 3BT a t mis disposition
7. une importance capitale la fois pour l exercice quotidien de la m decine et et pour des d veloppements terminologiques futurs En effet c est sur base de ce dictionnaire que les notices boites des m dicaments ont t adapt es la lecture grand public et que nos le contenu des avertissements et patients peuvent comprendre pr cautions prendre lors de l usage de m dicaments x Ce projet a t soutenu l poque 1990 1995 par la Commission europ enne et execut par le Heymans Institute of Pharmacology de l Univbersiyt de Gand et le d partement de Linguistique appliqu e de l cole Mercator Le systeme contient la forme lectronique de 8 glossaires soit 1830 termes m dicaux populaires et techniques dans 8 des langues officielles de l Union Europ enne English Dutch French German Italian Spanish Portuguese and Danish Il y a quatre types de documents dans ce syst me 1 La liste des termes m dicaux techniques et populaire ces listes contiennent un index de tous les termes m dicaux avec des r f rences crois es entre les termes techniques et les termes populaires une liste pour chaque langage 2 Glossaire des termes m dicaux techniques et populaire ces glossaires contiennent des notes et des commentaires de traducteurs et utilisateurs pour chaque terme des 1830 dans le langage s lectionn 3 Collection multilinguistique de lemmes Cette liste contient 1830 pages une pour chacu
8. 47 Modification d un terme DCM os ou U r X DiB D Bronchiolite aique DiB DB Bronchiolite virale Dill Carcinome bronchioloalv olaire DIMAFCR Ad nocarcinome bronchiolo alv Di Carcinome bronchioloalv olaire bhMH Fraction bronchique LBA DDO Asbestose et cancer pulmonaire ou bhMHD Lymphocytes fraction bronchique L DCi Neo bronchique du lobe pulmonaire Dis Ulcere bronchique bhMHE Eosinophiles fraction bronchique LE DmE2 Neo bronchique du lobe pulmonaire bhMHA Rendement fraction bronchique LB DtMAFAB ad nome bronchique DtMBGP tumeur bronchique alv ol intravascu DrH2a Ad nome bronchique de Jackson gt DrH2b Epith lioma pidermoide bronc DrH2c Epith lioma spino bronchique Dr8 amp aE Tuberculose bronchique DmC2 Neo bronchique du lobe pulmonaire ICDS 466 1 ICD10 321 9 ICPC1 B78 Langue n pe v G rer v x Figure 1 Lexique DCM recherche des termes commengant par BRONCHI Le code choisi DrBOD Bronchiolite aigue correspondant a plusieurs codes en vert au bas de la figure Au premier rang les codes a une position du sommaire tablissent une diff rence entre les plaintes ou interrogatoire l examen clinique les diagnostics et les param tres ainsi qu entre les demandes d examen leurs r sultats et divers domaines plus techniques ou administratifs Au second rang les codes a deux positions diff rencient dans chacun de ces grands domaines les diverses sp cialit s m dicales Ainsi Diab
9. A Annu Symp Proc 2009 Nov 14 2009 291 5 http www ncbi nlm nih gov pmc articles PMC2815379 Smith B Ashburner M Rosse C Bard C Bug W Ceusters W Goldberg L J Eilbeck K Ireland A Mungall C J The OBI Consortium Leontis N Rocca Serra P Ruttenberg A Sansone S A Scheuermann R H Shah N Whetzel P L and Lewis S 2007 The OBO Foundry coordinated evolution of ontologies to support biomedical data integration Nature Biotechnology 25 1251 1255 http www obofoundry org ontologies shtml 7 Canguilhem G The Normal and the Pathological Cohen New York Zone Books 1991 Smith B Ceusters W Klagges B K hler J Kumar A Lomax J Mungall C Neuhaus F Rector AL Rosse C Relations in biomedical ontologies Genome Biol 2005 6 5 R46 Epub 2005 Apr 28 http www ncbi nlm nih gov pmc articles PMC1175958 tool pubmed Robert H Dolin Kent A Spackman amp Markwell D Selective retrieval of pre and post coordinated SNOMED concepts AMIA Symp 2002 210 214 http www ncbi nlm nih gov pmc articles PMC2244193 10 Wonca International Classification Committee Icpc 2 R International Classification of Primary Care by 2005 11 Rogers J Bodenreider O SNOMED CT Browsing the browsers In Proc KR MED 2008 Representing and sharing knowledge using SNOMED Phoenix Arizona http mor nlm nih gov 8000 pubs pdf 2008 krmed jr pdf 12 Cornet R de Keizer N Forty years of SNOMED a literature review Med Inform Decis Mak 2008 8 Sup
10. C 2 PLUS to SNOMED to form a first cut Australian GP subset for Primary Care Recently 2 500 000 diagnostic data collected in electronic patient records throughout 2006 within the County Council of Stockholm and coded in ICD10 Swedish primary care version have been mapped to SNOMED CT The use of Is a relationships in SNOMED CT aggregated the diagnostic data to 2861 concepts showing a new multidimensional view of different specific medical aspects where every view can be further explored The authors conclude SNOMED CT provides a different view of diagnoses and health problems on a chapter level and adds significant new views of the clinical data with aggregations generated from SNOMED CT Availability of translations Following a source from Infoway inforoute Canada SNOMED_CT translation in French is not yet finished Inforoute Sant Canada has begun the translation of a list of actives concepts following determined priorities and actually only about 10 30 000 concepts are available in French From a source in The Netherlands nothing has been translated in Dutch till now but this has to be confirmed SNOMED CT is available in several other languages of which Spanish 6 Does SNOMED CT encompass the field of GP FM Quick look through the Cliniclue browser Examining the four fields of the Figure 5 one could say that SNOMED CT succeeds extremely well in the biomedical field It is probably the most powerful nomenclature for use in patho
11. ED Systematized nomenclature of medicine servait identifier les chantillons histologiques Elle est toujours utilis e dans ce sens par les laboratoires d anapath Il s agit donc historiquement d un classement de pi ces sans vie Au cours des trente derni res ann es le produit s est d velopp pour r pondre aux besoins essentiellement de l industrie am ricaine des soins de sant dont on sait l orientation hospitali re exclusive et la pauvret de d veloppement des soins primaires Dans les ann es 2000 SNOMED a volu doublement d une part en s adjoignant les codes Read sens s repr senter la clinique de la m decine g n rale anglaise et d autre part en suivant le mouvement qui dans le domaine de la gestion de la connaissance et de l intelligence artificielle a donn naissance aux ontologies ou du moins la capacit pour les super ordinateurs de bureau d enfin pouvoir traiter les concepts Dans une volont d h g monie mondiale et on y voit en filligramme les besoins mondiaux de l industrie de la sant l American College of Pathologist a loby de fa on intensive entrainant avec elle une s rie d experts de diff rents pays et a r ussi a lancer le label SNOMED CT comme une marque au m me titre qu Yves St Laurent ou Adidas Plusieurs pays ont accept parfois contre l avis de leurs terminologistes de fonder une sorte d institution internationale aspirant au passage la 15 notion et le terme de standard IHTSDO qu
