Title: Development of an ACR Appropriateness Criteria database
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Title: Development of an ACR Appropriateness Criteria database
Physical Description: Book
Language: English
Creator: Belliappa, Goutham, 1977-
Publisher: University of Florida
Place of Publication: Gainesville Fla
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Publication Date: 2001
Copyright Date: 2001
 Subjects
Subject: Cancer -- Radiotherapy -- Data processing   ( lcsh )
Computer and Information Science and Engineering thesis, M.S   ( lcsh )
Dissertations, Academic -- Computer and Information Science and Engineering -- UF   ( lcsh )
Genre: government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )
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Summary: ABSTRACT: This thesis examines the translation of the American College of Radiology Appropriateness Criteria (ACRAC) into a standard multipurpose machine-readable format. It specifies, validates, and formally documents a relational database structure to contain the ACRAC. The appropriateness criteria currently are a series of word documents available in electronic and printed versions from the ACR. Health service professionals all over the world use this data on a daily basis to examine the validity and applicability of their treatments. The use of this data requires hospitals to hire "expert coders" who examine specifics from the printed documents and report them to radiologists/ doctors etc. These results come at a high cost including salaries, time to lookup, inaccuracies, and inadequacies. The current form of the data also ensures that no statistical (or other) analysis, lookup or update can be performed easily. This research focuses on designing a database to hold all current ACRAC data in a manner that easily lends itself to analysis, update, distribution, and lookup.
Summary: KEYWORDS: ACR, ACRAC, database, CPT, ICD-9
Thesis: Thesis (M.S.)--University of Florida, 2001.
Bibliography: Includes bibliographical references (p. 136-137).
System Details: System requirements: World Wide Web browser and PDF reader.
System Details: Mode of access: World Wide Web.
Statement of Responsibility: by Goutham Belliappa.
General Note: Title from first page of PDF file.
General Note: Document formatted into pages; contains viii, 138 p.; also contains graphics.
General Note: Vita.
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Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
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Resource Identifier: oclc - 48515008
alephbibnum - 002766281
notis - ANP4320

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DEVELOPMENT OF AN ACR APPROPRIATENESS CRITERIA DATABASE











By





GOUTHAM BELLIAPPA


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2001





















"Perfection of means and confusion of goals, seems in my opinion to best characterize our age."

Albert Einstein














ACKNOWLEDGEMENTS


First I would like to acknowledge my indebtedness to two people who have

supported me throughout this work. I thank Dr. Dankel, without whose encouragement,

counseling and help, I would not have considered writing a thesis in the first place. I thank

Dr. Chris Sistrom who supervised this work and provided me all the help I needed and more

in every stage of the work.

I also thank Dr. Newman and Dr. Su for serving on my committee. Last, and most, I

thank my parents for their constant help and support in more ways that I would have

imagined possible.















TABLE OF CONTENTS



page


ACKNOW LED GEM ENTS ................. ......................................................................................................... iii

LIST OF ABBREVIATION S ................................................................................. ............................... vii

ABSTRACT ................................ .. ..................................................... viii

CHAPTERS

1 INTRODUCTION ....................................................................................................................................... 1

2 BACKGROUND ......................................................................................................................................... 5

D definitions of T erm s ................................................................... ............................................... 5
The ICD -9 Codes........................................................................ ............................................. 5
The CPT Codes........................................................................... ............................................. 8
Appropriateness Criteria.................................................................................. ....... ................ ....... 9
The ACRAC Documents ............................................................................................ ....................... 11
Putting It A ll T together ................................................................................. .......................... 14
3 SCOPE AND OBJECTIVES............................................................................... ...... ................ ....... 18

Contem porary A ttem pts: A CRA C Encoding...................................... ........................ 20
Self-Documenting Structured Reports Using Open Information Standards.................. .................. 20
The ICD -9 Coding System ......................................................................................... .......................... 22
Im ageCoderTM ............... ........................................... .... ............... 25
O objectives ....................... .................................................................................................................27
4 DATA ANALY SIS: Analysis of the Appropriateness Criteria Data. ............................. ........... ...... 30

Procedure N am es ...........................................................................................................................31
Contributors .................................................................................................. ............................. 33
References ....................... ................................................................................................................34
The CPT D ata.................................................................................... ........................................41
ICD -9 D ata .....................................................................................................................................43
Conditions ....................... ................................................................................................................44
Procedures .......................................................................................... ........................................45
A ncillary D ocs and D efinitions.................................................................. ........................46
G guidelines ........................ ................................................................................................................47
5 COM PLETE DATABASE STRUCTURE................................................................... ................. 49
Data Definition Syntax: ............................................................ ................................................... 51
Data Definition ................................. ................................................... ............ ....... 52
Contributors .......................................................................................... ...... ............. ........ 53
References ................................................................. 55
6 CONCLU SION S AND FUTURE W ORK ................................................................... ................. 60











G oals A ccom plished........................... ......................................................................................60
Future W ork......................................................................... .................. ........... ............. 61
Potential Benefits of the A application .................. ..........................................................63
APPENDICES

1 ICD 9 CODE SET EXAM PLE ............................................................................... ............................ 65

2 THE ICD-9-CM INDEX TO DISEASES: A .............................................. .......................................... 66

3 THE CPT DATA FILE DETAIL: 2001 SHORT DESCRIPTION UPPER CASE................................ 70

4 CPT DATA FILE DETAIL: 2001 MEDIUM DESCRIPTION UPPER CASE................................... 71

5 THE CPT DATA FILE DETAIL: 2001 LONG DESCRIPTION UPPER CASE.................................. 73

6 THE CPT DATA FILE DETAIL: 2001 LONG DESCRIPTION UPPER ............................................ 75

7 SAMPLE ACR DOCUMENT; ROLE OF IMAGING IN CANCER OF THE CERVIX...................... 77

8 COM PLETE DATA DEFINITION ..................................................... ............................................... 82
C o n trib u to rs .................................................................................................................... ... ............ 8 2
References ............................................................... 85
Guideline Reference .................................................................................................. ....................... 89
Condition Procedure .................................................................................................. ....................... 90
Procedures ............................................................... 91
CPT Procedure...................................................................... ........ .. ......... ............ ....... 93
ICD-9 Condition......................................................................................................... ................... 94
ICD-9_Synonyms ....................................................................................... .................................... 95
ICD-9 Codes ......................................................................................... ................ ................. 96
ICD-9_Type............................................................................... ............ ................. 96
Authors ..................................... .. ............ .......... ......................... ................. 98
G u id elin e s............. .......................................................................... .. ........ ............ .......... .......... 9 9
Reference Author................................................................................................... ...................... 103
Guideline-Contributor ............................................................... ................................................ 104
CPT Codes.......................................................................... ................................................ 105
Definition Guideline ................................................................................................ ....................... 106
Definitions ............. .......................................... .... ..... ..... 107
Conditions ................................................................................. 107
Ancillary Docs.................................................................. .................................. ............. 109
9 PARSER TEST CASES ................................................................................................ ....................... 112

Test File 1 ......................................................................................................................................112
Input file 1 Contents: ............................................................................................. ....................... 112
Output File 1 Contents: ................................................................................ ................................ 112
Output File 1 Contents: ................................................................................ ................................ 113
Test File 2.......................................................................................... .......................................114
Input File 2 Contents ................................................................................................ ....................... 114
Output File 2 Contents.............................................................................................. .................... 115
Test File 3......................................................................................... ........................................116
Input File 3 Contents: ............................................................................................ ................ ....... 116
Output File 3 Contents: ................................................................................ ................................ 118
10 PARSER SOURCE CODE ................................................................................ ............................. 120











11 ACR PROPOSAL BY DR. SISTROM .......................................................................... ................. 123

Translating The American College Of Radiology Appropriatness Criteria Into Database Format.... 123
Specific A im s (B ase P roduct)................................................................................ ....................... 123
Specific Aims (Optional Enhancements) ............................................ 124
B background A nd Significance............................................................................... ................ ....... 125
Im plem entation Details (Base Product).................................................... ................................ 126
Implementation Details (Optional Enhancements)................................... 130
R eferen ce L ist...................................................................... ........................ .. .. ................ 13 1
12 M O D IFIER S .............. .................................. ........ ................. 133
B ody R region (In Table Procedures) ............................................ ................................................ 133
M odifier (In Table Procedures) ............................................... ..................................................... 133
M odifier (In Table Procedures) ............................................... ..................................................... 134
Location System (In Table Conditions)................................................................ ................. 135
R E F E R E N C E S .............................................................................. ................................... .......... ....... 136

BIO GRA PH ICAL SK ETCH .......................................................................................... ....................... 138












































vi














LIST OF ABBREVIATIONS


ICD-9
ICD-9 CM
Modification
ICD10
CPT
AMA
ACR
ACRAC
HCFA
DRML
HSP


International Classification of Diseases, Ninth Revision
International Classification of Diseases, Ninth Revision Clinical

International Classification of Diseases, Tenth Revision.
Current Procedural Terminology
American Medical Association
American College of Radiology
American College of Radiology, Appropriateness criteria.
Health care Financing Administration.
Data Entry and Reporting Markup Language
Health service provider















Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial
Fulfilment of the Requirements for the Degree of Master of Science

DEVELOPMENT OF AN ACR APPROPRIATENESS CRITERIA DATABASE

By

Goutham Belliappa

August 2001

Chairperson : Dr. Douglas D Dankel II
Major Department: Computer and Information Science and Engineering

This thesis examines the translation of the American College of Radiology

Appropriateness Criteria (ACRAC) into a standard multipurpose machine-readable format.

It specifies, validates, and formally documents a relational database structure to contain the

ACRAC.

The appropriateness criteria currently are a series of word documents available in

electronic and printed versions from the ACR. Health service professionals all over the

world use data on a daily basis to examine the validity and applicability of their treatments.

The use of these data requires hospitals to hire "expert coders" who examine specifics from

the printed documents and report them to radiologists/ doctors etc. These results come at a

high cost including salaries, time to lookup, inaccuracies, and inadequacies. The current form

of the data also ensures that no statistical (or other) analysis, lookup or update can be

performed easily. This research focuses on designing a database to hold all current ACRAC

data in a manner that easily lends itself to analysis, update, distribution, and lookup.















