Telemedicine Standards

Telemedicina e eSaúde

Telemedicine Standards 1

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Telemedicine StandardsTelemedicina e e-Saúde

2019/20

Pedro Brandão

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References

• Sources are indicated by [RefSource] where the complete citation will be at the end

• Insite citations will be From: CitationSource

TeleSaude 19/20 - Standards - pbrandao

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Standards


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Standards

Based on Digital Imaging and Communications in Medicine (DICOM) Part 1: Introduction and Overview, National Electrical Manufacturers Association, 2018 [DICOM-INTRO]


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Objectives

• Facilitate imaging medical devices interoperability by specifying:

o A set of protocols for network communication

o The syntax and semantics of Commands and the protocol information

o Data storage services that should be implemented by devices that implement the standard

Includes file formats and directories structure

• Reuse international standards as possible

• Define the requirements to be conformant with the standard


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DICOM – Does not specify

• Implementation details;

• Set of capabilities and functionalities that a system with compliant devices should provide;

• The test procedure or validation to be compliant with the standard

o Only the requirements

o Some other consortiums do (e.g.: Wi-Fi Alliance)


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http://dicom.nema.org/medical/dicom/current/output/html/part02.html



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DICOM – Standard parts


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7. Message Exchange8. Network CommunicationSupport for MessageExchange

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Protocol Architecture


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Network

TCP/IP

DICOM Upper Layer Protocol for TCP/IP

DICOM Application Message exchange

Medical imaging application

Upper Layer Service Boundary

[DICOM-NET]

HTTP

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Association request example


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[DICOM-NET]

SAP – Service Access PointUL – Upper Layer



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PACS

• Picture Archiving and Communication Systems

• Composed of :o Acquisition device(s);

o Communication network (secure);

o Archive system(s);

o Visualization stations;

• DICOM is the standard that defines the communication and storage.


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UMLSUnified Medical Language System Standards

Based on UMLS Basics (tutorial) [UMLS-TUTORIAL]


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http://www.nlm.nih.gov/research/umls/new_users/online_learning/index.htm

https://www.nlm.nih.gov/research/umls/new_users/online_learning/OVR_001.html

http://www.nlm.nih.gov/research/umls/new_users/online_learning/index.htm



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UMLS

• Enable the development of applications that understand biomedical language;


13[UMLS-Tutorial]

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UMLS Sources of data

• The Meta-Thesaurus has more than 100 vocabularies;

o ~71.2% in English, with 25 other languages (including PT, 2.04%) (stats)

o Concepts: 4 258 810

• Example:


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Atrial fibrillation ICD-9-CM

AF NCI Thesaurus

AFib MedDRA

Atrial fibrillation (disorder) SNOMED Clinical Terms

atrium; fibrillation ICPC2-ICD10 Thesaurus

[UMLS-Tutorial]

https://www.nlm.nih.gov/research/umls/knowledge_sources/metathesaurus/release/statistics.html



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Categories

• Most important categories of the used dictionaries;


15[UMLS-Tutorial]

data from 2016

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Entry example

• Concept Unique Identifiers (CUI): a meaning of something. Associated with the several names of the concept. Identifier starts with C + 7 digits. C0018681 in the figure.

• Lexical (term) Unique Identifiers (LUI): lexical variants. Identifier L+7 digits, example has 3 LUIs.

• String Unique Identifiers (SUI): each “name” for the unique concept or string has a unique permanent identifier with S+7 digits.

• Atom Unique Identifiers (AUI): sources of the strings/concepts from where the MetaThesaurusis built. Identifier A + 7 digits.