12. OMED RT DAMON CO F2 disorder No F avourtes s Search ZEE Epepow 800 219060000 Vicom epilepsy dsorder Der ibura inode 193002005 Psychosensory epliepsy Gsorder Vecera epbepsy Asorder 193017000 Koymvnikow s eptepsy disorder unes ww Benin neonate consona dont 193008000 Somatosensory eptiepsy iaeordern rf 193011005 Unilateral epeegry disorder Cartreceghabc ep epyy dander 230381000 Localzaton reiated ep epsy disorder Curve sere d monter oat trauma c 230392005 Aiinencephatc eptegsy disorder Pos unaistt eplapey daneri Sri Eri Bri Eri Er Eri Eri Ge Er P E 230901003 Arygdao NMEpOC ampal epiiepsy disorder 230306000 Crue eptepsy Asordar Upslegey dmorder Wohbsctulfter s wyrd roma Georder 230400000 Operc utar eptegsy diorder Peychosersory eptapty Simota 230399001 Dorsotaleral epilepsy disorder Somatosensory eplepsy deoner Undateral eo epty dacnde Other tora of epdepey ronder locatur aten rviated oplepey mortier Epdopey undetermined whether focal or generated dmorder 730908000 Orbtofrontal epmepsy Gorter 2044100 Orup Nawed epteoty order 230444006 Menus epaepsy SON Bri Eri Eri Bri Eri Br Br EaMEMENMN 230445007 Nocturnal ep epsy disorder Drug duced eplvepey porter Figure 19 Snomed browser the occurrence of the concept Epilepsy with visual presentations of its relationships using Snoflake the
13. ONCHUS EN PARANEOPLASTISCH SYNDROO R84 R1622 NEO BRONCHUS HILAIR R84 R16222 NEO BRONCHUS HILAIR ADENOCARCINOOM R84 R162244 NEO BRONCHUS HILAIR KLEINCELLIG CARCINOO R84 R16229 NEO BRONCHUS HILAIR NNO R84 RC340 NEO BRONCHUS HOOFDTAK R84 RC342 NEO BRONCHUS MIDDENKWAB R84 R16242 NEO BRONCHUS MIDDENKWAB ADENOCARCINOOM R84 Tableau 1 MEDIDOC Extrait de la terminologie Occurrences sur l entr e NEO BRONCH vue partielle Dans l application diff rents choix sont aussi possibles ainsi qu un lien vers une banque de donn es qui d taille la pathologie et propose les codifications internationales rysipele Codifications internationales ICD 9 CM 035 ICPC 5761 ICD 10 A46 ICHPPC 2 034 ICPC2 576 Tableau 2 Correspondance du terme Erysipele Medidoc 4 Bartholomeeusen S Truyers C Buntinx F Intego een registratienetwerk van huisartsen in Vlaanderen Huisarts Nu 2005 34 11 14 De Cantelis Medici La banque de donn es DCM de 27 000 termes De Cantelis Medici fait partie int grante de Medigest En fait DCM n est pas une banque de donn es il s agit r ellement de multiples banques de donn es le sommaire offre la possibilit de g rer 62 banques de donn es en une seule codes de0 9 deA Zetde a az Environ 11 000 termes sont li s ICD10 et 10 000 ICPC2 La banque MED contient 21 000 termes dont 15 000 conditionnements sont li s aux codes CNK avec une structure similaire ATC
14. REGM 2010 3 6 The Clinical Terms Identifier SCTID a 64 bit integer Each _id is represented by a 64 bit integer not always presented in full length the SNOMED Clinical Terms Identifier SCTID like 101291657896189 00 9 the last digit being a Verhoeff algorithm control code used for primary key for most tables The two digits before the last one are 10 for concept 11 for description 12 for a relationship but this form of presentation is rather uncommon For example the Concept_id 22298006 means myocardial infarction The concept id could contain a Namespace Identifier a code or that part of the 64 bit integer that identifies the organization responsible for creating and maintaining a standards based extension or a standards based derivative Namespace Identifiers are 7 digit numbers that IHTSDO issues to those who create extensions to SNOMED CT The ConceptStatus is quoted by a number O Current 1 Retire without specified reason 2 Duplicate 3 Outdated 4 Ambiguous 5 Erroneous 6 Limited Classification 10 Moved Elsewhere 11 Pending Move Example the 3 following SCTID Figure 14 are linked in such way that the Relationship_id identifies the chain of knowledge between two concepts readability Concept id1 RelationshipType Concept id2 human Cholecystectomy procedure is_a attribute Biliary tract excision procedure machine 302619004 116680003 38102005 human Gastric ulcer clinical finding Is
15. Relationships Controlled vocabularies can be conceived as graph theoretical structures consisting on the one hand of terms which form the nodes of each corresponding graph linked together by means of edges called relations Is a Has finding site Has associated morphology Has method Part of Has direct procedure site Has causative agent Has active ingredient Has dose form Figure 10 frequent relations in SNOMED CT In SNOMED CT s a links concepts within a hierarchy while Attribute relationships allows links between concepts across hierarchies 23 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 Hierarchy Em um C t Status current MX atrial fibrillation Descriptions i 4128238001 chronic heart disease Definition Fully Defined as 45128238001 chronic heart disease 116680003 isa L 5349436004 atrial fibrillation 263502005 clinical course 390734009 chronic 363698007 finding site 24964005 cardiac conducting system structure 363698007 finding site h 59652004 atrial structure Qualifiers te 12005 severity Lp272141005 severities 246456000 episodicity Lp3288526004 episodicities Codes Original SNOMED Id D3 31526 Read Code Ctv3ld XUfOj Figure 11 SNOMED CT left the concept Chronic atrial fibrillation is a sub hierarchy of clinical finding Right relationships of the c
16. Snomed online CT browser from Dataline Software http snomed dataline co uk 5 To what extent Is SNOMED CT in use in practice It is unclear if SNOMED is really useful in clinical practice A review of the available literature performed in 2006 and published in 2008 examines 250 published studies on SNOMED These studies look particularly relevant for proving the value of SNOMED in theory Few studies are available on the usage of SNOMED in clinical practice An interesting study but yet outdated compares the usefulness of 2 739 clinical codes of a dictionary ICPC based developed by Bob Bernstein Canada versus the 140 000 SNOMED 1993 entries The SNOMED coding specialists took more than 250 hours to encode 2 739 ICPC based codes to SNOMED Xref and the author took over 100 hours to revise them Practical use Practical use seems not so easy A university based hospital of 650 beds serving 140 000 patients has implemented SNOMED CT recently The authors describe three levels of implementation which implies heavy and time consuming work for skilled professionals in IT and terminology Entry Terminology this is the user interface the terms used to interact with users during data entry process representative of the local natural language including abbreviations and jargon Reference Terminology this is the format used to store data knowledge information should be stored in this layer Aggregate Terminology dif
17. Terminologies informatique et soins primaires Belgique 1980 2010 Projet REGM Minist re de la Sant Publique Bruxelles 2010 D cembre 2010 Jamoulle M Terminologies informatique et soins primaires Belgique 1980 2010 Projet REGM Minist re de la Sant Publique Bruxelles 2010 Sommaire 1 Dictionnaires et terminologies en usage dans les logiciels belges de m decine g n rale 5 1 1 Standardis r lesdTiOts eee opere ter ar ater ee er EE adeo pense eus Fiesta tee ERR PER praevia 5 1 2 Enqu te Prorec pour SEMINOP iii 6 1 3 Les dictionnaires propri taires issus 6 1 4 Le LOCAS Logiciel de Codage et d Acquisition de Synonymes seen 9 1 5 Multilingual Glossary of technical and popular medical 11 terms in nine European Languages ii nnanhn inia inanis ia aa ia sa ias iieri iiti 11 1 6 3BT limites de la terminologie de premi re g n ration eeeesseeeeee 12 1 6 1 3BT d velopp sur base de l exp rience du LOCAS sess 12 1 6 2 Br ve tude du contenu de 3BT 2009 essssssesessssseees ener enne nnne 13 2 LES propositions F centes cocer tace eer e eve lute cu uae dept o ud eve oe tco edat 15 2 1 Exemple d une terminologie de deuxi me g n ration SNOMED CT 15 2 2 Vers une Belgian end user terminology in 16 2 3 Annexe Some views about SNOMED CT sess ener nennen nen 16 Abstract La