CHAPTER 1
INTRODUCTION

The medical field has often followed a path of almost absolute but seemingly subtle

resistance to change, especially from outside influences. Its community, to an outsider,

appears as one that looks inward for inspiration. This is quite similar to the computer science

community where a large percentage of research focuses inward, directed at the Computer

Sciences. Developments are usually measured in terms of efficiency, security, and other

metrics; and almost never human influence, comfort, ease of use, etc. In our blind drive to

increase software efficiency, we tend to forget human factors and other aspects that need

input from the outside. Similarly, the medical community, though very modern has been

wary of integrating and modernizing in areas that do not directly involve the patient.

The ACRAC, which is a printed version of an electronic word document, has never

been distributed or made available for use electronically. This is because of the medical

community's suspicions regarding the security and reliability of modem distribution

methods. The need for change, as is often the case, should be prompted form outside.

Before this initiative, the ACR had never ventured into cataloguing their information on a

database or into means for electronic distribution, in spite of being aware of such needs.

This thesis benefits those involved in the medical community through techniques

and methods of the Computer Sciences. It attempts to simplify, automate, and increase the

efficiency in a certain specific region (beginning with Radiology) of the medical field that was

highly inadequate. In this attempt, much weight is given to opinions of the medical

community rather than those of pure computer professionals. As far as possible,









representations and designs are simplified to be understandable to the target audience: the

Radiologic community. This research was conducted in a manner to enhance future works to

be directed at wider areas in medicine.

The development and use of guidelines and policies for medical practice has been

advocated by influential medical organizations for over 10 years. These include the American

Medical Association and the Institute of Medicine [1,2]. Hillman outlined the need for

research about and barriers to guideline implementation in radiology. He felt that if

recommendations are available only in printed form they tend to be minimally influential in

terms of actually altering practice patterns [3]. Dorfman stressed the importance of assessing

current patterns of diagnostic testing utilization, developing guidelines, and performing

rigorous outcomes based clinical research to determine efficacy of instituting guidelines in

routine practice [4].

An essential preliminary step to instituting and evaluating radiology procedure usage

guidelines is to adapt them to current healthcare information technology infrastructures. In

addition to converting guidelines into a machine-readable format they should be mapped

onto pre-existing and widely accepted coding schemes. Examples of these are the American

Medical Association Common Procedural Terminology (CPT 2001) and International

Classification of Diseases, 9th edition, Clinical Modification (ICD-9 CM). These coding

schemes represent medical (including radiological) procedures and clinical problems

respectively and have been designated as national standards [5,6,7,8].

Coding schemes are needed for standardization. Current medical practice in the

United States is funded by various sources through medical insurance companies such as

Medicare and Medicaid. These companies have rigorous guidelines for medical

reimbursement. Guidelines range from billing structures to specific reimbursable and non-










reimbursable treatments. These specifics are largely unknown outside of those companies. A

hospital has, presently, no sure way of knowing if the costs of a particular treatment will be

paid for other than from past statistics.

This thesis examines an approach around this cloud of uncertainty is consensus

based standardization. The ACRAC is a consensus based standardization initiative to

regulate radiologists all over the United States to use a common treatment pattern. This is

presently largely ignored because of the lack of distribution and the lack of availability of the

documents. This thesis examines how the ACRAC and other standard codes will be

integrated into the reporting mechanisms that Radiologists and doctors presently use to

expand its usage.

This document outlines a platform independent data model of the ACR

Appropriateness Criteria imaging guidelines for specific clinical situations (variants). This

takes the form of a loosely structured listing of individual table definitions including detailed

attribute (field) listings with data type, purpose, and constraints for each. This is not intended

to be machine-readable but to be used as documentation of the formalized structure for

future developers of the primary database. The intention is for this documentation to be

kept current so as to reflect any subsequent changes to the structure. After development and

population of the database is complete, the document will serve as a user guide for software

developers and or corporations wishing to incorporate the Appropriateness Criteria into

their software or medical infrastructure.

Three standardization measures are examined in tandem.

The International Classification of diseases 9th Edition (ICD-9) Code set: A
set of codes, each of which is a standard representation for a condition or disease.

The Current Procedural Terminology (CPT) Code set: A set of codes each one
of which is a standard way to describe a treatment.












The American College of Radiology Appropriateness Criteria (ACRAC): A set
of guidelines that define the applicability of a treatment to a condition.

The first two are requisites for any reimbursement request to an insurance company.

The hospital needs to justify the need for a reimbursable treatment

(specified by a CPT code) with an ICD-9 code. The ACRAC guidelines are examined to

standardize and to avoid conflicts in treatment procedures. This thesis examines a way to

integrate the three measures into a single database to be used later to enhance the reporting

mechanism used by Health Service Provider (HSP).

Chapter 2 gives more detailed definition of the standardization measures mentioned

in Chapter 1 and explains their interrelation. Chapter 3 is a brief survey of past attempts at

making the standards more accessible to HSPs and doctors, followed by a detailed look at

the objectives of this attempt. Chapter 4 is an analysis of all data that needs to be in the

proposed database. Chapter 5 specifies the database structure in detail. Chapter 6

summarizes the thesis and details future work.















CHAPTER 2
BACKGROUND

This chapter defines and attempts to clarify the three main standardization measures.

Their integration into one database is discussed in the following chapters. These

standardizations are applicable to different areas of the health service reporting system. The

ICD-9 code is a code that defines cause for treatment specified by the CPT code. ACRAC is

a guide specifying the applicability of the treatment to the condition on a scale of 1 to 10

with 1 being least (not very) applicable. Non-applicable treatments have a score of 0 and are

not mentioned in relation to the condition. For instance:

Chemotherapy would have a score of "0" for the condition "23 year old male with broken arm".

For "Moderate or severe acute closed head injury, stable", CT Scan has a score of "9."


Definitions of Terms

The ICD-9 Codes

Medical procedure and diagnosis codes represent the elemental unit for all

professional health care service transactions. The ICD-9 code is a code uniquely identifying

any abnormal physiological condition that may occur to/with a human body. The codes are

classified by either cause or body region (see Appendix 1). Each condition that may occur is

then classified as a subclass of the main class in a series of levels (see Appendix 2). The

final/leaf node in the classification is given a code called the ICD-9 code. This code is useful

for billing, transaction, analysis, and other similar purposes.

The International Classification of Diseases, Ninth Revision, and Clinical

Modification (ICD-9-CM) was developed by the National Centre for Health Statistics for use









in the United States. It is based on the WHO international ICD-9. The Electronic

International Classification of Disease is based on the International Classification of

Diseases [9], Ninth Revision, Clinical Modification (ICD-9-CM) as published by the U.S.

Public Health Service and Health Care financing Administration (HCFA).

The Tenth Revision of the International Statistical Classification of Diseases and

Related Health Problems [10] is the latest in a series of attempts to classify diseases that was

formalized in 1893 as the Bertillon Classification or International List of Causes of Death.

While the title has been amended to make clearer the content and purpose and to reflect the

progressive extension of the scope of the classification beyond diseases and injuries, the

familiar abbreviation "ICD" has been retained. In the updated classification, conditions have

been grouped in a way that was felt to be most suitable for general epidemiological purposes

and the evaluation of health care.

The ICD code series have been tailored to fit specific guidelines provided by Health

Care Financing Administration (HCFA). These codes are needed to allow health care

providers to work in tandem (not around) complex and often tedious billing requirements of

Medicare. As identified in [11, p. 5], "Establishing medical necessity is the first step in third

party reimbursement. Justify the care provided by presenting the appropriate facts. Payoffs

need the following information to determine the need for care. Knowledge of the emergent

nature or severity of the patient's complaint and condition; and all facts regarding signs,

symptoms, complaints or background facts describing the reason for care such as required

follow-up care."

The HCFA 1500 claim form is used by hospitals to claim reimbursement for services

(i.e., treatments). This states that the first diagnostic code must describe the most important

need for care. This often consists of a single ICD-9 code.










Some HCFA guidelines are summarized below to provide a better understanding [12,

p.l: Introduction]:

"Identify each service, procedure or supply with an ICD-9 code to describe the

diagnosis, symptom, complaint, condition or problem.

Identify services or visits for circumstances other than disease or injury such as

follow-up care after chemotherapy with V codes provided for this purpose.

Code the primary diagnosis first followed by the secondary and tertiary -and so on.

Code any coexisting condition that affects the treatment of the patient from that visit or

procedure as supplementary information.

Code to the highest degree of specificity. Carry the numerical code to the fourth or

fifth digit when necessary."

The ICD code series started as an aid for doctors to report what conditions were

treated in a well-defined and standardized manner. The need for this code was \[....: _.'s

increasingly complex administrative requirements for clinical diagnostic laboratory

reporting" [13].

Documentation of Radiologic services for many medical payers (such as Medicare)

dictate that each report for a procedure or examination be appended with one or more codes

found in the ICD-9 CM. These codes serve to document the sign, symptom, or appropriate

clinical diagnosis needed to justify the service. "In most cases, this task falls to coding clerks

employed by the physician or hospital. In some cases, radiologists themselves are given the

task of coding cases as they dictate them"[14 p.4]. This task adds an additional step to

interpreting a radiologic exam. An electronic (automatic) means to assist Radiologists in

locating an appropriate code will eliminate the need for ICD-9 coders saving time and

money.









The CPT Codes


CPT [15] is an acronym for the Current Procedural Terminology. CPT codes are

published by the American Medical Association, and the fourth edition is the most current.

The purpose of the coding system is to provide uniform language that accurately describes

medical, surgical, and diagnostic services.

A CPT code is a five digit numeric code (with an optional two digit modifier) used to

describe medical, surgical, radiology, laboratory, anaesthesiology, and

evaluation/management services of physicians, hospitals, and other health care

providers. CPT is the Current Procedural Terminology and was developed by the

American Medical Association in 1966. Each year, the publication is updated to reflect

changes corresponding with significant updates in medical technology and practice. Current

Procedural Terminology (CPT), Fourth Edition, contains a listing of descriptive terms and

identifying codes for reporting medical services and procedures [16]. The most recent

version of CPT code book, CPT2001, contains 7,928 codes and descriptors.

