fundamentals about why we need coding

1. Introduction to Coding and
SNOMED-CT
11 October 2010
Dr.F.Jahedi
iGENE - INFOVALLEY

2. Data
Process
Information
Process
Process
Knowledge
Coding
Wisdom

3. Principles
Patterns
Relationships
Data
Wisdom
Knowledge
Information

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. 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. 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. Mapping
• An example of mapping RCC to ICD-9

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. 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. 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. 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. SCTID

13. Types of concepts

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”?

16. 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

17. Benefits of Coding
• Data reduction
• Standardized terminology
• Enabling statistical overviews & research
• Support of management and planning
• Coupling with DSS

18. Any Question?

19. Thank you