August 28, 2002
Presented by: David Lareau
Chief Operating Officer
Medicomp Systems, Inc.
14500 Avion Parkway, Suite 175
Chantilly, Virginia 20151
Good morning, Mr. Chairman, and members of the subcommittee. I am David Lareau, Chief Operating Officer of Medicomp Systems. Peter Goltra, our CEO, and I thank you for the opportunity to participate in your process of defining the scope and criteria for selection of standard PMRI terminologies.
To put my comments in context, I will provide a brief background of Medicomp and the nature of our work, which uses the Medcin clinical terminology.
Medicomp was established in 1978 to provide tools to enable documentation and clinical decision support specifically at the point of care. In working with clinicians over the past 24 years we have been constantly challenged to address the particular dynamics of the clinician-patient encounter. A major part of the challenge was to determine how to accommodate the clinical thought process.
We have found that clinicians process “clinical concepts,” versus individual or “atomic” terms, and the relationships between them, in order to determine a diagnosis and formulate a plan for patient care.
To illustrate the importance of concept processing at a clinical, versus a strictly terminological level, consider the example of a patient with “chest pain radiating to the left arm” as opposed to “chest pain radiating to the back.”
In the case of “chest pain radiating to the left arm,” the clinician might reasonably suspect a diagnosis of angina and, absent other findings, order an electrocardiogram or a cardiac stress test.
Even though it is terminologically quite similar (in that many of the same words are used), the concept of “chest pain radiating to the back” might reasonably lead a clinician to suspect a diagnosis of aortic dissection. In this case, further questions about recent trauma or an order for imaging studies might be appropriate, but a cardiac stress test would definitely not be in order.
To further illustrate the importance of fully expressed clinical concepts at the point of care, consider “neck pain radiating to the left arm.” Again, although many of the same terms are used and even some of the same secondary concepts, “neck pain radiating to the left arm” might indicate a nerve problem originating in the neck, for which cervical spine imaging studies might be appropriate.
Two of these examples include the concept of “radiating chest pain,” and two include the concept of “pain radiating to the left arm,” but all three indicate very different medical problems and require the fully expressed concept in order to be actionable at the point of care.
To enable efficient point-of-care use of these concepts, we found it necessary to organize concepts into a hierarchical structure. This hierarchy of pre-coordinated concepts enables assignment of predictable properties to each concept, such as its relevance to various diagnoses.
In the previous example of “chest pain radiating to the back,” this concept has higher relevance to aortic dissection than does “chest pain radiating to the left arm,” although both inherit the properties of their hierarchical grandparent, “chest pain.”
The combination of fully expressed clinical concepts and predictable properties for use by software applications has given software developers the means to build applications for clinical documentation and decision support which are usable by clinicians at the point of care.
The balance of our testimony will reflect the bias of our experience in dealing with terminology use at the point of care. We recognize that more granular terminologies may be more appropriate for other uses, like research, and further acknowledge that mapping between terminologies must be a priority for all terminology standards developers.
We suggest the subcommittee give careful consideration to accommodating the terminology needs of health-care providers at the point of care. In terms of the organization of the subsets of PMRI terminologies, this can be reflected by either establishing an additional subset for point-of-care terminologies or, in a somewhat more radical change, including point-of-care terminologies as a separate type of convergence terminology.
The value of a very granular, or atomic, convergence terminology for research, outcome studies and other analysis is clear. Over time, use of this data will provide valuable information to monitor population health and should lead to improved outcomes.
However, even in a large population, outcomes are improved one patient at a time, a process in which the patient-clinician encounter is a primary component. At that moment, information must converge in a way that is actionable during the encounter and does not unduly interfere with the clinical thought process or lead to decreases in clinician productivity.
In defining the scope of PMRI terminologies, it is also important to consider the role of the patient. As use of the Internet expands, patients will be increasingly involved in the management of their own health care. We believe terminology standards must allow for appropriate levels of participation by patients as well as clinicians.
Existing investments in billing, laboratory, and pharmacy systems total in the billions of dollars, and much of the healthcare reimbursement structure is based on the use of diagnosis, procedure, drug, and laboratory codes.
The effect of any change in terminology requirements for these systems may be significant, and could require extensive modifications to existing applications and reimbursement criteria. Payers, providers, healthcare enterprises and application developers must be given sufficient lead time to implement any changes which may be forthcoming.
From Medicomp’s perspective, highest priority should be given to terminologies directly affecting current widely implemented processes. In decreasing order of priority these are diagnosis and procedure codes, drug codes, and laboratory codes.
Message-specific codes, such as HL7, should be next. Developers need to have a firm understanding of how their systems will be required to communicate within the national health information infrastructure and have sufficient lead time to implement the new standards.
The lowest priorities will be convergence and point-of-care terminologies. These are not as widely implemented nor are they as critical to existing processes. Also, it may be premature to select convergence standards without having in place the points from which they converge.
The criteria for selection of HIPAA PMRI terminologies are comprehensive and appropriate. Our only comment regarding modification of the criteria is to consider that
terminologies may require fully expressed combinatorial clinical concepts in order to be actionable at the point of care, and should not be limited to purely atomic terms.
It is our opinion that the balloting process required of ANSI standard developers, and the consensus process, could inhibit the ability to distribute terminology updates to end users in a timely fashion and should not be an absolute requirement. PMRI terminology developers should be encouraged to maintain a practice of timely and public notification of standards development meetings.
We also believe it is important to emphasize that terminology standards developers will be expected to actively participate in mapping efforts and to provide software tools to assist in mapping.
In closing, I would like to thank the chairman and members of the subcommittee for allowing us to participate in this meeting.