18. a t quip de cette terminologie entre 1990 et 2000 environ ont contribu son d veloppement en renvoyant des commentaires des corrections ou des demandes de synonymes Le LOCAS initi lors de la publication de la CISP 1 1987 a t r vis apr s la publication de la CISP 2 et les codes sont donc ceux de la CISP 2 1998 Le LOCAS est disponible en fichier de base de donn es Le mode d emploi forme le volume 1 et est mis la disposition des chercheurs et producteurs de logiciels de m decine g n rale Bien qu ils soient couverts par des droits d auteur ils sont utilisables librement condition de ne pas les alt rer et d en citer la source Le fichier t l chargeable sur le site http trix docpatient net rubrique CISP comprend un fichier lisez moi qui d crit ces modalit s et les sources citer en d tail ICPC Wonca WICC LOCAS2 est une base terminologique destin e tre utilis e en clinique de m decine g n rale Les concepts sont ceux d finis par le WICC groupe de travail international de la Wonca l organisation mondiale de la m decine g n rale Le Wonca International Classification Committee a cat goris une s rie de concepts de pr valence forte en clinique de m decine g n rale les a d finis et les a munis de crit res d inclusion et d exclusion L outil a t appel International Classification of Primary Care ICPC et traduit en Fran ais sous le nom de Classification Internationale des Soi
19. al health fgov be pls portal docs 1 10732006 PDF 16 Marc Jamoulle July 2010 Family doctor Health data management specialist WICC member CAMG UCL marc jamoulle com Report to SEMINOP Belgian Ministry of Health Some views about SNOMED CT by a General Practitioner Abstract SNOMED CT is is a concept oriented and machine readable medical terminology which has gained popularity this last ten years It has been proposed as the reference terminology for use in electronic medical records and is supposed to cover the entire field needed to care and cure This paper is examining its complexity and ability to cover the fields of general practice family medicine presented as the focus point of information in medicine Dr Marc Jamoulle is a free lance researcher This work has been supported by a travel grant of the Centre Belge d Information Pharmacoth rapeutique C B I P Belgium http www cbip be 17 Sommaire 1 Semantic interoperability and general practice 19 2 About SNOMED CT amp IHTSDO nickname itsido sees enne 20 2 1 International Health Terminology Standards Development Organization 20 2 2 IHTSDO member countries 2010 21 3 SNOMED CT a complex controlled medical vocabulary cccccccccesssssssecececeseesesscaeeeeeessessessaaeees 21 3 1 What saSNOMED Concept iris miii nidi initi nai 21 A unit of meanings te ete tesi tates eate etate eta aa 21 F
20. anaging information is a new duty for the GP FM a complex domain as is General Practice itself a crossroad between human and collectivity between to do and to be between patient interests and public expenses If biomedical field is the first training step and experience reality drives the practitioner through the depths of this symbolic animal called human being psychodynamics This one lives in community and quantitative epidemiology and qualitative anthropology interactions are daily modifiers of practice Consequently GP FM is also the crossing point of Narrative Based NBM and Evidence based Medicine EBM Let us assess whether SNOMED CT s complexity is able to render the GP FM one To do To be individual Bio math medicine Mental health community Epidemiology Anthropology Figure 5 Four fields of General Practice Family medicine Adapted from M Van Dormael 13 This paper has been written form material received at SNOMED cr Training Class April 27 2010 during the IHTSDO conference in Copenhagen and from several Internet sources 19 2 About SNOMED CT amp IHTSDO nickname itsido SNOMED CT means Systematized Nomenclature of Medicine Clinical Terms SNOMED is patented as a system and method for medical language extraction and encoding SNOMED CT is a standardized clinical cerminology comprised of codes terms and relationships for use in recording and representing clinical information across the sco
21. by the enormous inflation in the terminology of the SNOMED INTERNATIONAL 1993 passed from 44 487 to 132 641 terms As stated above SNOMED CT has now 308 000 active concepts 791 000 active descriptions organized into 19 hierarchies with more than 951 000 relationships The great Umberto Eco has written a demonstrative essay On the impossibility of drawing a map of the Empire on a scale 1 to 1 Knowledge is not the Empire but it s doubtful that inflation of terms and relations will help to manage it 8 References 1 Thomas R Gruber A Translation Approach to Portable Ontology Specifications Knowledge Acquisition 5 2 199 220 1993 http tomgruber org writing ontolingua kaj 1993 htm Van Dormael M M decine g n rale et modernit Regards crois s sur l Occident et le Tiers Monde Thesis Bruxelles Universit Libre de Bruxelles 1995 286 p 3 Greenhalgh T amp Hurwitz B eds Narrative Based Medicine Paperback BMJ 1998 30 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 WangAY BarrettJW Bentley T et al Mapping betweenSNOMED RTand clinical terms version 3 a key component of the SNOMEDCT development process Proc AMIA Symp 2001 741 5 http www ncbi nlm nih gov pmc articles PMC2243316 tool pubmed 5 Joubert M Abdoune H Merabti T Darmoni S Fieschi M Assisting the translation of SNOMED CT into French using UMLS and four representative French language terminologies AMI
22. d to retrieve pre and post coordinated concepts The process for selectively retrieving pre and post coordinated SNOMED CT concepts relies on a syntactic transformation into a standard form Loosing redundancy ICPC ICD SNOMED CT Signifier B25 i64 397825006 Signified Fear of AIDS Stroke Gastric ulcer Figure 17 Loose of redundancy in signifier signified relationship Machine readable implies that human beings cannot reasonably retain the code of the concept In the Figure 17 the signifier is the code while the signified is the concept ICPC has been designed to be used in Paper and Pencil format and incorporate mnemotechnic tricks For instance B stands for Blood and in the whole classification the number 25 is reserved to Fear of A GP who is familiar with the International Classification of Primary care ICPC could quickly recognize the B25 code in the context as Fear of Blood disease of which the main one is Fear of AIDS ICD10 code are not 26 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 mnemotechnic and a normal doctor will not retain that i64 is the code for Stroke while a dedicated coder could remember it But the number 397825006 can only be understood by a computer One remarks that going from left to right one looses redundancy While enhancing its precision he code looses internal information which allows human readers to understand it 4 SNOMED Browser