The CPT codes are published in two versions: The "CPT Physician's Current Procedural

Terminoloy" (the most common) and The "CPT Physician's Current Procedural Terminology

S-.. j Annotated for Hospitals." The Hospital version contains all the information in the

original version with additional special Medicare guidelines and notations for identifying

criteria applicable to outpatient hospital billing.

The rules for assigning the appropriate code are complex, and any individual who is

determining the appropriate codes should receive proper training and credentials for their

use. This includes any office or clinic personnel who play a significant role in coding.

CPT descriptive terms and identifying codes currently serve a wide variety of

important functions. This set of terminology is the most widely accepted medical










nomenclature used to report medical procedures and services under public and private

health insurance programs. CPT is also used for administrative management purposes such

as claims processing and developing guidelines for medical care review.

The Standards for Electronic Transactions mandates the use of CPT for the

following [11]:

Physician services,

Physical and occupational therapy services,

Radiological procedures,

Clinical laboratory tests,

Other medical diagnostic procedures and

Professional hearing and vision services.

Each condition that a person can have is treated with a standard procedure. In the

United States, insurance companies pay for almost all of these procedures reported by a CPT

code. Each CPT is associated with a code. This is normally referred to as the CPT code.

Each procedure in the CPT is described in standardized long form, medium form, and short

form to avoid confusing localized or individual terminologies. Appendixes 3 through 7 show

examples of the different forms in which the CPT codes are distributed. The CPT is aimed

at the convergence of procedural terminologies so all entities including the patient, doctors)

and the insurance company involved know what exactly was done to treat a condition.

Appropriateness Criteria

"In 1993, the leadership of the American College of Radiology (ACR) determined

that in the changing health care environment, a premium would be placed on the efficient

use of resources including appropriate use of radiological services. Additionally, ACR

leadership concluded that there was an immediate need for nationally accepted, scientifically










based appropriateness criteria to assist radiologists and referring physicians in making

appropriate imaging decisions for given patient clinical conditions and that a system needed

to be developed for the creation of these criteria." [16, p.1]

Radiologists, hospitals, and payers seemed to want such criteria to become available

so that treatment procedures could be standardized leading to smoother reimbursement and

lower chances of lawsuits. These discrete entities emphasized the need for the discipline of

radiology to take a leadership role in criteria development. The ACR Task Force on

Appropriateness Criteria was created for this purpose.

It was recognized from the beginning that the best way to set criteria would require

use of broad-based consensus techniques, because data from existing scientific outcome and

technology assessment studies are usually insufficient for this purpose. It was also

recognized that the input of physicians from other medical specialties would be invaluable to

the effort. As a result the ACRAC documents were created.

"Clinical practice guidelines are meant to apply to the majority of patients. More

specifically, the ACR Appropriateness CriteriaTM(ACRAC) are intended to guide radiologists,

referring physicians, and patients in making initial decisions about diagnostic imaging and

therapeutic techniques. The complexity and severity of a patient's clinical condition dictates

the selection of appropriate imaging procedures and treatments. Additionally, the availability

of equipment or trained personnel may influence the selection of appropriate imaging

procedures or treatments. The ultimate decision on the appropriate use of any specific

examination or treatment is one that is made by the radiologist and the referring physician in

light of all the circumstances presented in an individual situation" [17 p.2].

Market forces are influencing physicians and provider organizations to practice cost-

effective medicine while still maintaining quality. Utilization management of radiology










services is a significant component of this change. The ACR Appropriateness CriteriaTM can

be used as a basis for utilization management by retrospective or prospective review.

The use of the Appropriateness Criteria was to achieve a degree of standardization in

treatment procedures. Though the primary need might seem to be to streamline and increase

efficiency in hospitals, the secondary need for cheap and efficient means of compensation

from insurance companies made the use of the ACRAC more pressing.

The appropriateness criteria are a means for dictating what procedure or treatment

routine is most applicable under certain circumstances. Isolating the cause of a condition is

often a critical function of the radiologist. Two processes achieve this. One process is aimed

at isolation of the cause by proof and the second at isolation by elimination. One can only

imagine the number the different combinations of methods to arrive at a hypothesis. The

ACRAC is aimed at streamlining and standardizing this process. The ACRAC is classified by

consequences and dictates what procedure is most appropriate in determining the causes or

alleviating the consequences of a disease or condition.

The ACRAC Documents

The electronic version of the ACRAC consists of 171 word documents stored in 17

folders. Each folder deals with a specific aspect of radiology as shown in Figure 2-1 and

described in Table 2-1.












F-l,: I-.1ll -" LV.:. .:.- r.F


E :,.:i i[.


111111 1i 111


Liii.:.



iF


J I



r I "0 rJI ic'


ACR_App


WI-BREAST 20110
.I.-I : I J I .- I

Modified:
5/20/2001 8:48 PM


RO LUNG
2000



WI 2000


I-..' I .1r J




RO
PROSTA...



WI-BREAST
2000


I-.. I- ir j




RO RECTAL
2000



Introduction....


F.ITH 200-




TH 2000


HIl'll' I



UR 2000


1 :.l- l, I .l,-,:4.. ,j


Figure 2-1. The ACR Folder




The above figure shows the layout of the folders that form the electronic version of


the ACRAC Each folder contains up to 11 different documents that pertain to a certain


class of imaging procedures. For instance, WI Breast 2000 is a folder that contains


documents that relate to Imaging of a Woman's breast. The 2000 indicate that the


documents contained are part of ACRAC 2000.


' i r l :.i. i..-..,ii.h










Table 2-1. Folder Map.


S1 Folder name Class of documents contained No of
no Documents
1 CV 2000 Cardiovascular Imaging Year 2000 19
version
2 GI 2000 Gastrointestinal Imaging 16
3 IR 2000 Interventional Radiology 7
4 MS 2000 Musculoskeletal Imaging 23
5 NI 2000 Neurologic Imaging 16
6 PD 2000 Pediatric Imaging 11
7 RO 2000 Radiation Oncology-Bone Metastasis 1
8 WI-BREAST 2000 Women's Imaging-Breast 4
9 WI 2000 Women's Imaging 11
10 UR 2000 Urologic Imaging 19
11 RO PROSTATE 2000 Radiation Oncolog-Prstate 7
12 RO RECTAL 2000 Radiation Oncology-Rectal/Anal 4
13 RO LUNG 2000 Radiation Oncology-Lung 6
14 RO HODGKINS Radiation Oncology-Hodgkin's Disease 7
2000
15 TH 2000 Thoradc Imaging 11
16 RO BREAST 2000 Radiation Oncology-Breast 5
17 RO BRAIN 2000 Radiation Oncolog-Brain Metastases 4
TOTAL 171

All documents are classified into two major categories: Procedures [18] which are

detailed in Appendix 6 and Treatments [19] which are detailed in Appendix 7. Procedures are

simple actions that can be taken which have a direct and often unambiguous result. For

instance, creating an X-Ray image to detect a broken bone would be a procedure.

Treatments and their follow-ups consider a larger number of facts. Their application is often

complex, time consuming, and involves procedures that needed to be conducted over a

period of time like chemotherapy.

ACRC documents start with a review of literature and a short introduction to the

specifics of the condition. After discussing the condition and reviewing various exceptions,

the variants of the disease are discussed and appropriate treatments for each condition are

listed along with the appropriateness of each treatment. It should be noted however, that all

172 documents that form the ACRAC series are meant to form one huge text. All individual

documents are subsets of the ACRAC 2000 document. The page numbers in the individual










documents signify their position in the document. The documents and their specifics are

discussed in greater detail in the following chapters.

Putting It All Together

Every commensurable action performed by a HSP is billed to some health insurance

provider. Each billed action must be specified by a CPT code as a result of an ICD-9 code

that justifies treatment. What complicates this process is communicating with insurance

companies and proving to them that a particular applied treatment was absolutely necessary

for the given condition. To compound the problem, insurance companies refused to pay for

certain treatments either due to their high cost or due to some internal guideline. HSPs are

often at a disadvantage because typical patients are often unable to pay for the treatments

leaving the HSPs responsible for treatment.

The critical relationship between an ICD-9 code and a CPT code is that the

diagnosis supports the medical necessity of the procedure [20]. Since both ICD-9 and CPT

are numeric codes, health care consulting firms, the government, and insurers have each

designed software that compares the codes for logical relationships. For example, a bill for

CPT 31256, a nasal/sinus endoscopy, would not be supported by ICD-9 826.0, a closed

fracture of phalanges of the foot. Such a claim would be quickly identified as inappropriate

and would be rejected.

The crux of the matter is that insurance companies refuse to publish data on the

applicability of procedures for obvious reasons. If such data was published, HSPs could

determine the most expensive treatment for each condition and use this to charge insurance

companies. On the other hand, HSPs would possibly reduce the quality of care to avoid

being left "holding the buck" and to reduce chances of insurance companies refusing to pay

the bill.










In the "current" system, the ordering physician identifies the test (coded by CPT) by

specifying the examination and then giving a reason (usually a minimal sentence or phrase).

The coders (or radiologists in this case) then make their best guess for reason behind the

examination (the ICD-9 code). This is called "back end" coding because it is done after the

examination has been ordered, scheduled, performed, and interpreted. The current system is

shown in Figure 2-3.

To standardize the process of care giving and to reduce the chance of conflicts, the

ACR decided to develop the appropriateness criteria. The appropriateness criteria take into

account a whole series of conditions requiring radiologic and related procedures and

treatments. It was developed as a series of documents describing each condition in detail

with a chart identifying treatments and procedures. Each treatment is gives a score, often on

a scale of 1 to 10. This score is meant to be a recommended measure of the applicability of a

treatment to a condition. The score takes into account several factors ranging from the

efficacy to the cost. It is however the radiologist's/doctor's role to decide which treatment

among those rated is the most applicable under the given circumstances. The current

procedure followed by a typical HSP is detailed in Figure 2-3.