16[UMLS-Tutorial]



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Semantic

• Semantic types

o High level categories

o Ex.: Physiologic Function

• Semantic relationso Relation between types

o Ex.: disrupts


17[UMLS-Tutorial]

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Specialist Lexicon and tools

• English lexicon that includes biomedical terms and current words. With the information on:o Syntax

o Morphology

o Spelling

• Tools:o Lexical variants generator

o String normalizer

o Word indexer


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Process Outcome

Remove genitive Hodgkin diseases, NOS

Remove stop words Hodgkin diseases,

Lowercase hodgkin diseases,

Strip punctuation hodgkin diseases

Uninflect hodgkin disease

Sort words disease hodgkin

The norm program exemples(NOS, No Other Specification)



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SNOMED CTSystematized Nomenclature of Medicine Clinical TermsStandards

Based on SNOMED Clinical Starter Guide July 2017 International Release, The International Health Terminology Standards Development Organisation [SNOMED-SG]


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SNOMED CT

• Aggregation of

o SNOMED Reference Terminology (SNOMED RT) by the College of American Pathologists (CAP)

o Clinical Terms Version 3 (CTV3) from the UK NHS

• Composed by:o Concepts, terms and relationships

• Portugal is a member, represented by Centro de TerminologiasClínicas


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https://confluence.ihtsdotools.org/display/DOCSTART

http://www.ctc.min-saude.pt/



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Hierarchies (examples) • Clinical finding

• Physical force

• Procedure

• Event

• Observable entity

• Environment or geographical location

• Body structure

• Social context

• Organism

• Situation with explicit context

• Substance

• Staging and scales

• Pharmaceutical/biologic product

• Linkage concept

• Specimen

• Qualifier value

• Special concept

• Record artefact

• Physical object


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Granularity


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Fonte [SNOMED-SG]



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Identifiers

• Concepts

o Numerical Identifier

• Descriptionso Numerical Identifier


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ConceptID 22298006: Fully Specified Name: Myocardial infarction (disorder)DescriptionID 751689013 Preferred term: Myocardial infarction DescriptionID 37436014 Synonym: Cardiac infarctionDescriptionID 37442013

Uniquely identifies a concept

Semantic tag semantic category

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Relationships

• Navigation

• Aggregation

• Definition

• Qualification

• Kind-of-value

• Additional


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Fracture of tarsal bone (disorder) IS_A Fracture of foot (disorder) FINDING SITE Bone structure of tarsus (body structure)ASSOCIATED MORPHOLOGY Fracture (morphologic abnormality)

See Summary#Relationships

https://confluence.ihtsdotools.org/display/DOCEG/Summary



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Attributes define (examples):

• Clinical Findings

• Procedures

• Evaluation Procedures

• Specimen

• Pharmaceutical / biologic product

• Explicit context

• Events

• Physical objects


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See Editorial Guide/ConceptModel/Attributes

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Other nomenclatures


https://confluence.ihtsdotools.org/display/DOCEG/Attributes



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ICD

• International Classification of Diseases

• Defined by WHOo Current version 11 (18-June-2018)

• For clinical and management use;


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ICPC-2

• International Classification Primary Care, 2nd Edition

o 2018, 2e-v7.0

• WHO accepted the std for encounters’ reasons

• It allows to classify:o Reasons for “meeting” (doctor visit)

o Diagnostic

o Procedure used


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http://www.who.int/classifications/icd/en/

https://ehelse.no/icpc-2e-english-version

http://www.who.int/classifications/icd/adaptations/icpc2/en/index.html



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WHO others

• ICF – International Classification of Functioning, Disability and Health

• ICHI – International Classification of Health Interventions


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LOINC

• Logical Observation Identifiers Names and Codes

o LOINC Version 2.65, 89 271 Terms • Released 2018-12-14

• Maintained by the Regenstrief institute

• Defines codes to identify test results and clinical observationsand measures.o On the context of HL7 and CEN TC251 messages

• Allows the suggestion of new terms

• Freely available.


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http://www.who.int/classifications/icf/en/

http://www.who.int/classifications/ichi/en/

http://loinc.org/



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LOINC (cont.)