23. des concepteurs de logiciels informatis s et certains comme Epicure l ont introduit comme base de r f rence terminologique Sans d veloppement d interface utilisateur pouss et sans corrections ce produit terminologique fournit plus de bruits que de r sultats Interrog selon les techniques de pick list trois premiers digits ou premiers digits de deux termes qu on pense associ s il fournit une liste impressionnante et absconse de terme en relation avec les trois lettres recherch es Ainsi dans Epicure Version V14 de 2010 la requ te sur D pression au moyen des quatre digits depr fournit 97 occurrences dont la pertinence terminologique et l ad quation des codes est tr s souvent erron e Un simple coup d oeil la Figure 4 montre que D pression c r brale et D pression c r brovasculaire ne sont pas class es dans la m me cat gorie et cela probablement en raison d une traduction erron e du n erlandais vers le francais On voit que toute statistique qui serait bas e sur les codes issus de l usage de cette terminologie serait sujette caution 1 6 2 Br ve tude du contenu de 3BT 2009 On reproduit ici une tude br ve r alis e compte personnel en 2009 par l auteur de ces lignes The Belgian Biclassified Terminology is embedded in some EMRs in GP FM in Belgium t is also being translated in Brazilian Portuguese by members of the Wonca International Committee The Belgian Evidence based medicine centre cebam be a
24. e se traduisant par un oed me pop BE papule f bouton pop g E paracentese f ponction pour vacuer un liguide anormal pop g E paradoxal sommeil activit c r brale rapide sommeil pop BE parall le pop parall le g E parall le parall ls pop g E paralysie de l accommodation de l oeil pop cyclopl gie f gg paralysie l g re ou incompl te pop par sie f E Ej paralysie f paralysie pop Il g Pw absie pop paralysie f g E param tre m parametre pop Figure 3 Multilingual Glossary Extrait en Fran ais 1 6 3BT limites de la terminologie de premi re g n ration 1 6 1 3BT d velopp sur base de l exp rience du LOCAS Sur base de l exp rience du LOCAS une collaboration entre l Universit Libre de Bruxelles Dep de med gen Prof M Roland et L universit de Gand Dep de med gen Prof De Maeseneer soutenu annuellement par le Service Public de sant F d ral a permis apr s plusieurs ann es de constituer une immense base terminologique de plus de 50 000 entr es bilingue cod e sur ICPC et ICD10 Le produit a t pr sent comme termin en 2009 apr s de grosses difficult s m thodologiques et relationnelles entre les quipes francophones et n erlandophones Le produit d nomm 3BT pour Belgian bilingual biclassified terminology repr sente un travail consid rable et est un mix des termes retrouv s dans ICD10 et dans ICPC avec de nombreux synonymes
25. e terminologie hospitalo centr e remarquable et qu on peut certainement tirer profit de cette somme de connaissance accumul e Elle ne peut toutefois pas tre un mod le terminologique pour les soins paires y compris aux USA L auteur de ces lignes a publi une tude d taill e sur SNOMED CT Cette tude est pertinente aux choix actuels et est reproduite en annexe de ce rapport pour le lecteur int ress Elle est aussi disponible sur Internet 2 2 Vers une Belgian end user terminology Nous n avons analys ici que les aspects soins primaires des terminologies disponibles Le r cent rapport du groupe SEMINOP auquel l auteur de ces lignes a particip tudie plus largement toutes les classifications et terminologies en usage en Belgique quelque soit le niveau de soin Le rapport SEMINOP conclut a une norme disparit d outil qui se superpose ais ment ou font double emploi Un long et cons quent travail d harmonisation doit se mettre en place qui fera la part belle aux outuils du web s mantique pr parant l informatique m dicale de demain 2 3 Annexe Some views about SNOMED CT 1 Jamoulle M Some views about SNOMED CT by a General Practitioner Internet SEMINOP Jul 2010 Available from http docpatient net onto doc SNOMED CT study MJ 2010 pdf s Seminop Rapport final disponible sur http www health belgium be eportal Healthcare Telematics Studygroups SEMINOP index htm fodnlang en Groupe SEMINOP voir https port
26. ement d velopp des dictionnaires internes leur produit logiciels puis essay de les faire correspondre aux diff rentes classifications existantes La technique utilis e a t syst matiquement conditionn e par l informatique disponible Quasi tous ont commenc en DOS et Dbase et ont suivi en ACCESS puis SQL et donc la fabrication de liste de mots fr quents puis moins fr quents puis rares puis tres rares est devenue une occupation plein temps pour certains au fur et mesure que le dossier m dical informatis se raffinait L tat belge a m me sponsoris pendant dix ans une quipe de chercheur pour tablir une liste de mots encore plus longue Pendant ce temps l informatique allait son chemin et les ordinateurs devenaient de plus en plus puissants permettant des traitements d information inimaginable jusqu alors L mergence du langage OWL en 2001 a sonn le rassemblement des terminologues documentalistes et informaticiens et autres sp cialistes du Knowledge management autour de ce que Wuster appelait la Th orie G n rale de la Terminologie il a fallu encore quelques temps pour que les professionnels de la m decine emboitent le pas de cette nouvelle approche et consid rent ces nouveaux outils que le monde industriel a d j engramm depuis plusieurs ann es Nous examinons ici les diff rentes approches terminologiques disponibles dans les logiciels belges l effort d une terminologie centralis e connue sous le nom
27. ferent data formats outputs for user analysis 28 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 Smith and Ceusters have pointed a capital point for GP FM time Existing biomedical information systems including SNOMED CT are not concerned by keeping track how entities such as symptoms or diseases develop over time This is the corner stone of the International classification of Primary Care the tool created by the Wonca International Classification Committee WICC for epidemiological purpose since the 70 ICPC proposes a retrieval methodology based on Episode which means time Mapping Mapping translation of clinical data into alternative representations without corrupting the primary clinical mission is already done for ICD 9 CM The task has been completed by mapping ICD9 for billing purpose in 200916 IHTSDO has several teams involved in this issue in all the main fields of classifications like ICD10 NANDA or ICPC Special Interest Group SIG has been launched to study the problem and propose ad hoc solution The IHTSDO Special Interest Group in Primary Care SIG PC has been launched in Copenhagen after an agreement between the World Organisation of Family doctors WONCA and IHTSDO Some Wonca International classification committee members will lead this group The Family Medicine Research Centre at the University of Sydney of which leading members are also members of WICC is currently mapping ICP
