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Extending the ENV 1828 Model to Support Regional Terminology Requirements ... NHS Centre for Coding and Classification, Loughborough, United Kingdom.
Clinical Administration Procedures in the Read Thesaurus: Extending the ENV 1828 Model to Support Regional Terminology Requirements David Robinson MB BS MSc, Colin Price MPhil FRCS, Philip J. B. Brown MRCGP NHS Centre for Coding and Classification, Loughborough, United Kingdom. Documentation of the administrative aspects of clinical practice (fee claims, referrals, visits etc.) is essential and a controlled terminology for the electronic health care record needs to support this requirement. The Read Codes - used in the United Kingdom for over 10 years - include a chapter of administration terms for this purpose. The latest version, the Read Thesaurus, adopts a partially compositional approach to concept representation. We describe an extension of the ENV 1828 surgical procedure scheme developed as a provisional model to represent administrative procedures. Applicable concept fields, semantic links and modifiers are identified and compared. A compositional approach appears to provide a flexible and manageable method of representing administrative procedures, and readily accommodates regional variations.

We reviewed existing models, including the NHS Data Dictionary9, and the NHS Information Management Centre Generic Model10. However, these concentrate on the high level processes involved in the provision of health care, rather than at the concept level required for the purposes of the Read Thesaurus. In this paper, we describe our adaptation of the ENV 1828 scheme as a provisional model for the clinical administration chapter of the Thesaurus.

INTRODUCTION

ENV 1828

The Read Thesaurus (Clinical Terms Version 3)1, was produced during the Terms Projects, a series of collaborations between the NHS Centre for Coding and Classification (NHSCCC), the Conference Information Group of the Medical Royal Colleges, the Nursing, Midwifery and Health Visiting Professions, and the Professions Allied to Medicine (PAMS)2'3. These projects aimed to provide a comprehensive clinical coding scheme, including specialist detail and encompassing the full domain of health care.

The draft structure includes concept fields, modifiers and semantic linkages with combinatorial rules that specify appropriate normative constructs. Additional informative detail may be used to optimise the clinical procedure record (Figure 1).

We suggest that an essential requirement of the administration model is that it should be flexible enough to encompass regional variations, for example, between England and Wales, Scotland and Northern Ireland, where legal and administrative procedures vary. Such regional differences are of particular concern to developers of large-scale clinical vocabularies intended for widespread use.

Extent

The Thesaurus includes a template file4 that supports both qualification and semantic definition of concepts5. Using object-attribute-value triples1'4, extensive semantic definition has been undertaken in the surgical procedures section, based on a modification of the ENV 1828 Pre-standard structure produced by the Comite Europeen de Normalisation (CEN) Technical Committee

Deed e.g. Excision

has direct object

Surgical

Human

Pathology

h J indirect object

has l

means

}a

VI

I direbt object

Interventional Equipment e.g. Stent, Laser

2516. Number

In the Thesaurus, clinical administration terms have been expanded from those provided in earlier versions7' 8 to support General (Family) Practice (GP) use, to satisfy the multi-professional needs for recording data relating to clerical, reimbursement, surveillance and related procedures. 1091-8280/98/$5.00 © 1998 AMIA, Inc.

Figure 1: ENV 1828 Concept diagram for surgical procedures (dashed rectangle encloses normative references)

There are four principal concept types: deed (excision, aspiration, etc.); human anatomy (heart, lung etc.);

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pathology including post-surgical states e.g. cyst, colostomy); and, finally, interventional equipment (including implants, prostheses, surgical instruments, imaging devices and physical agents such as liquid nitrogen). Table 1 sunmarises the ENV 1828 concept fields for procedures and the exclusions:

and budget setting for General Practitioners (GPs). Indeed, the original Read Code administration terms were introduced to satisfy the needs of GPs to document item-of-service procedures (e.g. minor surgery), and compliance with surveillance targets (e.g. for cervical smears).