Figure 2-3 describes a part of the process that hospitals follow from the initial

patient visit to the payment for services. The process begins with a patient approaching a

doctor. The doctor performs a diagnosis and prescribes some treatment. The diagnosis is

forwarded to an ICD-9 coder. It is the coder's task to assign the appropriate ICD-9 code

describing the main cause for the treatment along with any sub-codes. The treatment plan is

forwarded to a radiologist who performs the prescribed task and prepares a report. The

report is forwarded to an expert coder who assigns CPT codes to the treatment for billing.

The report along with the diagnosis is sent to a billing expert who prepares a bill.







16





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l I


Patient
with condition
E-: r i -r ;' F,.:. .....i* .t













t I I .[


Bill
/ -L- "-- -- "




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Figure 2-3. Typical Hospital Procedure

The bill is sent the insurance company for reimbursement. If the bill meets all the

insurance company's guidelines, the hospital is reimbursed. If the bill fails to satisfy some

criteria, it is sent for review along with comments. The hospital (billing expert) and the

insurance company may need to jointly review the case to arrive at a consensus. The billing

expert then prepares a fresh bill and sends it to the insurance company for a payment.






17


The ICD codes, the CPT codes, and the ACRAC are standardization measures

applied at different levels of this hospital procedure. These measures are developed and

deployed independently. This thesis attempts to formalize a database relating the three

standards in a formal manner to propagate their use, development, and deployment.















CHAPTER 3
SCOPE AND OBJECTIVES

This research was born initially from a need in the Radiology Department at Shands

Hospital. Dr. Sistrom, a radiologist at Shands Hospital, had seen the need for a tool to

improve efficiency in the coding processes that occupy a significant portion of a radiologist's

time. A radiologist must dictate a report after each procedure or treatment. This report

requires the radiologist to include the specification of the CPT codes located in a published

volume. To increase efficiency, Dr. Sistrom developed a CPT code lookup application.

The primary cause/need for the treatment was specified by a short arbitrary

description given by the doctor along with one or more ICD code appended by the coder,

an individual trained in specifying ICD codes. Radiologists and their coders often had to deal

with non standard and non-specific data. This lead to non-standard treatments and

inconsistent billing, thus creating a dire need for standardization beginning from the doctor

to the final procedure.

The thesis explores the means to achieve this. It consists of two parts. The first part

is the development of a plan to achieve a means to converge the three related standards: the

CPT, the ICD 9, and the ACRAC. The second part is to design and specify a database

relating the standards using the ACRAC as a base. This database is designed to serve as the

base for further development of a larger initiative to make the technology available to HSPs

and doctors. To achieve the desired level of standardization, doctors will firstly need to

reference the database. They will prepare standardized diagnosis and prescribe standardized

treatments using standardized CPT codes. Since the doctors are referencing the database, ICD









codes can automatically be appended to their reports and/or diagnosis as and when needed.

Radiologists will use this information consisting of a formal report in the standard form

along with the necessary ICD codes to reference the database to identify a set of ranked

standardized procedures. Once the radiologist chooses a procedure or treatment, a

standardized report can automatically be generated with the corresponding CPT code. This

report will contain consistent information starting from the doctor's diagnosis to the

radiologist's report making the task of the billing expert easier and greatly reducing the

chances of conflicts. Consensus based standardized treatment procedures will greatly

enhance the quality of care and reduce greatly the chances of a potential lawsuit.

The following example will help illustrate the above process. A patient with extreme

pain in the arm consults his assigned physician. The general practitioner has no authority to

conform a broken bone. He can only suspect a fracture. The patient is "referred" to a

radiologist with a report stating the physician's suspicions and the reasons for such a

suspicion. The radiologist looks up "suspected broken bone" in the database is given a list of

possible methods to confirm the fact. The radiologist prepares an X-Ray image to confirm

the fact. Once the fact is confirmed, the radiologist prepares a report that confirms the fact.

Since the condition is confirmed, the radiologist will need to append the condition code

(ICD Code) to his report. He will also need to append the CPT code for the X-Ray to

charge the patient. This report is forwarded to the physician who will use this information to

prescribe a treatment/regimen (possibly a cast). The physician prepares a final report

appending more CPT codes to the radiologist report, corresponding to the treatment that is

prescribed.

The second part of this thesis is to design and specify a database structure. The final

product, from the design and implementation perspective was developed to reside, work,










and run on systems all using Microsoft products. The database is designed with MSSQL

conventions, to be implemented on MS Access, which will later be upgraded to a MS sequel

server running on the latest Microsoft server operating system. The applications and

interfaces will be developed using MS Visual BasicTM. VB script will be used to run stand-

alone applications that will be securely distributed to access a backed. Secure authentication

protocols will be part of the end product. Later editions may also be web-based, with

possibly a system independent application to access, modify and distribute the database.

Contemporary Attempts: ACRAC Encoding.

Self-Documenting Structured Reports Using Open Information Standards



Structured reporting systems deal with standardizing data elements. They use

predetermined input and output formats resulting in standard input formats and

standardized reporting. An article by Charles. E. Kahn, Jr. [21] describes a system for

structured data entry and reporting that generates reports encoded in the Standard

Generalized Mark-up Language (SGML), an open, internationally accepted standard for

document interchange. A structured report is self-documenting: in terms that the document

itself includes a definition of its allowable data fields and values encoded as a report-specific

SGML document type definition (DTD). Using external vocabularies and appropriate

linking, the system can generate open, universally comprehensible structured reports.

Doctors (and radiologists) have to document all diagnosis and procedures with

reports. These reports serve as documentation of observed conditions; actions performed,

and recommended courses of action. In the general case, arbitrary reports are prepared

depending on local circumstances. Arbitrary reporting made use of these reports by third










parties extremely difficult; especially when the third party involved was an insurance

company. A dire need for standardization of reports exists to this day.

Dr. Charles E Kahn developed the SPIDER user interface. SPIDER was a web-

based data entry system allowing doctors to prepare reports on a patient's condition [22].

The data entry system asks questions similar to the conditions and variants of the ACRAC.

The report prepared makes the doctor's task easier and more standardized. The conditions

and variants are stored in standard XML.

SPIDER's knowledge base is specified in the Data-entry and Reporting Mark-up

Language (DRML), an SGML-based mark-up language that was developed to allow

physicians to define the data-entry elements and format of a wide variety of reporting

applications [23]. DRML uses hierarchically organized reporting concepts, and provides a

means for users to exchange knowledge bases for reporting systems across different