28. i la CAP a revendu son produit pour une somme consid rable tout en gardant la haute main sur l organisation et le contr le de qualit Ce qui frappe quand on assiste un congr s SNOMED c est l ambiance marketing et business management Quand on examine de pr s le produit on voit qu il garde les traces historiques de sa construction quadrill par 19 grandes parties qui sont cens e recouvrir l ensemble des besoins de sant Il r pond probablement aux besoins de l industrie am ricaine de la sant mais malgr tous les efforts de diffusion il n est encore utilis nulle part avec succ s sauf en Argentine par une compagnie d assurance priv e qui poss de ses h pitaux Du point de vue des soins primaires malgr une tentative de rapprochement avec la Wonca l organisation des infirmi res ou l OMS on a de la peine voir comment SNOMED pourra articuler le complexe de la m decine de premier recours qui croise les champs du somatique du social du psychologique et de l anthropologique Il faut souligner que les aspects mentaux de SNOMED sont un calque du DSM IV de l Association Am ricaine de Psychiatrie dont les liens avec l industrie pharmaceutique ne sont plus un secret pour personne L APA s est acharn e d truire le courant freudien aux Etats Unis et cr er des nouvelles entit s maladies correspondants aux besoins de cette m me industrie qui payait ses travaux Cette critique acerbe n enl ve rien au fait que SNOMED est un
29. ism pharmaceutical biologic product physical force physical object procedure qualifier value record artifact situation with explicit context social context special concept specimen staging and scales substance Figure 8 The 19 hierarchies of SNOMED CT concepts with their unique identifiers Cliniclue browser extract SNOMED CT International Edition 2010 01 31 http www cliniclue com 22 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 123037004 body structure 4404684003 clinical finding administrative statuses adverse incident outcome categories calculus finding clinical history and observation findings clinical stage finding cyanosis deformity disease acute disease AIDS associated disorder angioedema and or urticaria biphasic disease chromosomal disorder chronic disease 4191268006 chronic anemia 4398155003 chronic anterior uveitis 4312923002 chronic central serous chorioretinopathy 128284006 chronic digestive system disorder 128529002 chronic disease of breast 4111422001 chronic abscess of breast 4 76513003 chronic fibroadenosis of breast 421648003 chronic mastitis 4314955001 local recurrence of malignant tumor of breast Figure 9 SNOMED CT Disease as sub hierarchy of Clinical finding The fig shows the opening of chronic disease of breast Cliniclue browser extract SNOMED CT International Edition 2010 01 31 http www cliniclue com 3 4
30. isorder hierarchy The chain of character epileps is present 216 times in SNOMED CT International Edition 2010 01 31 Cliniclue browser The Figure 19 shows some of them with their respective numerical identifier For pedagogic purpose one of the linked concept Reflex epilepsy disorder has been represented in the visual display of the left windows with its numerical identifier ID 79745005 This helps to understand that the computer plays with numbers and shows readable items The lines between concepts are actually relationships which have also their own numerical ID The concepts are presented here with human readable words but for computer use chains of numerical ID are enough as shown in Figure 14Figure 14 Note that in the upper line of the left window one can read the SNOMED RT CAP codes and CTV3 former Read code or clinical codes UK This kind of formal representation of concept forms the basis of ulterior transfers or analysis XML is particularly fit to such transfer as in this example Figure 18 the xml tag description id contains all the characteristics of the Epilepsy as a SNOMED CT entry description id 178739011 term epilepsy status 0 type 1 language en initialCapital 0 conceptid 84757009 conceptStatus 0 gt lt description gt Figure 18 XML tag for SNOMED CT concept Epilepsy 27 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 TE SN
31. lateur pour des motivations videntes Objective facts instead symptoms or complaints ICPC is not intended to code facts or objective findings like azoospermie coded Y10 or status post salpingo ovariectomie coded X28 Disease instead symptoms or complaints is already included in the wrong code rubric but the number of such error is so high that have to mention it Like scl rose prostatique coded Y06 or exposition une temp rature extr me coded Z29 should be A88 Process instead symptoms or complaints this is particularly present in chapter W partly due to inherent ICPC problem like examen de contr le gyn cologique dans le cadre d un suivi de la contraception orale coded W11 should be W31 but also in Y chapter as test de fertilit chez l homme coded Y10 should be Y38 Bad translation Dutch French is not frequent as in affection des organes g nitaux for complicaties geslachtsorganen Double coding needed with 100 occurrences of which 94 in chapter W this is clearly a point of interest to be discussed with the authors of 3BT For instance the double syntagme h morragie du post partum due un placenta incarc r includes two concepts one is related to symptoms and can be coded W17 post partum bleeding but the second is a medical diagnosis which has nothing to do here The relationships quoted here are relevant of the structure of the information and not of the classification itself Conside
32. le M Roland M Van Bruwaene B Vandenbergh Ph Vander Stichele R Recherche pr liminaire en rapport avec le d veloppement d un serveur belge de terminologie dans le secteur de la sant SEMINOP MIM Bruxelles octobre 2010 6 Medidoc Jau pu obtenir du Dr Bartolomeeussen maitre d uvre du projet Intego une page extraite du serveur terminologique du software Medidoc titre scientifique La liste ci dessous est manifestement prise la fa on des terminologies de premi re g n ration en introduisant le mot clef NEO BRONCH qui retourne une s rie d occurrences dont seulement quelques unes sont pr sent es ici Ce genre de liste analogue celles pr sent es par le 3BT cfr infra sont g n ralement peu ais es manipuler et ne sont g rables que gr ce des astuces d crans pr par es par les informaticiens et qui introduisent souvent des biais de s lection s agit souvent des occurrences les plus fr quentes qui sont pr sent es par d faut ou des occurrences pr f r es d un utilisateur MinVanMddc Cod Diagn Mddc ICPC Cod R16281A NEO BRONCHIOLO ALVEOLAIR R84 R16235 NEO BRONCHUS BOVENKWAB R84 R16232 NEO BRONCHUS BOVENKWAB ADENOCARCINOOM R84 R162312 NEO BRONCHUS BOVENKWAB EPIDERMOID CARCIN R84 R16233G NEO BRONCHUS BOVENKWAB GROOTCELLIG CAR R84 R16233 NEO BRONCHUS BOVENKWAB GROOTCELLIG CARCI R84 R16234 NEO BRONCHUS BOVENKWAB KLEINCELLIG CARCI R84 R16239 NEO BRONCHUS BOVENKWAB NNO R84 R1626 NEO BR
33. logy general internal medicine and surgery A rare disease and related concept as Apoliproteine has 90 occurrences in the Cliniclue browser while the color Blue is quoted 645 times which is explained by the huge use of this term in tissue stain in Pathology The field of psychodynamics is clearly dominated by the DSM IV concepts and system of classification which could be certainly a problem as this particular view of psychiatry and psychodynamic suffers of a story of parti pris and 19 20 competing interests Nevertheless from the Primary Care point of view one will appreciate the Wonca International Classification Committee WICC http globalfamilydoctor wicc 29 MJ Terminologie et informatique en soins primaires Belgique 1980 2010 REGM 2010 147 occurrences of the term fear of From epidemiological point of view the vocabulary looks not so developed with 23 occurrences of the concept Public health 4 for nosocomial and 3 for normal distribution The anthropological field looks very poor and marked more by common popular view than scientific analysis particularly when addressing the issue of separating the human beings groups As usual in medical North American literature the term race is still in use for this purpose despite scientific recommendations21 while the concept of ethnicity suffers from a lack of knowledge It is quite amazing to read that Belgians is an ethnic group wedged alphabetically between the Basque a