Table 1: ENV 1828 Procedure Pre-standard: concept fields

EXTENSION AND MODIFICATION OF ENV 1828

Concept field Deed

Anatomy Pathology

Exclusions Anatomy; E uipment Laterality statements Anatomy; Specific diagnosis

Although, at first sight, administration and surgical procedures do not appear to be similar, both are types of intervention and share some common features. Extensive modelling of surgical procedures in the Read Thesaurus'112 had resulted in experience of using ENV 1828, and it seemed logical to utilise and extend the principles established during the course of this work. As well as underpinning the organisation of the new administration procedure hierarchy, it should also allow testing of the extensibility ofthe ENV 1828 model itself.

Three main modifiers are proposed: extent (applied to the surgical deed), side (applied to anatomy) and number (applied to deed, pathology or equipment). The semantic linkages are direct object (the direct target of the deed); indirect object (anatomy when this is not the direct object); and the means by which the deed is performed. Each of these semantic roles may be filled by a concept from a number of concept fields as shown in Table 2. Table 2: Semantic roles within concept fields Semantic role | Applicable concept fields Anatomy; Pathology; Equipment Direct object Anatomy; Pathology; EquipmentIndirect object 1 Anatomy; Equipment Means

A preliminary concept diagram was produced by modifying the elements and relationships defined by ENV 1828 (Figure 2) and a number of equivalent components in the extended and original models were identified (Table 3).

l

It can be seen that items from any one concept field may perform a number of roles in a construct to represent a surgical procedure. According to the ENV scheme, the kidney is the direct object in nephrectomy (excision of kidney); the indirect object in aspiration of renal cyst; and the means (surgical material) in renal transplant.

Combinatorial rules specify that the minimum representation includes a Deed + Direct object and that there must be an anatomical representation, either as direct or indirect object. Finally, pathology should not be included unless it is impossible to represent the procedure without it.

object I

interverionatuI

I

e.g. telephone

l

I I

Equipment

Person Service

4 Establishment I I

Figure 2: Extended ENV 1828 concept diagram for administration procedures (compare Figure 1)

ADMINISTRATION IN THE READ THESAURUS Records relating to clinical administration, encompassing such concepts as transfer of care, claim procedures and specialist referral, are essential to the provision of clinical care and have important medicolegal implications. Furthermore, although in the UK health care is predominantly free at point of contact, costs of procedures such as hospital admissions and outpatient referrals affect health care commissioning

In our initial extended model we re-utilised the notions of the direct object, indirect object and means. In addition, we postulated that administration, like surgical procedures, should have as a minimum a deed and direct object. Whereas surgical procedures typically involve anatomy and pathology, administration

procedures involve persons, forms, services and places.

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Table 3: Examples of ENV 1828 equivalent components in surgical and administrative procedures within the Read Thesaurus

ENV 1828 Model Deed Direct Object Indirect Object Means Urgency

Surgical Procedures Routine laser excision of breast cyst Excision Breast cyst Breast structue Laser Routine

The interventional equipment used to perform the deed also translates readily: the scalpel used to excise has its administrative parallel in the telephone used to make a referral. Administrative procedures involve an agent, usually the health carer performing the deed, equivalent to the operating surgeon. Some of the informative detail for surgery assumes greater prominence in administration procedures. There is often a need to capture extra detail about personnel, such as profession or grade, and also urgency (e.g. urgent referral). Repetition (follow up) and the location of the direct or indirect object, e.g. home visit, may need to be documented.

Object

|Patient I

hindirect Telephone

Cardiologist

proess0

A/Q A/Q A

A

Value Referral

A A

A A

Patient Health care

Priority

A

Q

Urgent

(Urgency) Indirect object Using (Means)

A A

Q

Cardiologist Telephone

Q

Submitting minor surgery claim. This example is particularly relevant to General Practice in the UK, where a substantial proportion of GP income is derived from item-of-service fees (Figure 5). The basis of the representation is that an agent (general practitioner) performs the deed (submitting) of a direct object (form) to indirect object (health authorityt). In practice, the claim is submitted by letter or by an electronic communication known as GP Links. Within the general model for submitting the claim, the form used varies within the UK: GMS4 form in England and Wales, GPC form in Scotland and Multi 1 form in Northern Ireland.

