Billing and disease codes

[Matt Wright DVM DACVR www.animalinsides.com]

It looks like the standards discussion is forking a little bit into
two discussions

1. Who has the most appropriate disease codes
2. Which path should we take to achieve a universal communication
standard for the veterinary profession.

In an effort to educate myself about topic 1 - I searched the VTSL
SNOMED browser but I could not find veterinary specific disease
processes that I would expect to see in any code list. I am 99%
certain that this is because I was improperly searching for them.

John - you said that the AAHA codes were in SNOMED. How do we access
the codes to use them and take a look at them? Are they posted online
somewhere that developers such as my company can use them and
incorporate them into our software?

Thanks.

Matt

[Jim Case]

Matt et al.,

 

I have recently taken position with the National Library of Medicine as their SNOMED expert and would be willing to look at the kind of terminology you state is not in SNOMED.  I would be surprised if the ommissions were the majority concepts needed.  I have not seen the AAHA codeset so do not know the level of fidelity in their map to SNOMED.  I would say that the NLM is very anxious to have all areas of healthcare adequately represented in SNOMED and actively used in medical records systems.

 

I think a cooperative effort between AAHA, VetXML and interested other parties to adopt SNOMED as their reference terminology would be welcomed by the NLM and while I cannot say what resources would be available to assist in its adoption, I can say that no obstacles would be put in the way to using it.

Let me know in what way we might be of assistance.

 

Jim Case

[Matt Wright DVM DACVR www.animalinsides.com]

I think I am going to need some education on exactly what AAHA has as
far as the codes. If Jim Case has not seen these things - where are
they. I just looked on the AAHA website and cannot find them.

John - can you post a link to the codes?

Thanks.

Matt

[Jim Young]

I am coming into this with limited information but from what I have
been able to gather from the postings and personal research - John
certainly can correct or clarify any of my points:

1. AAHA - had taken SNOMED code and added "veterinary specific"
coding to address conflicting terminology. The adoption or changes
occurred through a AAHA (member practices) appointed internal working
group with participation from some vendors. Do not believe that means
that they deleted or renamed codes
2. Code has not be released - still in Beta with vendors and selected
sites (assume practices that participate in the naming/development)

OK my take on the issue.

1. I believe that veterinary medicine needs to adopt SNOMED and
petition for adoption of any veterinary specific additions. We are
not only looking at what the Standards can/should be within our
profession but "One Medicine", public health reporting,
interoperability... leads us to follow the standards already in
place.
2. Veterinary medicine is a late comer in the informatics discussion
and quite frankly a minor player. But if we can develop parallel
systems and adhere to guidelines established we could overcome vendor
lock and struggles of development (perhaps even get support from
government to assist with implementation)
3. The organizations and associations representing veterinary medicine
need to be united in supporting Open Standards. Additionally taking
the lead in facilitating manufactures, vendors and distributors
compliance

Main problems I see is that the profession is naive and perhaps dis-
interested on the issues. Momentum is going to require a major
education focus - likely going to have to come from the schools to
produce "junior Informaticist", such is the move in medical schools.
Second point, we do not have the healthcare reform pressure to respond
and especially if asking practices to "pony up" to implementation (for
something that is poorly understood and undervalued).

Regardless, I am excited about the opportunities and potential that
can be achieved.

Jim Young

[Matt Wright DVM DACVR www.animalinsides.com]

John...we all seem to be waiting for a clarification on exactly what
AAHA is up to. Along with John, my research indicates that the AAHA
project is really no more open that the Mac iPad.

Please clear the air and let me and Jim know we are off base by
releasing these codes and posting them online.

Thanks.

Matt

[Matt Wright DVM DACVR www.animalinsides.com]

Jim

I disagree a little bit about what you say about the profession.
Education will be necessary and is essential but IF and only IF we are
able to come to an agreement and adopt a universal standard for all of
the veterinary profession, vendors who support it will educate the
dickens out of the veterinary profession during the sale of their
equipment. Veterinarians probably wont know exactly what they are
talking about but they will know that they need to have it. This is
precisely what happened with DICOM. Most of the education came from
the vendors who supported it and now DICOM is ubiquitous in veterinary
medicine.

Additionally, everyone keeps saying that this stuff is sooooo
expensive to implement and we need to "pony up" and all the rest. I
disagree. That is EXACTLY what they said about DICOM. Standards will
benefit the profession and the companies and practices who support and
implement them will be successful. An investment in standards is an
investment in their future.

Matt

[John Albers]

Matt:

AAHA will not "release" the codes without a license nor post them on line.
If that were done, there would be no way of protecting them. Again, the
intent is to release them via open source licenses, but that won't happen
for a while, pending the outcome of these on-going consortium discussions.

Vendors and others who signed non-disclosure agreements have had access to
an XML and SNOMED sample of the codes (about 300 terms) produced by VA Tech.
The sample has been available since last April. The sample was sufficient
for them to program their software so that they would be prepared once the
entire list was completed and mapped.

At this stage, I've asked AAHA to make this sample set available to anyone
who wants to see it. I believe that would give everyone an opportunity to
evaluate what has been created. Assuming that AAHA agrees, I will post a
link as soon as it is available.