34. maceutical Industry Psychother Psychosom 2006 75 154 160 http www tufts edu skrimsky PDF DSM 20C01 PDF Lane C Shyness How Normal Behavior Became a Sickness Yale University Press 2007 2n Witzig R The Medicalization of Race Scientific Legitimization of a Flawed Social Construct Annals of internal medicine October 15 1996 vol 125 no 8 675 679 http www annals org content 125 8 675 abstract ae Jeanty C Critics of SNOMED INTERNATIONAL Critique du SNOMED International in French Not dated 1994 969696269469626969696969696962696069696 696969696069696 696 31
35. mise en place de syst mes d information de sant coh rents et volutifs n cessite l adoption de terminologies de r f rence dans le domaine de la sant Nous examinons ici les diff rentes approches terminologiques disponibles dans les logiciels belges l effort d une terminologie centralis e connue sous le nom de 3BT la tendance internationale autour d un produit anglo saxon d nomm SNOMED CT et nous indiquons la voie qui nous parait la plus ad quate pour le d veloppement d une informatique m dicale plus fluide dans les ann es venir condition indispensable pour l analyse ult rieure de donn es de morbidit 1 Dictionnaires et terminologies en usage dans les logiciels belges de m decine g n rale 1 1 Standardiser les mots La mise en place de syst mes d information de sant coh rents et volutifs n cessite l adoption de terminologies de r f rence dans le domaine de la sant Cela parait tre une vidence dans la bouche d un professeur de sant publique en 2010 mais il a fallu plusieurs dizaine d ann es pour s apercevoir que les efforts des concepteurs de logiciel s belges pour munir leur produit de terminologies se traduisent par une cacophonie de dictionnaires non standardis s rendant infaisable l agr gation du savoir indispensable l analyse Standardiser les mots n est pas une t che de docteurs et pourtant ce sont des m decins qui depuis les ann es 80 ont souvent avec un admirable acharn
36. n des 1830 concepts dans ce syst me On trouvera sur chaque page tous les termes techniques et populaires de tous les langages 4 Dictionnaire cette liste contient une description courte en anglais de chaque terme 8 Vander Stichele et coll Multilingual glossary of technical and popular medical terms in nine European languages Final Report Heymans Institute of Pharmacology University of Gent and Mercator College Department of Applied Linguistics Gent Belgium December 1995 disponible sur http users ugent be rvdstich eugloss information html 9 A 5 xis r En linguistique un lemme est une unit autonome constituante du lexique d une langue wikipedia 11 List of technical and popular medical terms French p Back to welcome Back to e selection Ee to previous selection BE palliatif s et am traitement qui agit sur les sympt mes sans agir sur la maladie pop 9 Ej Palp bral de paupi res pop g E palpitation f contraction cardiague anormales pop g E pancr atite f inflammation du pancr as pop Fi Ej Pancytopenie f diminution simultan s des trois type de cellules sanguines pop BE panniculite f inflammation du tissu adipeux sous cutan pop g E papillaire relatif de papillez en forme ds pop E ES rsrillite f inflammation de la papille optique des papilles de la langue pop Ic E papillite papillaire oed me inflammation de la papille optiqu
37. nd the Black ethnic group Cliniclue browser A concept like second generation which is the corner stone of a consultation in European cities where ethnic groups are so prevalent is not present in SNOMED CT terminology behalf for second generation drugs Ethnicity 7 entries Ethnic group 1 entry defined by is_a group Race 16 entries the term Race alone is defined is a demographic history detail Race white 1 entry defined is a racial group There is no Race African or black But well a Black ethnic group second generation 7 entries but only related to the concept of second generation drugs The concept second degeneration of an ethnic group is absent Figure 20 Separating the human beings groups in SNOMED CT 7 Conclusion While one can acknowledge the fantastic work of aggregating so huge quality products and the high level of expertise involved in it on can note that despite to be owned by a non profit organization SNOMED CT is a proprietary product which searches an expansion of his market This implies some rules of confidentiality which are incompatible with Knowledge as a resource of mankind for thos who don t have full access granted Considering the availability of high level Ontologies in open source it is worth to evaluate also this way of dealing with medical knowledge SNOMED is still growing In the 90 Dr C Jeanty a Belgian doctor involved in SNOMED use since 1975 was already astonished
38. nd the recent project of registration in GP FM are considering using it As an expert in classification and member of the WICC I have been asked at several moments to give comments on coding since 3BT has been developed but I didn t have the opportunity to have a good insight into the product 13 There are the reason why have begun to revise 3BT systematically at least in the most difficult components the Symptoms and Complaints ones Thus have tried to analyze all the items proposed in 3BT code between 01 and 29 chapter by chapter After a quick insight in P D and A chapter have decided to continue systematically beginning by the last one the Z chapter have finished to revise 4 chapters Z social Y and X genitals and W pregnancy The number of problems have met is growing so much that think it s necessary to share my analysis without finishing the 17 chapters Findings on 4 chapters Wrong code 98 items of which 48 in the Z chapter the code as been examined from the point of view ICPC and not from ICD one Basic term missing terms like manque d eau lack of water or manque d acces aux soins lack of health care accessibility are missing Term not understandable or inadequate or irrelevant 92 of which 84 in the Z chapter with syntagmatic expression such as difficult s li es la pr sence d un parent handicap dans la famille et provoquant une tension dans le foyer or moral affirmation such as simu
