Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Biophysical Semeiotics, Clinical Information Standards and “human” Medicine.
- Sergio Stagnaro (23 May 2003)
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Clinical coding: when to standardise ?
- Jeremy E Rogers (27 May 2003)
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Why clinical information standards matter
- Robin Y Mann, John G Williams (30 May 2003)
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Clinical Terminology numbering
- Charles A West (30 May 2003)
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Using people to save work for computers
- Adrian K Midgley (20 March 2009)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy.
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Sirs, Martin Gardner (BMJ 2003;326:1101-1102, 24 May) states rightly that clinical information standards are essential resources for future clinical decision support, audit, governance, research, education, and training, underlining some relevant questions about “what clinical information standards doctors need, who should develop them, and how they should be evaluated”. In my own experience, however, clinical information standards become now-a-days still more complex as a consequence of recent developments in the field of physical semeiotics (See HONCode site http://digilander.libero.it/semeioticabiofisica). In fact, thanks to these biophysical-semeiotic progresses, doctor can assess at the bed-side, e.g., both function and structure of microcirculatory bed of every biological system, under both basal and stress conditions, that parallell local parenchimal events (http://digilander.libero.it/microangiologia). Consequently, I am speaking about “microcirculatory activation, type I, associated”, “microcirculatory dissociation”, a.s.o. Certainly, the answer to the questions on who should develop standards is today even more difficult. I can not see, at the moment, who or what organisation might develop biophysical-semeiotic clinical information standards. This account for the reason I am very grateful to BMJ.com, Medscape, as well as to italian sites Piazzetta and Katamed. In any case, from solving this problems depends clearly the future of clinical, “human” Medicine, i.e., “Single Patient Based Medicine” (See: BMJ.com, Stagnaro S.: “Single Patient Based Medicine” versus EBM.,16 May 2003) Competing interests: None declared |
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Jeremy E Rogers, Clinical Research Fellow Manchester M13 9PL
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Editor, As somebody working in the unglamorous area of clinical terminology and ontology standards, I am encouraged to see the problem reach the editorial pages of the BMJ. That clinical coding has historically been viewed as of very marginal interest to ordinary clinicians is unsurprising but disappointing: substantial sums of money have been and are being spent internationally on developing clinical coding standards, and on employing clinical coders in hospitals. In UK primary care, much effort is spent actually entering codes - my own data suggests around 90,000 coded entries are manually added each year in a typical five partner practice, equivalent (using Brown's 30 seconds per code timings) to more than four person months per year of effort in each practice (though only 40% of all manually entered codes are entered by a GP - the majority are keyed in by other practice staff). Meanwhile, the NHS is set to spend GBP 2.3 billion over the next 3 years on a massive IT modernisation programme. This includes the introduction of clinician-facing electronic patient records across secondary care as a cornerstone goal. Coding of the patient state may no longer be something that happens by unnamed coders in the hospital basement only when the patient leaves the hospital, but may occur daily, as potential input to computer systems that attempt variously to support or critique clinical care decisions. Who will enter this data ? That this level of resource has been, and continues to be, committed without an agreed evaluation methodology, and whilst the data produced in UK general practice at least appears to be of limited value for monitoring even common diseases, should be of greater general concern. Gardner's recognition that our focus must move from building lists of terms for humans to read and understand to building systems of concepts (ontologies) for computers to manipulate is at the heart of the difficulty. The significance of this shift is often underestimated, hence the widespread mistaken belief that the problem of standardising clinical information is already a done deal. The 'ontology problem' is by no means unique to medicine, being the focus of an accelerating activity in the Semantic Web initiative. The need for continuing flexibility, experimentation and evaluation in the coming years is, as Gardner says, greater than ever. This raises a question not asked by Gardner: when to standardise ? How much can you, or should you, standardise when rapid change is anticipated ? The NHS decided in 1999 to declare what is now called SNOMED CT as its chosen standard clinical terminology. Although this mandated standardisation may facillitate the immediate goal of its ambitious information systems upgrade, it may turn out to be premature given the anticipated rapid change in ontology technologies. Competing interests: OpenGALEN ontologist |
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Robin Y Mann, Development Officer - Health Informatics Royal College of Physicians, Regent's Park, London NW1 4LE, John G Williams
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Sir, Gardner has described three types of clinical information standards and wonders who should develop them.(1) We would suggest that it is not who should do it that is so important as how it should be done. We believe that standards development should start from the evidence-base and be evaluated and developed in a manner that clinicians are able to understand and accept. We have reviewed the evidence-base for structuring medical records and found that structure can also improve patient outcomes and doctors performance.(2) There is a strong argument for having a common high-level structure to the clinical record, in the form of agreed headings.(2,3) Whilst some purists of lexicons and ontologies think this level of standardisation is unnecessary, we believe that common headings protect clinical context when information is communicated between people or systems. The problems arise when they are not commonly understood, and implementation fails to address change in culture.(4-6) We have also made evidence-based recommendations for the admission and follow-up entries in the record and the discharge/transfer communication. These draft record-keeping standards for inpatients have been made available for consultation purposes at www.rcplondon.ac.uk/college/hiu/recordsstandards. We have included example admission and discharge proformas, and an audit tool, which form part of a generic educational programme that can be used to help implement the standards locally.(7) We acknowledge that this needs to be followed by research into what information
should be recorded under each heading, and how that information may itself be
structured to the level of detail that Gardner describes, but we hope that colleagues
will engage in a constructive debate to achieve these important goals. References:
Competing interests: None declared |
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Charles A West, Associate Director, Stakeholder Relations, NHS Information Authority NHS Information Authority, Aqueous 2, Aston Cross, Birmingham B6 5RQ
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Like other respondents I am glad to see the interest in Clinical terminologies. Philip Brown's article on page1127 suggests, as one might hope and expect, that the more extensive and newer Terminology is better able to represent accurately the concepts that GPs need to record. Unfortunately the numbering of different versions of the Read Codes is not straight forward, and Martin Gardner's leading article compounds the problem by getting it wrong. There is no version 5 of the Read codes. The two terminologies compared in these articles are version 2 of the Read codes tested here in it's most widely used 5 byte variant; and version 3 of the Read codes which became known as Clinical Terms version 3 or CTV3 for short. Version 2 of the Read Codes was developed through the 1980s and made generally available to the NHS in 1990. Version 3 was first released in 1994. Charles West Competing interests: None declared |
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Adrian K Midgley, GP Exeter EX1 2QS
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If several codes are selected by people, each meaning something that the searcher regards as the same thing, then the searcher must search on any of them. This doesn't take extra time, and it takes minimal effort, by one person, the searcher, in constructing their search. To suggest instead that everyone else should change what they do seems overambitious to me. Unless the searcher is successful in persuading us all that they are right and we are wrong, or in removing and arrnaging the automated replacement of the codes he doesn't like, then he replaces a minor irritation on his part with a persisting source of errors, and a cognitive load on many other people. This seems to me to be so dumb it suggests the understanding of searching using codes may not be as complete as one would hope in an author. Competing interests: None declared |
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