• Used by/compatible with other standards

o HL7 (used by)

o UMLS (maps to)

o SNOMED (used with)


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MeSH

• Medical Subject Headings

• Maintained by the national library of medicine from the USA

• Defines an hierarchical structure of medical terms

• Used to indexed medical articles;o Books, documents, audio-visuals


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http://www.nlm.nih.gov/mesh/meshhome.html



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HL7

• Health Level International 7

• Defines standards for the exchange, integration and search of health information on an electronic format.

• Supports the clinical practice and management

• + 2300 members

• The 7 refers to the OSI layer


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Session

Physical

Logic

Network

Transport

Application

Presentation

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HL7

• Promotes the interoperability between systems:

o Functional Int.: information exchange

o Semantic Int.: information usage

• Divided in several working groups;

• Workgroup for EHR

• Standards freely availableo HL7 Standards

o Some restrictions


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http://www.hl7.org/about/index.cfm

http://www.hl7.org/implement/standards/nocost.cfm?ref=nav

http://www.hl7.org/implement/standards/nocost.cfm?ref=nav



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Model

• RIM – Reference Information Model:o Object Model that identifies the life-cycle of the events carried by the

messages;

o Model shared by all domains, i.e., from all create their messages;

o Based on the UML (Unified Modelling Language) methodology

• HDF – HL7 Development Frameworko Supports the extension of the semantic interoperability semantic to “all”

medical information.

• Fast Healthcare Interoperability Resources (FHIR®) is on the way…


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American Telemedicine association (ATA)Standards


http://www.hl7.org/Special/committees/fiwg/overview.cfm



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Guidelines

• Defined for/by several working groups

• Core Operational Guidelines for Telehealth Services Involving Provider-Patient Interactions o Contains the basic definitions for all other documents;

o Defines the nomenclature (glossary), what are the technical, administrative and clinical standards;


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Home Telehealth Clinical Guidelines

• Defines terminology,

• Criteria for patients, medical institutions, technologies

• Interactive services, monitoring

• From 2003o Updated in other guidelines, last from 2014


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http://hub.americantelemed.org/resources/telemedicine-practice-guidelines

http://thesource.americantelemed.org/resources/telemedicine-glossary



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Home Telehealth Clinical Guidelines Example

• Use of Sensor Technology

o If a detached remote sensor is employed for a home communications unit the following is required:

Indication of out of range for wireless operation

Indication for low battery status

Indication that the sensor is working properly

o The sensors should not damage or irritate the patient’s skin, and should not irritate the patient during sleep.

o The sensors should not contain elements that pose a danger if chewed, licked or otherwise manipulated by the patient.


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Source [ATA-CLINICAL]

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Telehealth Practice Recommendationsfor Diabetic Retinopathy

• Defines:

o Professional qualifications

o Equipment specifications

o Legal requirements

o Validation

o Quality control

• From 2011


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Telehealth Practice Recommendationsfor Diabetic Retinopathy


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Flow diagram for an ocular telehealth system [ATA-RECDIA]

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• Practice Guidelines for Video-Based Online Mental Health Services, Aug 2009

• Quick Guide to Store-Forward Teledermatology and Live-Interactive Teledermatology, June 2017

• Evidence-Based Practice for Telemental Health Oct 2009

• Best Practices in Videoconferencing-Based Telemental Health, April 2018

• Let There Be Light: A Quick Guide to Telemedicine Lighting, July 2017

• …


42Other guidelines




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• By the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

• With definitions, appropriate use, comments

• Revised October 2010o But currently not in publications site


43Guidelines for the Surgical Practice of Telemedicine

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Example: Telesurgery (Remote Surgery)

• Definition: o Surgery, procedure or intervention performed on an inanimate trainer, animate model, or patient, in

which the surgeon or operator is not at the immediate site of the model or patient being operated upon. Visualization and manipulation of the tissues and equipment is performed using tele electronic devices.

• Appropriate Use: o Demonstration and/or teaching technique or procedures using inanimate trainers as the objects of the

procedure.

o Demonstration and/or teaching techniques or procedures using animate model for purposes of testing technology.

o Demonstration and teaching techniques or procedures on patients under strict guidance of an IRB and only when a qualified surgeon is present to intervene in a timely fashion if technical difficulties arise.