cardiologist

I

referal to cardiologist 0

Figure 4: Alternative representations of Urgent telephone referral to cardiologist

|Urgent|

has means

Object Refeml to health

professional

Urgent telephone referral to cardiologist. Figure 3 illustrates the model for this procedure. Normative elements include the deed (referral), the direct object (patient) and the indirect object (cardiologist). Other elements are the priority (urgent) and the means (telephone). The implied agent is a health care professional.

Health Care Professional

Urgnttelqehow

Attribute Administration action (Deed) Direct object Agent

A number of administration scenarios were tried against the provisional extended model: we discuss three illustrative examples and then consider the implications for its wider application.

hsdirectI _ ~~~~~obiectl 4!

Cardiologist Telephone Urgent value (OAV) triples is illustrated in Figure 4. This concept can be represented either by an explicit enumerated term ., in which each attribute is defined as atomic (A) or by a partially compositional approach, in this case, a less specific object concept S is qualified with additional detail for priority, indirect object and using (Q).

APPLICATION OF THE EXTENDED MODEL

Refeural l l Urgent referral to

Administration Procedures Urgent telephone referral to cardiologist Referral Patient

I

Figure 3: Concept diagram for Urgent telephone referral to cardiologist The relevant Read Thesaurus template table representing this information using object-attribute-

t UK Health Service local administrative unit

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Submitting

has direct object

Claim

I.

mk...

Ibaed

General Practitioner has means

Submitting minor Surgery claim form I

GMS4 form GPC form

b . Vmdirect . T ~~~~Authority &a onect,

|l

Figure 5: Concept diagram representation of Submitting minor surgery claim form

Figure 7: Comparison of Direct and Indirect Object Types

DISCUSSION Follow

home visit by diabetes

up

nurse.

Much of the

The use of ENV 1828 as a basis for the development of an administrative procedures model was driven by the desire to reuse knowledge and experience gained in other areas of the Thesaurus, and also to maintain consistency both within the Thesaurus and with external standards and models. There was a need to establish whether such an approach would satisfy the requirements of a different domain.

management of diabetes mellitus is carried out by

clinical nurse specialists and Figure 6 illustrates how this concept may be modelled. Here the deed is visiting, the direct object the patient, and the agent the diabetes nurse.

The examples support our view that representations of like surgical - procedures require a deed and a direct object. Applicable concept fields for administration include persons (usually the patient) and documents (e.g. claim forms). In many cases, an indirect object is also necessary, including persons (usually health care professionals), establishments (e.g. health authorities) and services (e.g. palliative care). The means in ENV 1828 applies to a heterogeneous set of concepts including anatomy and interventional equipment. Similarly, administration procedures reference diverse concept types such as objects, communications technology, and services. Persons involved in an administrative procedure may be agents (usually health carers but possibly the patient as in selfreferral) or direct objects (usually the patient). Specification of individuals as indirect objects is important: for example, referral of a similar problem to a rheumatologist or to an orthopaedic surgeon may result in a very different opinion. administrative -

Diab-

|

Follow up

I

home visit

I

diabetes nurse

etes

Nurse I

P

by

I

Figure 6: Concept diagram representation ofFollow up home visit by diabetic nurse.

There are two pieces of additional information. The follow up nature of the visit is temporal informative data equivalent to revision status in the surgical procedures, and the location of the patient is at home. Wider application

The full administration procedures hierarchy currently contains over 2100 enumerated concepts. These have been analysed to determine the occurrence of different concept types as direct or indirect objects and the results are presented in Figure 7. The patient accounts for over 85% of direct objects, whereas most indirect objects are health carers (61%) or establishments and services

In the ENV 1828 model, each modifier has identified concept fields to which it applies. In our extension of the model to administration we have recognised urgency and revision status, and environmental location as possible modifiers. Urgency appears to apply to the deed as does revision status (e.g. follow-up) which captures the temporal relationships between multiple events.