39. ns Primaires CISP La version utilis e ici est la version 2 publi e en 2000 et usage informatique Ces concepts ont t associ s des codes en trois caract res le premier alphanum rique pour l un des 17 chapitres Les deux suivants num riques pour les composants Ces codes ont des caract ristiques mn motechniques ICPC et ses diff rentes version et traductions appartiennent la Wonca qui doit tre avertie de l utilisation des codes dans des syst mes informatique La Belgique a achet la licence d utilisation Le LOCAS 2 est libre de droit et peut tre utilis condition de citer les sources et les auteurs Il ne peut tre modifi Toute utilisation en dehors de la Belgique doit faire l objet d un accord avec la Wonca 10 1 5 Multilingual Glossary of technical and popular medical terms in nine European Languages No 0001 abdomen Danish Technical term g abdomen Popular term n mave German Technical term n Abdomen Popular term n Bauch Spanish Technical term g abdomen nm Popular term g vientre nm French Technical term H abdomen m Popular term g ventre Italian oy Technical term H addome Popular term H addome Dutch fy Technical term H abdomen Popular term H buik Portuguese fey Technical term H abdomen Popular term g barriga ventre Figure 2 Multilingual lemma Bien que cet outil ne figure pas directement dans les logiciels de m dicine g n rale il a
40. nships could quickly become tautological as in the Figure 7 It s interesting to see the lack of stability of the relations used to describe interrelated concepts which are at the aim of the practice The relation is a normality findings could also be interpreted as part of normality findings and one can wonder why normal is anormality findings while abnormal is a modifier Indeed the question of relations in ontologies is still discussed 21 SNOMED CT Term occurrences Definition by relations Borderline 188 is_a reference range interpretation value Normal 1814 is_a normality findings Abnormal 788 is_a modifier related to clinical specialty AND or occupator Pathological 92 is a normality findings Figure 7 Occurrences of usual terms in Clinical Clue Browser Cliniclue browser extract SNOMED CT International Edition 2010 01 31 http www cliniclue com WC the above is of course nonsense 3 3 The hierarchies or Roots of SNOMED CT They are 19 Upper level hierarchies or roots revealed by the Cliniclue browser Each hierarchy roots has sub hierarchies Hierarchy 106237007 d 363787002 1410607006 1273873005 478621006 471388002 d 362981000 d419891008 d243796009 048176007 123038009 254291000 4 105590001 ubtype hierarch DCT gt body structure clinical finding environment or geographical location event linkage concept observable entity organ
41. oncept within a hierarchy is a or across hierarchies including mapping to original codes Cliniclue browser extract SNOMED CT International Edition 2010 01 31 http www cliniclue com 3 5 The tables of SNOMED CT SNOMED CT comprises 9 tables of which 3 core tables concepts descriptions and relationships collectively defining a compositional description logic ontology of the medical domain and a lexicon of associated preferred or synonymous descriptions The most recent international release January 2010 contains more than 308 000 active concepts 791 000 active descriptions organized into 19 hierarchies with more than 951 000 relationships 3 Concepts Descriptions Relationships Core tables 2 Subsets Subset Members 3 Cross Map Sets Cross Maps CrossMapTargets 1 Component History Figure 12 9 tables in SNOMED CT distributed in the form of tab delimited text files Core tables characteristics Concepts Relationships Descriptions Concept_id Relationship_id Description_id Concept Status Concept id1 Concept_id Fully Specified Name RelationshipType Description Status CTV3_id Concept id2 Term SNOMED id CharacteristicType Intial Capital Status Is Primitive Refinability Description Type Relationship Group Language Code Gastric ulcer Is a Gastrointestinal ulcer Figure 13 Core tables characteristics 24 MJ Terminologie et informatique en soins primaires Belgique 1980 2010
42. pe of health care which allows data to be captured coded retrieved exchanged and understood SNOMED CT has been created by combining SNOMED RT the terminology produced by the College of American Pathologists http www cap org and a computer based nomenclature and classification known as Read Clinical Codes Version 3 CTV 3 The Read Codes were invented and developed by Dr James Read in 1982 for use in General Practice In 1990 the NHS bought the Read Codes from Dr Read and made them NHS standard Systematized Nomenclature of pathology SNOP ancestor of SNOMED has been published in 1964 In the Medical subject heading of the National Library of Medicine SNOMED has gained its place between MeSH and UMLS It has been proposed but not yet accepted as the interface vocabulary for all the Electronic Health Records in the USA Since 2003 there is an agreement between the U S Secretary of Health and Human Services and the College of American Pathologists that will make SNOMED CT available to U S users at no cost for the users but a unknown cost to the US government through the National Library of Medicine s Unified Medical Language System UMLS In April 2007 the International Health Terminology Standards Development Organization a non profit organization based in Denmark http www ihtsdo org acquired the intellectual property rights of SNOMED Clinical Terms SNOMED CT and its antecedents from the College of American Pathologist
43. pl 1 S2 http www ncbi nlm nih gov pmc articles PMC2582789 Lussier Y A and Bourque M Comparing SNOMED and ICPC retrieval accuracies using relational database models Proc AMIA Annu Fall Symp 1997 514 518 http www ncbi nlm nih gov pmc articles PMC2233545 14 Gambarte ML Osornio AL Martinez M Reynoso G Luna D de Quiros FG A practical approach to advanced terminology services in health information systems Stud Health Technol Inform 2007 129 Pt 1 621 5 http www ncbi nlm nih gov pubmed 17911791 5 Smith B Ceusters W An Ontology Based Methodology for the Migration of Biomedical Terminologies to Electronic Health Records AMIA Annu Symp Proc 2005 2005 704 708 http www ncbi nlm nih gov pmc articles PMC1560617 tool pubmed 15 UDM Breaking News November 18 2009 SNOMED CT ICD 9 CM Map Released http www healthdatamanagement com news 39384 1 html a Wang Y Patrick J Miller G O Hallaran J 2008 A computational linguistics motivated mapping of ICPC 2 PLUS to SNOMED CT BMC Med Inform Decis Mak 2008 Oct 27 8 Suppl 1 S5 http www ncbi nlm nih gov pubmed 19007442 doptzcitation 8 Vikstr m A Nystr m M Ahlfeldt H Strender LE Nilsson GH Views of diagnosis distribution in primary care in 2 5 million encounters in Stockholm a comparison between ICD 10 and SNOMED CT Inform Prim Care 2010 18 1 17 29 2 Cosgrove L Krimsky S Vijayaraghavan M Schneider L Financial Ties between DSM IV Panel Members and the Phar
44. ries 2010 Spain Australia Lithuania Sweden Canada New Zealand The Netherlands Cyprus Singapore United Kingdom Denmark Slovak Republic United States Estonia Slovenia 3 SNOMED CT a complex controlled medical vocabulary 3 1 What s a SNOMED concept A unit of meaning In SNOMED CT a concept is a Unit of meaning described by a unique numeric code a unique name Fully Specified Name a set of terms descriptions one Preferred Term and one or more Synonyms SNOMED CT concepts are either primitive or fully defined A fully defined concept can be differentiated from its parent and sibling concepts by virtue of its relationships with other concepts Otherwise it is primitive Fully Specified Name Unambigous name of concept unique for active concepts which includes a trailing hierarchy tag in brackets Ex Hematoma morphologic abnormality Hematoma disorder 3 2 Descriptions versus definitions A concept definition is the list of its relationships to other concepts There is no cursive definition of concepts available While SNOMED CT considers relationships as the unique way to define a concept other authors of ontologies don t agree with this view arguing that the ontologies have to include textual definitions for all terms and that terms should be defined so that their precise meaning within the context of a particular ontology is clear to a human reader Indeed definitions by relatio