• Comments: o Remote surgery remains investigational and should be performed with IRB approval and only by

surgeons familiar with the technology. The introduction of telerobotic surgery, coupled with improvements in bandwidth and reduction in time has allowed for the remote safe completion of common surgical procedures (19-23).

o ....


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Fonte: [SAGES]

https://www.sages.org/publications/guidelines/

https://web.archive.org/web/20161108042129/http:/www.sages.org:80/publications/guidelines/guidelines-for-the-surgical-practice-of-telemedicine/



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HON Code(Health on the net)Standards

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What is

• “HONcode is the oldest and the most used ethical and trustworthy code for medical and health related information available on Internet. “

• Improve the information quality for health professionals and patients


46Source: http://www.hon.ch/

http://www.hon.ch/



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HONCODE Principles• Principle 1: Authority o Give qualifications of authors

• Principle 2: Complementarity o Information to support, not replace

• Principle 3: Confidentiality o Respect the privacy of site users

• Principle 4: Attributiono Cite the sources and dates of medical

information

• Principle 5: Justifiabilityo Ability to back claims

• Principle 6: Transparencyo Accessibility, provide valid contact

details

• Principle 7: Financial disclosureo Provide details of funding

• Principle 8:Advertisingo Clearly distinguish advertising from

editorial content


Source : http://www.hon.ch/ 47

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The endTelemedicine Standards


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http://www.hon.ch/



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References – Standards• [DICOM-INTRO] Digital Imaging and Communications in Medicine (DICOM) Part 1: Introduction and

Overview, National Electrical Manufacturers Association, 2019 http://www.dicomstandard.org/

• [DICOM-NET] Digital Imaging and Communications in Medicine (DICOM), Part 8: Network Communication Support for Message Exchange, National Electrical Manufacturers Association, 2018

• [UMLS-TUTORIAL] UMLS Basics (tutorial)

• [SNOMED-SG] SNOMED Clinical Terms® Starter Guide January 2017 International Release (US English), The International Health Terminology Standards Development Organisation

• [ATA-RECDIA] Telehealth Practice Recommendations for Diabetic Retinopathy, American Telemedicine Association February 2011

• [ATA-CLINICAL] American Telemedicine Association’s “Home Telehealth Clinical Guidelines”

• [ATA-Process] Krupinski EA, Bernard J. Standards and Guidelines in Telemedicine and Telehealth. Healthcare. 2014;2(1):74-93. doi:10.3390/healthcare2010074.

• [SAGES] Guidelines for the Surgical Practice of Telemedicine (archived version on WayBack Machine)


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• American Telemedicine Association, Standards and Guidelines

• I do Imaging, Free Medical Imaging Software

• OpenEHR


50References – Standards – Sites


http://www.dicomstandard.org/


https://www.nlm.nih.gov/research/umls/new_users/online_learning/OVR_001.html

https://confluence.ihtsdotools.org/display/DOCSTART

https://thesource.americantelemed.org/viewdocument/home-telehealth-clin-1

https://web.archive.org/web/20130228025034/http:/www.sages.org/publication/id/21/


https://idoimaging.com/

http://www.openehr.org/



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Acronyms

• EHR – Electronic Health Record

• HON – Health On the Net

• ICD – International Classification of Diseases

• ICF – International Classification of Functioning, Disability and Health

• ICHI – International Classification of Health Interventions

• ICPC – International Classification of Primary Care

• IHE – Integrating the Healthcare Enterprise

• LOINC – Logical Observation Identifiers Names and Codes

• MeSH – Medical Subject Headings


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Acronyms• PACS – Picture Archiving and Communication System

• RCT – Randomized Controlled Trial

• RIM – Reference information Model

• RIS – Radiology Information System

• SAP – Service Access Point

• SNOMED CT – Systematized Nomenclature of Medicine Clinical Terms

• UL – Upper Layer

• UMLS – Uniform Medical Language System

• WHO – World Health Organization


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