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Introduction to medical coding standards and SNOMED-CT


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fundamentals about why we need coding

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Introduction to medical coding standards and SNOMED-CT

  1. 1. Introduction to Coding and SNOMED-CT 11 October 2010 Dr.F.Jahedi iGENE - INFOVALLEY
  2. 2. Data Process Information Process Process Knowledge Coding Wisdom
  3. 3. Principles Patterns Relationships Data Wisdom Knowledge Information
  4. 4. 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
  5. 5. 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.
  6. 6. 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
  7. 7. Mapping • An example of mapping RCC to ICD-9
  8. 8. 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)
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. SCTID
  13. 13. Types of concepts
  14. 14. 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”?
  15. 15. 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
  16. 16. Benefits of Coding • Data reduction • Standardized terminology • Enabling statistical overviews & research • Support of management and planning • Coupling with DSS
  17. 17. Any Question?
  18. 18. Thank you