45. ring this analysis of only 4 chapters which has been really time consuming suggest a complete process of revision of 3BT and urge my colleagues from WICC who are in a translation process to participate to this revision before to use the product The revision of 3BT has to be up to the Belgian Classification Committee with the help of all groups interested to have a good biclassified terminology for use in Primary Care This kind of product which has to be disseminated as an open document is a central issue in the development of EMR and particularly in open source EMR 14 chapter W X Y Z Total change of code proposed 0 14 36 48 98 basic terms missing 2 8 7 11 28 term not understandable or inadequate or irrelevant 1 4 3 84 92 remarks and comments 10 14 3 10 37 objective facts instead symptoms or complaints 1 9 9 19 disease instead symptoms or complaints 3 10 25 38 process instead symptoms or complaints 36 0 17 0 53 bad translation Dutch French 1 1 3 0 5 double coding needed 94 6 0 0 100 145 59 88 178 470 Tableau 4 470 annotations on 4 chapters of 3BT M Jamoulle 2009 2 Les propositions r centes 2 1 Exemple d une terminologie de deuxi me g n ration SNOMED CT SNOMED CT est un produit typique de la culture am ricaine Produit au d part dans les ann es 70 par des anatomopathologistes la terminologie de premi re g n ration pick list SNOM
46. s SNOMED CT is a complex ontology and sophisticated browsers are required to make it understandable and useful Rogers amp Bodenreider have identified 23 SNOMED CT browsers that have been developed and inspected 17 They enumerate and provide test criteria for a master list of 143 browsing features supported by at least one inspected browser future work will determine which of these features are implemented by individual browsers Only 5 features were common to all 17 browsers 89 were found in less than one third of browsers They recommend that a core set of browsing features be defined and harmonized across browsers particularly for text to concept Browsers permit searching on the SNOMED CT terminology by displaying the hierarchy descendents and ancestors of a given concept and by displaying the relationships and terms detail associated with a particular concept search operations Different implementations of software offering SNOMED CT browsing capability are available Do refer to http www connectingforhealth nhs uk 4 1 An example of study with Dataline software The dataline SNOMED CT browser allows visual representation http snomed dataline co uk and is freely available on Internet One has studied how a concept in this case Epilepsy is presented in serial written way with its concept_ids left column and in a visual way right column Figure 19 The Epilepsy concept has the number 84757009 and pertains to d
47. s for 7 8 million Information Science Category Information Science Information Services Documentation Vocabulary Controlled Current Procedural Terminology Diagnostic and Statistical Manual of Mental Disorders Healthcare Common Procedure Coding System International Classification of Diseases Logical Observation Identifiers Names and Codes Subject Headings Medical Subject Headings Systematized Nomenclature of Medicine Unified Medical Language System Figure 6 SNOMED finds its place in the controlled vocabularies of the NLM http www ncbi nlm nih gov mesh 68018875 2 1 International Health Terminology Standards Development Organization By acquiring the SNOMED CT standard the IHTSDO which was established by a group of nine founding nations Australia Canada Denmark Lithuania The Netherlands New Zealand Sweden the United States and the United Kingdom will help to ensure the continued maintenance and 20 evolution of SNOMED CT as well as its availability on an international scale The IHTSDO assumed responsibility for the ongoing maintenance development quality assurance and distribution of SNOMED CT SNOMED Terminology Solutions a specialized team of the College of American Pathologists has been commissioned to support IHTSDO operations under an initial 3 year contract and will separately continue to provide SNOMED related products and services as a licensee of the terminology 2 2 IHTSDO member count
48. te sucr code DeB est un diagnostic D et endocrinologique De de surcro t La terminologie DCM est transcod e la CIM9 CIM10 CISP2 et DSMA On voit par exemple dans la Figure 4 que le terme cod DCM DrBOD est reli aux classifications ICD9 ICD10 ICPC1 et ICPC2 CNK A chaque nouveau conditionnement de sp cialit pharmaceutique est attribu un code unique le Code National ou Nationale Kode CNK Voir http www ipheb be annexe 20methodologique 20FR pdf 8 Health One Health one utilise une base de donn es terminologique propri taire de 10 000 termes identifi par un contenu et un code HO Code Chaque HO Code est li un code ICPC2 et ou ICD10 Les codes diagnostics sont classifi s en une hi rarchie de maladies et en une liste de termes pr f rentiels 1 4 Le LOCAS Logiciel de Codage et d Acquisition de Synonymes Le LOCAS est en r alit une base de donn es terminologique de premi re g n ration qui r pertorie les termes les plus usit s des m decins g n ralistes travaillant en Maisons M dicales entre 1990 et 2000 Ces termes sont transcod s ICPC 2 Le LOCAS a fait l objet d une publication L ouvrage est la transcription sur papier de la terminologie d velopp e sous l acronyme LOCAS Logiciel de Codage et d acquisition de synonymes Z01 0011 PROBLEME D ARGENT 201 0021 PROBLEME DE PAUVRETE 201 0031 PROBLEME DE SURENDETTEMENT Z01 0041 PROBLEME LIE A LA GESTION DE L ARGENT 201
49. ully Specified Name te E ber e EET OO PETERE RE ETE HERES 21 3 2 Descriptions versus definitions sisi 21 3 3 The hierarchies or Roots of SNOMED CT siennes 22 3 4 Relationships s ren Re RE 23 3 5 The tables of SNOMED GT 3 2 Rte tene ruta E en eene E n Ree tea ERE his a 24 Core tables characteristiCs s e e ti rte Potete rece Hin D eee ee a n 24 3 6 The Clinical Terms Identifier SCTID a 64 bit integer 25 3 7 Preand post coordinatiori ete eter tret e e ee x edat 25 Pre coordinated concepts HRS 26 Post coordination of concepts iii 26 Loosing redundanty el mete tie ete ix deo ee te Reb re eee dbese est ede tied 26 4 SNOMED BFOWS rS int Eee rre eee eer ee aene gebe aee y ee eaae eb A nn ee ve ehe titine 27 4 1 An example of study with Dataline software 27 5 To what extent Is SNOMED CT in use in practice serres 28 Practical USC ee M RE a entr 28 Mapping ceo tente ei ee om e eR RE E 29 Availabilty of translations ui des eet t e use cuted eeu c edt a dendi ie dde 29 6 Does SNOMED CT encompass the field of GP FM csccccsssceessecesseecssseeeaecesseecsseeccsaeeecaecessees 29 Quick look through the Cliniclue browser 29 Tes COMCWISION MEE 30 Be RETELENCES pe 30 18 1 Semantic interoperability and general practice This paper is driven by the acquisition of knowledge in the field of
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