John

-----Original Message-----
From: veterinary-heal...@googlegroups.com
[mailto:veterinary-heal...@googlegroups.com] On Behalf Of Matt
Wright DVM DACVR www.animalinsides.com

[Matt Wright]

John,

I am not clear on something. I thought the intent was to develop an open standard. I am probably wrong but aren't open standards open for use and readily available online?  In contrast, I offer you three websites:

1. http://medical.nema.org/ - the standard is readily available online
2. snomed terminology browser: http://terminology.vetmed.vt.edu/SCT/menu.cfm
3. vetxml standard data format: http://vetxml.org/StandardDataFormat.aspx

Question: what are you protecting? What is the license for? I am not aware that with SNOMED, VETXML, or DICOM anyone needs a license to use their products nor are these groups trying to protect anything.  I think that is what we are after with this group. If AAHA intends to do something different and license their items (e.g. change things in the future by altering the terms of the license) I see no reason why these codes should even be considered for us in this application.  Moreover, why are the codes not simply incorporated into SNOMED?

Finally - I have never heard of a non-disclosure agreement for an open standard. The terms "NDA" and "open" are mutually exclusive are they not?

Am I off base here?

Matt

--

[David Clunie]

Well, just to make the point that making them public accessible is not
synonymous with giving up control of them, I would point out that:

- the whole of SNOMED is publicly accessible, e.g., via the NLM UMLS
sites

- the whole of DICOM (including all of its codes in PS 3.16) are also
publicly accessible, and require no license agreement

In each case copyright is sufficient to protect their integrity.

Without question, codes that are not openly accessible and freely
implementable without a license fee will not be used, in lieu of
other alternatives that are.

I can promise you on behalf of DICOM at least, codes that are not
free and redistributable will not be referenced from our standard.

Non-disclosure agreements are anathema.

David

[John Albers]

Matt:

 

I will try to respond to your points.

 

When AAHA initiated this project, it was advised that if the goal was to have a commonly used standard, the terms would need to be protected (beyond just copyrights) by license agreements. Otherwise, if the terms were just put “out there” any individual or any practice management software vendor (there are about 25 selling systems to veterinary practices in North America) could make whatever changes they wanted and use those terms in their system. In short, we could conceivably wind up with numerous versions and no standard.

 

Subsequently, after receiving input from  numerous vendors and others, AAHA agreed in principle that the terms should be made more freely available, preferably under some form of open-source license. At that point we consulted with an attorney considered to be something of a guru in this area of licensing. (He was a founder of the Open Source Initiative, and has been intimately connected to and served as counsel to the Open Web Foundation and the Apache Software Foundation). He advised that if we simply made the terms available, as you suggest, things could, and probably would, proceed willy-nilly and an opportunity for a common standard could be lost.

 

His advice was a consortium, hopefully very broadly based, whose members would agree to support whatever standards were agreed upon. Once that was established, then the terms (and anything else developed by the consortium) could be licensed under reciprocal open-source licenses. If derivative works were created, the consortium members (and all other licensees) would have access to the changes and could decide to adopt them as a new standards if appropriate. In this way, he advised, it was much more likely to have one standard survive, rather than many.

 

His point was that over time, no one would really want to deviate from the widely accepted standard, or take the time and energy to develop something different, and the risk of having multiple “standards” would be slim. However, initially, he felt there was risk in releasing them without licenses and agreements in place.

 

I don’t know the history of DICOM but the history of SNOMED is similar to what AAHA is proposing to do. While you are correct that no license is needed NOW for SNOMED, that’s not always been the case. For most of its history you had to license SNOMED from the College of American Pathologists. (I know because AAHA was required to buy a license at one point – for $500.) A few years back SNOMED CT was acquired by the National Library of Medicine and licenses are no longer required. (At this point, who would want to develop their own list and codes for over a million diagnostic concepts!?)

 

While AAHA is not interested in owning or controlling the terms it has developed, it strongly believes that there should be ONE standard set of terms (and at this point we don’t know of any individual or any organization that has a better set than AAHA). If you or others have other suggestions on how to ensure that the profession winds up with one standards, please let us know.

 

John

[Jim Young]

Not sure if we are in disagreement.

Education is going to be huge
Standards are an absolute

The big question remains - who will be driving the bus?
Watching the events unfold on the human side, the direction is to EHR
which is the only reason we should be concern with Standards at all.
Otherwise, who cares if my software will not talk to your software...
(I really do care, just an illustration) ? Ultimately this is going
to become a Consumer Heathcare issue, with Personal Health Records
leading the charge. When PHR are the mainstay in healthcare, the
client is going to want the same for "Fluffy." Integration and
utilization of HL7... and the like will be the connectivity pieces
needed.

As for costs - yes having DICOM Standards in place made the process of
compliance less complicated and less expense than everyone assumed.
The efforts of folks within the profession (primarily ACVR) were
instrumential in shining the light and getting a generally accepted
policy (not sure I would give it an "A" quite yet but close).

Changing software is going to be a totally different game than
switching to DR. The cost to develop, moving away from legacy
products... is going to have to come from somewhere and is really the
source of current fighting occuring on the human side.

Bottomline is that I believe this is going to become a consumer driven
process and that will ultimately be the motivation for acceptance and
deployment in veterinary medicine. In order to function, we will have
to adopt the systems and standards developed on the human side (just
like DICOM).

Jim Y

[Dave Harvey]

John,

 

Just a quick cynical point…the main beneficiaries of complex licensing arrangements are lawyers – so perhaps they’re not necessarily the best people to ask for impartial advice!

 

Dave

 

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[Matt Wright DVM DACVR www.animalinsides.com]

John,

I am still not sure I understand, why not just petition to have the
codes incorporated into SNOMED and lets just all accept to use SNOMED
as the standard? Is that not an option?

Matt