hardware and software platforms. Figure 3-1 shows an example of a simple DRML

document. Each sentence in the DRML sheet starts with a mark-up title such as ,<br /> <br /> <Group header>, etc that specifies what the rest of the line contains. This allows for easy<br /> <br /> parsing and lookup.<br /> <br /> An HTML web interface allows doctors to enter their diagnosis by checking the<br /> <br /> appropriate boxes. The options are structured like the ACRAC. Once a doctor enters all the<br /> <br /> relevant information, SPIDER creates an SGML document containing the information. As<br /> <br /> with all SGML documents, it consists of an SGML declaration, a DTD, and a document<br /> <br /> instance. By creating a DTD that expresses the hierarchy, allowable elements, and<br /> <br /> relationships of the reporting application, SPIDER creates an open, standardized structured<br /> <br /> report that is self-documenting.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 3-1. A Sample part of a DRML document<br /> <br /> The resulting document is a report that could make a doctor's task easier. However,<br /> <br /> <br /> as the system is structured, the doctor deals with either a non-existent or a very restricted set<br /> <br /> of codes. The system does not use CPT or ICD-9 codes. The doctor or an expert coder<br /> <br /> must add these codes manually at a later time.<br /> <br /> The ICD-9 Coding System<br /> <br /> In radiology departments, radiologists are required to append one or more ICD-9<br /> <br /> <br /> code to the end of each report. Documentation [24] of radiologic services for many medical<br /> <br /> payers (such as Medicare) dictates that each report for a procedure or examination be<br /> <br /> appended with one or more codes found in the ICD-9 CM. These codes serve to document<br /> <br /> the sign, symptom or appropriate clinical diagnosis needed to justify the service. "In most<br /> <br /> cases, this task falls to coding clerks employed by the physician or hospital. In some cases,<br /> <br /> radiologists themselves are given the task of coding cases as they dictate them'124,p.1]. This task<br /> <br /> adds an additional step to interpreting a radiologic exam.<br /> <br /> <br /> <title>Renal Ultrasonography<br /> 'group header>Clinical Information<br /> <bin>Pain<br /> <bin>Hematuria<br /> '/group><br /> 'repeat by=row hidden header>Kidneys<br /> <num units="cm">Size<br /> 'group header option>Hydronephrosis<br /> <bin>None<br /> <bin>Mild<br /> <bin>Severe<br /> ,/group><br /> 'for><br /> groupp header>Left Kidney<br /> groupp header>Right Kidney<br /> '/repeat><br /> 'group header option>Diagnosis<br /> <bin>Normal<br /> <bin>Abnormal<br /> '/group><br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> The Radiology Department at the University of Florida, School of Medicine employs<br /> <br /> two coding managers and three quality coders. They are responsible for generating all bills for<br /> <br /> Radiologic services. "The volume of work however makes it impossible for them to do so"<br /> <br /> [25,p.3]. In addition, radiologists have access to information that the coders either do not or<br /> <br /> cannot comprehend. This makes the process even more complicated since the radiologist must<br /> <br /> assist the coders and append additional codes to each case. The usual method of coding is to<br /> <br /> have a list of all relevant ICD-9 codes at each reporting station. The radiologists and coders<br /> <br /> identify appropriate codes from the list based on information provided to them by the ordering<br /> <br /> physicians, radiologists, patient interviews, etc. Coders were often left with either inadequate<br /> <br /> information or non-updated versions of the codes which compounded their inefficient lookup<br /> <br /> procedure. The cost of an update to the set of codes was .:I. i-In .. All code books and code<br /> <br /> lists at all work stations had to be replaced. Additionally, new copies had to be distributed to all<br /> <br /> coders, and radiologists. Inefficiencies in the distribution system resulted in (but were not limited<br /> <br /> to) inaccurate reporting and problematic and unnecessary complications in the already<br /> <br /> complicated reimbursement process. Further more since coding was manual, radiologists and<br /> <br /> coders often made mistakes in the coding process.<br /> <br /> Recognizing problems with the existing process, Dr. Sistrom developed the ICD9 coder.<br /> <br /> This computer based system allows quality coders and radiologists alike to find, update, and add<br /> <br /> ICD-9 codes as necessary.<br /> <br /> This application while not containing the full compliment of codes ensured that anyone<br /> <br /> having access to the system could easily locate the code that they need. Whenever a new code<br /> <br /> was encountered (a code not already in the system), the person discovering this code, simply<br /> <br /> added it. All parts including the database and the application interface were developed using MS<br /> <br /> Access 97. The system was designed for use on any windows system having network access to<br /> <br /> the central database server.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> The package consisted of the following sub parts:<br /> <br /> <br /> ICD-9 Code Finder application: This application helps those looking for a code to locate<br /> <br /> <br /> it using some sub-string of its descriptor. Additionally, diseases could be located by entering a<br /> <br /> <br /> code. For Example, to locate Meningococcal Meningitis, one needs to enter only Meningitis. See<br /> <br /> <br /> Figure 3-2.<br /> <br /> <br /> ICD-9 Code Manager Application: This allows doctors to append codes to the database,<br /> <br /> <br /> providing the code to all other users. The user enters the code, enters a descriptor of the code,<br /> <br /> <br /> and checks a box indicating the division of Radiology using this code. Figure 3-2 shows the Add<br /> <br /> <br /> A New Code interface.<br /> <br /> <br /> I *l 11*I I *I I IU- I .. I<br /> <br /> <br /> I IIT P E T : -- f I I -<br /> i I EIIT-: L-- ,: FI-!<br /> iii I I.I '..I I" RI CODOE Kl<br /> <br /> <br /> [End Key] T i IJ : II .LE F E-I' H E I I _' 1<br /> I LiR -EaFl'n IC.,. I<br /> MEr.JcGOC.OC ,C.AL MENirJGITI 3=,1:36 0<br /> <br /> <br /> I i FF iT i F F F Ti. -i i<br /> <br /> I I II I<br /> <br /> <br /> S II II I. :I L ,., '. I lI It L I I I I II l I I I 'l I I- II' Il<br /> ........ ICD-9 Code 0360<br /> ['iert Key] [Delete Keym<br /> <br /> <br /> <br /> <br /> <br /> H I I I, i I<br /> S I I I I I I I JI I<br /> I,-'r I. I I'il c_ I 1 s h i2, II<br /> r r r r r r r r<br /> <br /> <br /> <br /> Figure 3-2. The ICD-9 coder screen images[24].<br /> <br /> <br /> 1' 'I I<br /> <br /> I- iL i J<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> UM ,i or rp.f<br /> <br /> <br /> <br /> 0 FI<br /> <br /> <br /> Toilayi tloli ix<br /> <br /> <br /> <br /> SU I I<br /> U 11 1 i 1<br /> <br /> <br /> <br /> <br /> U 11<br /> <br /> <br /> <br /> <br /> I I<br /> U I<br /> <br /> <br /> <br /> <br /> <br /> U I<br /> <br /> <br /> <br /> <br /> <br /> <br /> I I<br /> U I<br /> <br /> <br /> IU iijiI<br /> <br /> <br /> <br /> <br /> <br /> <br /> U I<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> U A<br /> U I "<br /> <br /> IU "<br /> I ]<br /> U ,) ,] ,<br /> <br /> I_ I<br /> U 1<br /> U "<br /> <br /> U 1<br /> IU :<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> IU<br /> <br /> I I<br /> I I J<br /> II j<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> I I ,<br /> <br /> <br /> <br /> U ,)<br /> IU ,) ",<br /> IU "<br /> IU , I<br /> U I<br /> <br /> <br /> le < lox |I iieiir ,| olly |I ijujilI p ls ilP sk 1| cliesi Iai 111111, 11. io| uldileenlliee<br /> r I i i i I PI I I I I I I IU I<br /> i- -iL-II I I- i U I I U U I U I I I 11<br /> .i i-i .i iI_ U I_ I'I U I U<br /> ii i,,li, i- i-. i i i 1-1 I_ I U I_ UI I I II I UI .<br /> S I ii ii i I I I I I I I I II I_ UI<br /> 11i-i i i ii ii l i- I I III II I I I U U<br /> <br /> I u I_ u u u<br /> SI I : I I 1 -i U I I I I_ I_ U I I i: 111<br /> i i- FI Ui i I I I I I<br /> ii I II I -I I I i-r I III -_ IIu ui<br /> <br /> <br /> ii_ i : Ti i-iii i. Ui i I U I_ U I u ,<br /> Ti: 11-1 i 1 I I_ U I -_ U I I : 1:111<br /> <br /> ii i. i i . I I .. I I I_ U I I ,i<br /> i--lli l i,1_-T I__ U I I l I_ U I_ U II 1I11<br /> S1 ': 1 1-:-I : -''l l II11'i' l-I: II U U U U "<br /> S11 111 1 I Ir U I_ I I U I U II 1<br /> i- I ii .. i- i I I I I_ U U I I UI I<br /> 1I:II II, H I' I II I I1" I II I II II iii<br /> <br /> i-i I I -. I i I I I I I I I I I ii i<br /> i I I_ I I i ii- Ii :I I II I_ U I I I I I I I<br /> 1 i-- 1-1i l- ii -- I I IIU I I I I U I U I I i<br /> ,I I-I i I I i I U I_ U I_ U I U I<br /> I iii-i: i I Ii I I:I I I I I II Ti<br /> i- i- I I r 1 1 iTI I U 1_ U 1 U 1_ U II<br /> II U I_ U i_ U i_ U II r<br /> i F 1 1: 1_ u c_ II u I_ u I<br /> I -r -I *I I -I i iT I I : I rI I- I I I I I I I I I I I<br /> 11 -_ 1 1: u u -_ u -_ u -<br /> I,, i I II I II I II I II ,<br /> i:,,:r -n, EL- 1:11, I:r--IN I u C_ u C_ u C_ u<br /> i-- I I i i_- i i i11- ii IL I I I I I I I I I I I I ,i<br /> I-II _-I I I-I l.I II, I. ii I I I I I II I_ U I_ UI I II<br /> -i i 11, ,1 i .i, II, I- II I II I II I I I ii ,,,<br /> <br /> ..EIlI I i ii- i nii II- :,, iii- I U I U I U I I U<br /> I- i-II. i I I IF I I_ U I U I I I i .<br /> H I i:_I- I I, I U I I U I U I U I<br /> 1- lI- I-I- ir i- 11- ,-i iI- I I I I I I I I I I i i.iii<br /> <br /> I-I, I 1- 1-- ii I- I- i IE U I U I U II U 11 1111i<br /> I-I I- i- i ll i T l i- I i: I- I I I I I I 1 U II 1 111<br /> I -I_- i II-I1- Ii I- '.i-'I_ III I-- I I I I I I I I:II<br /> .li.i_ U i U I_ U I_ U i<br /> I- II i 1:-1- T I- I- ,,i, ,1Iii I II I_ II I II I II ,<br /> i ii.:. .:. i_ ii @ i I U Ui ii<br /> i 1i i i Ii ,i : i i I- I I I I u I u I I I I II "<br /> <br /> -i II-i-_ I ll II. I- I_ I I.,II I_ U I_ U II I<br /> <br /> i : i- .I TI-_ i I U I I I I_ U U I<br /> , ,,II, I - I I I I_ II I I_ U I I : 1:111<br /> II II II : i ll T i i I II U I I U I I UI lI<br /> - I- i i- I i ii:i I 1 l I I I I I I I I I 1 111i 1<br /> <br /> <br /> Figure 3-3. Screen shot: Internal Data representation [24]<br /> <br /> <br /> This application is well designed and is tailored to its purpose. In addition it has the<br /> <br /> <br /> <br /> inherent advantage of being developed by a radiologist so it meets all objectives of the end users.<br /> <br /> <br /> <br /> ImageCoderTM<br /> <br /> <br /> <br /> ImageCoderTM, a product of A Life Medical Inc, is a tool that automatically assigns<br /> <br /> <br /> <br /> ICD-9 and CPT codes to transcribed "diagnostic radiology, diagnostic ultrasound, nuclear<br /> <br /> <br /> <br /> medicine, and simple interventional procedure reports" [25]. This system conveniently and<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> compliantly codes reports with the correct ICD and CPT codes with little or no human<br /> <br /> <br /> intervention, optimising coding to enhance revenue if a cost factor is associated with the<br /> <br /> <br /> codes. It also has a repository to store radiology reports. "ImageCoder helps to eliminate<br /> <br /> <br /> costly data entry steps, manual matching and reconciliation of source documents, and paper<br /> <br /> <br /> storage costs"[25]. Image coder is also configured to identify deficiencies in codes that may<br /> <br /> <br /> affect reimbursement. Figure 3-4 shows a screen shot of its interface.