(36%).

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However, further work may be needed to ensure compatibility with other emerging time standards for health care, such as ENV 1238113.

When both administration models are eventually complete, qualifying value sets shared by procedures and states will require harmonisation.

Documenting the environmental location may be more significant in administration than in a surgical procedure (generally performed in an operating room). The location modifier may apply to the direct object (e.g. visit to patient at home) or the indirect object (e.g. referral of patient to physician in emergency room).

References 1 O'Neil MJ, Payne C, Read JD. Read Codes Version 3: A User Led Terminology. Meth Inform Med 1995; 34: 187-192. 2Buckland R The Language of Health. BMJ 1993; 306: 287-8. 3 Severs MP. The Clinical Terms Project. Bulletin of Royal College ofPhysicians (London) 1993; 27(2): 910. 4NHS Centre for Coding and Classification. Read Codes File Structure Version3. 1 - The Qualifier Extensions. Technical Report. Loughborough: NHS CCC, 1994. 5 Schulz EB, Barrett JW, Price C. Semantic Quality through Semantic Definition: Refining the Read Codes through Internal Consistency. Proceedings of the 1997 AML4 Fall Symposium. Philadelphia: Hanley & Belfus 1997: 615-9. 6ENV 1828. Medical Informatics - Structure for Classification and Coding of Surgical Procedures. Brussels: CEN, 1995. 7Read JD, Benson TJR. Comprehensive coding. Br J Healthcare Computing 1986; 3: 622-5. 8 Bentley TE, Price C, Brown PJB. Structural and lexical features of successive versions of the Read Codes. Proceedings of the Annual Conference of the Primary Health Care Specialist Group of the British Computer Society 1996: 91-103. 9 NHS Executive: NHS Data Dictionary. Birmingham: Information Management Centre 1994. 10NHS Executive: Common Basic Specification Generic Model Reference Manual. Birmingham: Information Management Centre, 1990. 11 Price C, Bentley TE, Brown PJB, Schulz EB, O'Neil M. Anatomical Characterisation of Surgical Procedures in the Read Thesaurus. In Cimino JJ (Ed) Proceedings of the 1996 AMIA Annual Fall Symposium Philadelphia, Hanley & Belfus, 1996: 110-114. 12Price C, Brown PJB, Bentley TE, O'Neil MJ. Exploring the Ontology of Surgical Procedures in the Read Thesaurus. Proceedings of Conference on Natural Language and Concept Representation. Florida: IMIA WG6, 1997: 215-221. 13ENV 12381. Health care informatics - Time standards for healthcare specific problems. Brussels: CEN, 1997.

An administration procedure may be one of several components of a broader concept: Submitting minor surgery claim form is one component of the process of making a Minor surgery claim. The same is true of many surgical procedures, e.g. Opening abdominal cavity is a component of an appendicectomy. We have yet to determine the level of detail of sub-procedures required to capture the spectrum of administrative

activity. We suggest that a balance is required between enumerated and compositional approaches and, as part of the evolutionary development of the Thesaurus, we intend to adopt a strategy in which regional variations (e.g. forms, legal processes) are represented through the use of qualifiers. Thus different qualifying values may be used in different regions both within and beyond the UK.

CONCLUSION Administration procedures share many characteristics with surgical procedures and our experience suggests that the ENV 1828 model can be usefully adapted despite some differences in the domains. It is likely that further extensions will enable the model to be utilised for other types of health care interventions. Our testing of the extended model includes ongoing progressive semantic definition of the complete administration procedures section (2100 concepts in total). This has already suggested areas of prioritisation in shifting to a more compositional approach, in particular the refinement of discrete concept sets for health care professionals, services and establishments, numerically the most common indirect objects. Final confirmation of the utility of the model will involve practical field testing by clinicians using demonstrator software and feedback on interface issues from GP systems developers. Administration statuses (e.g. Under care ofstoma nurse) are an area in which we have yet to complete a model.

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