<br /> <br /> <br /> <br /> LII _- j- i,:<br /> <br /> <br /> IM i. "*. IIT B CPI -<br /> <br /> C4-nm. nv Ho, p-.i<br /> <br /> <br /> " ,uri IIii<br /> D 1: 1- 1,<br /> <br /> -i.- PflD- i" l.-,i ii n P D<br /> <br /> S 1rd.4 MP .- I r1ip. 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I- 1 .- J I .-<br /> <br /> <br /> <br /> <br /> <br /> <br /> I7 I I<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> I .... i r.,<br /> <br /> <br /> <br /> <br /> <br /> *<br /> <br /> <br /> I : Ji 1 . IL L 1 ,Ii<br /> <br /> <br /> Figure 3-4. Screen shot: A life medical coder<br /> <br /> The key benefits of the coder include the following:<br /> <br /> <br /> Automatic assignment of accurate codes,<br /> Increase in productivity and profitability,<br /> <br /> Acceleration in revenue turnaround,<br /> <br /> Streamlining of data,<br /> Lower archival and storage costs,<br /> <br /> Enhanced reporting and data management,<br /> <br /> Assured regulatory compliance, and<br /> <br /> Seamless integration with the current Radiology Information System (RIS) and/or billing system<br /> <br /> <br /> ~I t I ~dsr II- ~ I<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Other advantages include "ImageCoder's extensive CPT knowledge base covers<br /> <br /> diagnostic radiology, diagnostic ultrasound, nuclear medicine, and simple interventional<br /> <br /> procedures. ImageCoder correctly assigns common procedure modifiers [25].<br /> <br /> This is a useful tool for radiologists in preparing reports. While its advantages are<br /> <br /> listed in detail above, its scope however is restricted to preparing radiologic reports and<br /> <br /> requires more extensive testing. Its disadvantages include dependence on a single coding<br /> <br /> standard with no possibility of local updates to the database by users.<br /> <br /> Objectives<br /> <br /> The American College of Radiology (ACR) Appropriateness Criteria currently exists<br /> <br /> as a series of word (Microsoft Word) processor documents. In computer terms, these<br /> <br /> comprise unstructured data, only accessible by looking through the documents manually.<br /> <br /> There is no automatic/reproducible method to access the imaging and treatment<br /> <br /> appropriateness information and related clinical conditions. This limits the usefulness of the<br /> <br /> Appropriateness Criteria for research into utilization and incorporation into online order<br /> <br /> entry systems. Distribution of new versions of the Appropriateness Criteria is currently<br /> <br /> accomplished by mailing hard copies of the document to subscribers. These same<br /> <br /> documents are available on the ACR World Wide Web (WWW) site or on CD-ROM media,<br /> <br /> a format identical to the printed document. Third party organizations and companies2<br /> <br /> wishing to incorporate the guidelines into computerized systems must do so manually and<br /> <br /> individually. They must translate the Appropriateness Criteria into formats suitable to their<br /> <br /> software environments with no feedback from the ACR as to the accuracy and relevance of<br /> <br /> <br /> <br /> <br /> <br /> 1 Examine Appendix 8<br /> 2 Such as insurance and health services companies.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> the product. There have been an increasing number of requests to the ACR to distribute the<br /> <br /> Appropriateness Criteria in machine-readable form.<br /> <br /> The best and most efficient form of distributing almost any data is in the form of a<br /> <br /> relational database. This database must be well structured, fully documented and exist in a<br /> <br /> standard format either as native database files or platform independent text tables. If this can<br /> <br /> be accomplished, a wide array of organizations and companies may incorporate the database<br /> <br /> into their software systems. In addition to more efficient distribution of the Appropriateness<br /> <br /> Criteria, a structured database form will enable more accurate and controlled modification of<br /> <br /> the content for future version updates.<br /> <br /> In its current form, the ACR Appropriateness Criteria has no defined relationship to<br /> <br /> any standardized medical nomenclature or coding schema. The two obvious choices for<br /> <br /> coding schema to be mapped onto the Appropriateness Criteria are the International<br /> <br /> Classification of Diseases, 9th Edition, Clinical Modification (ICD-9 CM) and the Common<br /> <br /> Procedural Terminology of the American Medical Association (CPT). These robustly encode<br /> <br /> signs, symptoms, and relevant clinical diagnoses (ICD-9) as well as medical procedures<br /> <br /> (CPT), respectively. These two schemes have been designated as official methods for coding<br /> <br /> these domains for Medicare billing by the United States Health Care Financing<br /> <br /> Administration (HCFA). The database structure described within this thesis contains the<br /> <br /> needed table definitions and relationships to map the ICD-9 codes to the signs, symptoms,<br /> <br /> and conditions cited in the Criteria. Table definitions. It also contains relationships sufficient<br /> <br /> to map CPT codes onto the listed procedures.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Summary<br /> <br /> Existing implementations include the following research.<br /> <br /> Dr. Kahn's research on the self-documenting report, dealt with an "ACR like" questioning schema.<br /> It has no firm basis or conformance to ACRAC standards.<br /> It cannot suggest/rank treatments depending on the condition.<br /> Dr. Sistrom's research on the ICD-9 coder dealt exclusively with ICD-9 codes<br /> It does not deal with the ACRAC / CPT standards.<br /> It does not contain a full compliment of codes.<br /> It cannot verify or validity any of the ICD-9 codes.<br /> ImageCoder dealt with report preparation and had facilities for Automatic appending<br /> of ICD-9 and CPT codes.<br /> It contains no reference to ACRAC.<br /> It contains no method of relating the coding standards.<br /> <br /> The analysis of the three works gave an insight into the current state of<br /> <br /> standardization in the field of radiology. It shows that in spite of major advances in making<br /> <br /> electronic tools available, there still is no tool/software that tries to achieve a confluence of<br /> <br /> these three interrelated standards. This thesis discusses a means to achieve this confluence.<br /> <br /> The first step to achieving this is to design a relational database that will formally document<br /> <br /> the relationship among the standards. This is the aim of this thesis.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> CHAPTER 4<br /> DATA ANALYSIS: ANALYSIS OF THE APPROPRIATENESS CRITERIA DATA.<br /> <br /> This chapter deals with data analysis. Data pertaining to the ACRAC, CPT and ICD-<br /> <br /> 9 are analysed in great detail. The analysis covers both synthesis (where data from different<br /> <br /> areas are linked together either in one table or by using a linking table) and decomposition<br /> <br /> (where data from a single field is broken down to a more acceptable fundamental level). This<br /> <br /> data analysis is a prerequisite for database design.<br /> <br /> This chapter outlines a platform independent data model of the ACR<br /> <br /> Appropriateness Criteria imaging guidelines for specific clinical situations (variants). This<br /> <br /> takes the form of a loosely structured listing of individual table definitions including detailed<br /> <br /> attribute (field) listings with data type, purpose, and constraints for each. This is not intended<br /> <br /> to be machine-readable but to be used as documentation of the formalized structure for<br /> <br /> future developers of the primary database. We intend for this documentation to be kept<br /> <br /> current so as to reflect any subsequent changes to the structure. After development and<br /> <br /> population of the database is complete, the document will serve as a user guide for software<br /> <br /> developers wishing to incorporate the Appropriateness Criteria into their software.<br /> <br /> The criteria documents include guidelines of four distinct types including:<br /> <br /> 1. Imaging procedures for clinical situations (this includes guidelines on imaging for<br /> staging for various types of cancer.),<br /> <br /> 2. Radiation oncology therapy comparisons,<br /> <br /> 3. Oncology patient follow up protocols, and<br /> <br /> 4. Interventional procedure indications.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Criteria of the first type (1) are the most numerous and seem to be most desired by<br /> <br /> third parties for delivery in a machine-readable form. The other three kinds of criteria have<br /> <br /> not been examined by this thesis and will each be specified via a separate set of table<br /> <br /> definitions for their core construct content. Many of the ancillary tables (e.g. guideline<br /> <br /> authors, literature references, procedural nomenclature, and pointers to illustrative material)<br /> <br /> can be shared between the different types of guidelines. Linking tables for the code<br /> <br /> mappings will be separate for each guideline type but will share common ICD-9 and CPT<br /> <br /> code tables.<br /> <br /> The following is a detailed analysis of individual parts of the three standards. The<br /> <br /> analysis includes<br /> <br /> A decomposition of the various portions of the standards to make them more<br /> structured and searchable. For example, consider a reference to an article. While a<br /> reference typically consists of a single sentence, it can be decomposed into different<br /> tables holding the title of the article, list of authors, etc, each of which is a separate<br /> table.<br /> <br /> The synthesis of different fields into one table to demonstrate interrelation. For<br /> example, procedure table taken from the ACRAC is connected to the CPT table to<br /> demonstrate that each procedure is coded by an ACRAC code.<br /> <br /> <br /> The rest of this chapter discusses parts of the standards and how their interrelation<br /> <br /> composes the entire database. The database as a whole is specified in the following chapter.<br /> <br /> Procedure Names<br /> <br /> The ACRAC database was to have information from a host of sources. The primary<br /> <br /> source of information however is the ACRAC documents. "The ACR appropriateness<br /> <br /> criteria is organized primarily by subspecialty (e.g. "Neuro-imaging") and then by clinical<br /> <br /> condition (e.g. Epilepsy) and finally by variant (e.g. "At least 40 years old")" [25]. The<br /> <br /> problem with encoding the Appropriateness criteria is that procedure names are not<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> uniform and are sometimes incomplete [25]. For example, the clinical condition<br /> <br /> "cerebovascular disease," "carotid ultrasonography" is specified only as "ultrasound". This<br /> <br /> would certainly disallow indexing using such non-standard fields since indexing would need<br /> <br /> conformance. Indexing would need one term to refer to a single unambiguous instance.<br /> <br /> Since much of the ACRAC documents are designed to be used by a doctor and would need<br /> <br /> a doctor to interpret them, they do not easily lend themselves to indexing. A proposed<br /> <br /> workaround allows the listing of a standard terminology to encompass all synonyms. Figure<br /> <br /> 4-1 shows how standardization can be achieved. Each standardized procedure name could<br /> <br /> be referred by many non-standard "Original Procedure names." This allows standardization<br /> <br /> to be enforced without destroying the original context / term.<br /> <br /> <br /> Original Procedure name I Standard Procedure name<br /> 1 _<br /> <br /> <br /> Figure 4-1. Standardization of procedure names.<br /> Now indexing can be accomplished using standardized terminologies without<br /> <br /> loosing the originally used terms. The problem is that no consensus has yet been reached on<br /> <br /> the use of standard terminologies. The ACR still has no project to recommend or enforce<br /> <br /> use of standardized terms in their documents. Hence for the time being, non-standardized<br /> <br /> terms will need to be used in the standard procedure field, until standardized terms come<br /> <br /> into use and/or force. For the present, people or organizations wanting to use standardized<br /> <br /> terms, may do so by just modifying the standard procedure field. What should be noted is<br /> <br /> that the above format, will, for the present, not allow indexing. Efficient indexing will only<br /> <br /> be possible once standardizing occurs.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Contributors<br /> <br /> It was clear during development of this thesis that much importance needed to be<br /> <br /> placed on maintaining information about the contributors and references. A requirement<br /> <br /> was that the database hold explicit searchable information on he contributors. The<br /> <br /> contributors who cooperatively developed the Guideline(s) {see Appendix 6} are mentioned<br /> <br /> in the format shown in Figure 4-2 with references given in a footnote like the one shown in<br /> <br /> Figure 4-3.<br /> <br /> <br /> <br /> ROLE OF F IMAGING IN CANCER OF THE CERVIX<br /> <br /> Expert Panel on Women's Imaging: Hedvig Hricak, MD, PhD'; Ellen Mendelson, MD'; Marcela B6hm-V61ez,<br /> MD3; Robert Bree, MD'; H Il i- Fi.I r- MD Eili..i I. Fishman, MD6; Faye Laing, MD'; David Sartoris, MD';<br /> Amy Thurmond, MD'; Steven G .i..Iin M. .I<br /> <br /> Figure 4-2. Contributors<br /> <br /> <br /> <br /> ', I 1 ... I 1,, '. ... C Y......k, NY;'Pan lCha '.-. .. .. 11. 1 lii, I.<br /> Imaging Center, i', lI.. .-:1,. Pa; I ..., .., I ,I 11 1 1... Columbia, Mo; 'Phoenix Perinatal Associates, Phoenix, Ariz; The Johns Hopkins Hospital.<br /> I... l ,II n ., h. .11 .I,, .. I h. h I.I ,I .. ., l,.- 1 I. h. .. .,<br /> The complete work of the -' -vi". "I'* .....- Criteriam is available from the -n.-*....... i..- : ,I I l ..l..: ii**I I .,n White Drive,<br /> Reston, VA :.Ii J *''' in book format and may be accessed at Additional ."l 11 be made available online as they are<br /> completed.<br /> Reprint requests .. H.1I H... ,I II., PhD, Standards and Acrreditation I' i..........:, Anm rican ... II .1 ...I. .. 1191 Preston White<br /> Drive, Reston, VA 20191-4397.<br /> <br /> Figure 4-3. Contributors Footnote<br /> <br /> The primary issue was representing all the relevant information from both the<br /> <br /> contributor's list and any associated footnotes. Secondary issues involved (1) storing the<br /> <br /> names and details of each contributor so that they could be searched and indexed separately<br /> <br /> and (2) linking the contributors to each guideline so their role in the design of the guideline<br /> <br /> was well documented. The structure shown in Figure 4-4 was found to capture the<br /> <br /> information adequately.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Contributor<br /> <br /> <br /> 1 Guideline-Contributor<br /> cC<br /> Contributor ID<br /> Contributor Name Contributor ID<br /> Institution Name Guideline ID<br /> Contributor Number<br /> DepartmentName Contributor Function<br /> Address 1<br /> Address2<br /> City<br /> State<br /> ZIP<br /> E-MAIL<br /> <br /> <br /> <br /> Figure 4-4. Contributors<br /> <br /> The Contributor_ID is an automatically generated key to uniquely identify the<br /> <br /> contributor. Details on contributors, including their name and other details, are obtained<br /> <br /> either from the main list (see Figure 4-2) or from the footnote (see Figure 4-3). Each time a<br /> <br /> contributor (a name in the main list) is encountered; a check should be made to see if the<br /> <br /> contributor's name is already in the database. If not, a new entry is made to the contributors<br /> <br /> table. For each guideline and for each contributor that was involved with that guideline, a<br /> <br /> new entry is made in the Guideline_Contributor table specifying the Guideline, the<br /> <br /> contributor, and the role the contributor played in the making of the Guideline.<br /> <br /> <br /> <br /> <br /> References<br /> <br /> <br /> <br /> <br /> Another important aspect was searchable references. One goal of the database<br /> <br /> structure was to allow indexing of the references for each guideline. A typical reference<br /> <br /> would appear like the one shown in Figure 4-5.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Refi eiires<br /> <br /> 1 CP, Curtm JP, Townsend DE Tumors of the cervix. In:<br /> Morrow, ed. Synopsis of Gynecologic Oncology. 4th ed.<br /> New York: Chirchill Livingstone, 1993.111-152.<br /> 2 Wingo PA, Tong T, Bolden S Cancer statistics, 1995. CA<br /> Cancer J Clin 1995; 45(1):8-30.<br /> 3. American Cancer Facts and Figures. American Cancer<br /> Society 1995.<br /> 4 Pettersson F (ed) Annual report on the results of<br /> treatment in gynecologic cancer. Int Fed Gynecol Obstet<br /> 1991,36(suppl):27-130.<br /> 5 Hoskins WJ, Perez C, Young RC. Gynecologic tumors. In'<br /> DeVita VT, Hellman S, Rosenberg SA, eds.<br /> Cancer-Principles & Practice of Oncology, Vol. 1.3rd ed.<br /> Philadelphia: J. B. Lippmcott, 1989:1114-1119.<br /> 6 Hricak H, Quivey JM, Campos Z, et al. Carcinoma of the<br /> cervix: predictive value of clinical and magnetic resonance<br /> (MR) imagmg assessment of prognostic factors. Int J<br /> Radiat Oncol BiolPhys 1993;27(4)791-S0l1<br /> 7 Burghardt E, Pikel H. Local spread and lymph node<br /> involvement in cervical cancer Obstet Gynecol 1978;<br /> 522):138-145.<br /> 8. Piver MS, Chung WS. Prognostic significance of cervical<br /> lesion size and pelvic node metastases in cervical<br /> carcinoma. Obstet Gynecol 1975 46(5)507-510.<br /> 9. Gauthier P, Gore I, Shingleton HM, Soong SJ, Or JW Jr,<br /> Hatch KD. Identification of hstopathologic risk groups m<br /> Stage IB squamous cell carcinoma of the cervix. Obstet<br /> Gynecol 1985;66 569-574.<br /> 10. Van NagellJR Jr, DonaldsonES, Parker JC, Van Dyke AH,<br /> Wood EG. The prognostic significance of cell type and<br /> lesion size in patients with cervical cancer treated by<br /> radical surgery GynecolOncol 1977;5(2)142-151<br /> 11. White CD, Morley GW, Kunar NB. The prognostic<br /> significance of tumor emboh in lymphatic or vascular<br /> spaces of the cervical stroma in Stage IB squamous cell<br /> carcinoma of the cervix. Am J Obstet Gynecol 1984;<br /> 149(3)342-349.<br /> 12. Amenrcan Jbm C mvnitee on Ca2er. Mananual r Staging of<br /> Cah r.3rded. FI li, 1l, ilu i. [L,::11 I 1': 151-153.<br /> 13. Lagasse LD, C'.-. ,. ; ,1 I.!-:,,r Hi. Ford JH,<br /> Blessing JA. Results and complications of operative<br /> staging in cervical cancer: experience of the Gynecologic<br /> Oncology Group. Gynecol Oncol 1980;9(1) 0-98<br /> 14. Delgado G, Bundy B, Zaio R, Sevin BU, Ceasman VWT,<br /> Major F. Prospective surgical-pathological study of<br /> disease-free interval in patients with Stage IB squamous<br /> cell carcinoma of the cervix: a Gynecologic Oncology<br /> Group study. Gynecol Oncol 1990;38(3) 352-357.<br /> 15. Van Nagell JRJr, Roddick JWJr, LowinDM. The staging<br /> of cervical cancer: Inevitable discrepancies between<br /> clinical staging and pathologic findings. Am J Obstet<br /> Gvnecol 1971; 110()973-978<br /> <br /> <br /> treatment. Results of a 20-year cooperative study. Am J<br /> Obstet Gynecol 1981; 1397:7S2-759.<br /> 19. Singleton HM, Fowler WC Jr, Koch GG. Pretreatment<br /> evaluation in cervical cancer. Am J Obstet Gynec 1971;<br /> 110(3)385-389<br /> 20. Van Nagell JR, Sprague AD, Roddick JW Jr, The effect of<br /> intravenous pyelography and cystoscopy on the staging<br /> of cervical cancer. Gynecol Oncol 1975;3(3) :7-91<br /> 21. LindellLK, AndersonB. Routine pretreatment evaluation<br /> of patients with gynecologic cancer. Obstet Gynecol 1987;<br /> 69(1)242-246.<br /> 22. Innocent P, Pulli F, Savino L, et al. Staging of cervical<br /> cancer: reliability of transrectal US. Radiology 1992;<br /> 185(1)201-205.<br /> 23. Cobby M, Browmng J, Jones A, Wlupp E, Goddard P.<br /> Magnetic resonance imaging, computed tomography and<br /> endosonographyin the staging of carcinoma of the cervix.<br /> Br J Radiol 1990,63(753):673-679.<br /> 24. Whitley NO, Brenner DE, Francis A, et al. Computed<br /> tomographuc evaluation of carcinoma of the cervix.<br /> Radiology 1982; 142(2):439-446.<br /> 25. Walsh JW, Amendola MA, Konerding KF, Tisnado J,<br /> Hara TA. Computed tomographic detection of pelvic<br /> and nguinal lymph-node metastases from primary and<br /> recurrent pelvic malignant disease Radiology 1983; 137(1<br /> Pt 1).157-166.<br /> 26. Villasanta U, Whitley NO, Haney PJ, Brenner D.<br /> Computed tomography in invasive carcinoma of the<br /> cervix an appraisal. Obstet Gynecol 1983;62(2)218-224.<br /> 27. Matsuluma K, TsuLamoto N, Matsuyama T, Ono M,<br /> Nakano H. Preoperative CT study of lymph nodes in<br /> cervical cancer-its correlation with histological findings.<br /> Gynecol Oncol 1989,33(2).168-171.<br /> 28. Carmlien L, Gordon D, Fruchter RG, Maiman M, Boyce<br /> JG. Predictive value of computerized tomography in the<br /> presurgical evaluation of primary carcinoma of the cervix.<br /> Gynecol Oncol 1988;30(2)209-215.<br /> 29. Brenner DE, Whitley NO, Prempree T, Villasanta U. An<br /> evaluation of the computed tomographic scanner for the<br /> staging of carcinoma of the cervix Cancer 1982; 50(1):<br /> 2323-2328.<br /> 30. Newton WA, Roberts WS, Marsden DE, Cavanagh D.<br /> Value of computerized axial tomography m cervical<br /> cancer. Oncology 1987;44(2):4-124-127.<br /> 31. Walsh JW, Goplerud DR. Prospective comparison<br /> between clinical and CT staging in primary cervical<br /> carcinoma. AJR 1981,137(5)997- 103.<br /> 32. Vas W, Wolverson M, Freel J, Salimi Z, Smudaram M<br /> Computed tomography in the pretreatment assessment of<br /> carcinoma of the cervix. J Comput Asst Tomogr 1985;<br /> 9(4):359-369.<br /> 33. Kim SH, Choi BI, Han JK, et al. Preoperative staging of<br /> <br /> <br /> Figure 4-5. References [7 pg 6]<br /> <br /> The goal was to design a structure that could catch as much information about each<br /> <br /> <br /> individual reference as possible. Figure 4-6 details the structure that was developed. Note<br /> <br /> <br /> that some fields may, in most instances, remain empty because a typical reference does not<br /> <br /> <br /> contain that level of detail. The fields are present to allow the addition of extra detail<br /> <br /> <br /> regarding the authorss, etc.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Reference<br /> 1 Reference Author Authors<br /> Reference ID Reference ID Author ID<br /> PM ID cc Author ID ShortName<br /> Reference Type Author Order Last_Name<br /> Reference Title First Name<br /> Chapter No cc Middle_Name<br /> Journal Book Title Title<br /> Year<br /> Publisher Name<br /> Year Published<br /> Edition No<br /> Volume No<br /> Start Page<br /> EndPage<br /> Abstract<br /> <br /> <br /> <br /> Figure 4-6. Reference Structure<br /> <br /> <br /> The essential idea is that the different entities composing the reference were<br /> <br /> separated as and when possible. For instance, the author is quite distinct from the reference.<br /> <br /> For it to be searchable, the author was listed separately from the reference since the author<br /> <br /> could have authored many references and a reference usually has multiple authors. Reference<br /> <br /> ID and Author ID are again automatically generated primary keys.<br /> <br /> As can be seen from the relation entities in Figure4-6, there are several entities that<br /> <br /> come from sources other than the document itself. For instance, the PM ID is a key that<br /> <br /> helps obtain a copy of the actual referenced document from a web-based repository.<br /> <br /> The best way to obtain this data is by using the Medical Reference Manager software.<br /> <br /> Reference Manager analyses a reference in a specific format and automatically produces the<br /> <br /> additional data that the database requires about the reference. These data are obtained from<br /> <br /> the web-based repository. When Reference Manager locates a reference, it produces a hyper<br /> <br /> linked PM ID, a unique key that helps locate the reference in the repository. Using this<br /> <br /> information, an abstract and other low level details are obtained. Most doctors subscribe to<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> the site, which provides them with access to full-length texts of the reference. Some levels of<br /> <br /> access also entitles them to receive full-length hard copies of the reference from the nearest<br /> <br /> participating library.<br /> <br /> The problem with using Reference Manager to directly handle references is that the<br /> <br /> references are not standardized to one format. This is primarily because references of<br /> <br /> different types have different parameters.<br /> <br /> For example, consider the references in Figure 4-7a To the human brain, trained in<br /> <br /> the recognition of patterns, all of these variants are treated without distinction. To the<br /> <br /> computer however, it is difficult for a program to perceive that the second or third reference<br /> <br /> have no specific author and probably do not appear in any journal.<br /> <br /> <br /> Figure 4.7a<br /> <br /> <br /> Figure 4.7b<br /> <br /> Figure 4-7 Managing Reference Examples<br /> <br /> <br /> Differing reference types:<br /> 1. Anscher MS, Prosnitz LR. Prognostic significance of<br /> extent of nodal involvement in Stage D1 prostate<br /> cancer treated with radiotherapy. Urology 1992;<br /> 39(1):39-43.<br /> 2. American Medical Association. Attributes to guide the<br /> development of practice parameters. 1990.<br /> 3. Discussion by Expert Panel on Pediatric Imaging on<br /> June 28, 1995<br /> <br /> <br /> Nonspecific references<br /> 1. Anscher MS, Prosnitz LR. Prognostic significance of<br /> extent of nodal involvement in Stage D1 prostate<br /> cancer treated with radiotherapy. Urology 1992;<br /> 39(1):39-43.<br /> 2. Anscher MS, Prosnitz LR. Prognostic significance of<br /> extent of nodal involvement in Stage D1 prostate<br /> cancer treated with radiotherapy Urology 1992;<br /> 39(1):39-43.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Additionally, sometimes authors and proofreaders in haste fail to follow applied<br /> <br /> conventions. These may not appear significant to the human eye. For instance, examine the<br /> <br /> references in Figure 4-7b .To the human eye, these two references may appear the same.<br /> <br /> The computer, however, will, in the second part only be able to distinguish where the Title<br /> <br /> ends and the Journal statistics begin. All that is missing is a period before Urology in the first<br /> <br /> instance.<br /> <br /> A. Reference manager data format<br /> AU: Freeman JA, Lieskovsky G, Grossfeld G, et al<br /> TI: Adjuvant radiation, chemotherapy, and androgen<br /> deprivation therapy for pathologic<br /> Stage D1 adenocarcinoma of the prostate<br /> JO: Urology 1994; 44(5):719-725<br /> B. Input data<br /> 1. Freeman JA, Lieskovsky G, Grossfeld G, et al. Adjuvant<br /> radiation, chemotherapy, and androgen deprivation therapy<br /> for pathologic Stage D1 adenocarcinoma of the prostate.<br /> Urology 1994; 44(5):719-725.<br /> Figure 4-8. Managing Reference Examples; Supplement 2.<br /> <br /> <br /> <br /> Reference manager handles references in the format shown in Figure 4-8 A. Each<br /> <br /> reference consists of three parts. The first is a header AU, indicating the list of Authors.<br /> <br /> Second is the header TI indicating the title. Finally the header JO indicates a journal<br /> <br /> reference.<br /> <br /> The objective of the parser, is to parse references of the type shown in Figure 4-8-B<br /> <br /> into the acceptable format for reference manager as shown in part Figure 4-8-A.<br /> <br /> Further Analysis of references as data<br /> <br /> References in most standardized publications in all areas followed a common format.<br /> <br /> Each reference consists of a series of one or more fields delimited by either a period<br /> <br /> "." or an interrogator "?". These fields are called components with each reference being a<br /> <br /> fragment of the original file that consists of components.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Most references clearly identify the author, always have a title, and usually mention<br /> <br /> the details of its publishing.<br /> <br /> Typical references appear in Figures 4-7 and 4-8. However, it should be noted that<br /> <br /> references are not all of the same type/format. References come in variants as illustrated by<br /> <br /> Figures 4-9 through 4-13.<br /> <br /> <br /> <br /> ExampleS : Reference manager data Example: Fragment<br /> Type 1:( has 4 Components):<br /> Input:<br /> 2. Hanks GE. The challenge of treating node-positive cancer.<br /> An approach to resolving the questions. Cancer 1993; 71(3<br /> Suppl) :1014-1018.<br /> Output:<br /> AU: Hanks GE<br /> TI: The challenge of treating node-positive cancer. An<br /> approach to resolving the questions<br /> JO: Cancer 1993; 71(3 Suppl):1014-1018<br /> <br /> <br /> Figure 4-9. Managing Reference Examples; Supplement 3.<br /> <br /> As Figure 4-9 clearly illustrates, the first component is the author, the next two<br /> <br /> components form the title. The last component forms the journal field.<br /> <br /> <br /> Example : Reference manager data Example: Fragment<br /> Type 2:( has 3 Components):<br /> Input:<br /> 3. Anscher MS, Prosnitz LR. Prognostic significance of extent<br /> of nodal involvement in Stage D1 prostate cancer treated with<br /> radiotherapy. Urology 1992; 39(1):39-43.<br /> Output:<br /> AU: Anscher MS, Prosnitz LR<br /> TI: Prognostic significance of extent of nodal involvement<br /> in Stage D1 prostate cancer treated with radiotherapy<br /> JO: Urology 1992; 39(1):39-43<br /> <br /> <br /> Figure 4-10. Managing Reference Examples; Supplement 4.<br /> <br /> <br /> <br /> Figure 4-10 contains the most common form of reference. Each component clearly<br /> <br /> forms one field as shown. Figure 4-11 illustrates a case where there is no journal entry. The<br /> <br /> first component forms the author field and the second component forms the title.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 4-11. Managing Reference Examples; Supplement 5.<br /> <br /> <br /> Example : Reference manager data Example: Fragment<br /> Type 4:( has 1 Component):<br /> Input:<br /> 4. Discussion by Expert Panel on Pediatric Imaging on<br /> June 28, 1995<br /> Output:<br /> AU: NA<br /> TI: Discussion by Expert Panel on Pediatric Imaging on<br /> June 28, 1995<br /> JO: NA<br /> <br /> Figure 4-12. Managing Reference Examples; Supplement 6<br /> <br /> <br /> Figure 4-12 illustrates a case where there is no journal or author. The only<br /> <br /> component becomes the title field.<br /> <br /> Reference manager handles all cases satisfactorily. The only anomaly that can be<br /> <br /> encountered is when references are not coded properly. This is usually due to an oversight.<br /> <br /> Figure 4-13 illustrates an oversight, where the reference has to be checked and corrected<br /> <br /> manually. The format in Figure 4-13, however rare, did not conform to the delimited format<br /> <br /> that the rest of the references follow. Cases such as this have to be manually corrected.<br /> <br /> <br /> Example : Reference manager data Example: Fragment<br /> Type 3:( has 2 Components):<br /> Input:<br /> 4. American Medical Association. Attributes to guide the<br /> development of practice parameters.<br /> Output:<br /> AU: American Medical Association<br /> TI: Attributes to guide the development of practice<br /> parameters<br /> JO: NA<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> To parse references, an application in Microsoft Visual BasicO 6.0 was developed.<br /> <br /> This simple application allows the user to specify drive and folder (directory) where the<br /> <br /> reference file is located. The user selects the appropriate file and presses the parse button to<br /> <br /> parse the reference to a file also specified by the user. Figures 4-14 and 4-15 show two<br /> <br /> different screen shots of the parser.<br /> <br /> <br /> <br /> <br /> Example : Reference manager data Example: Fragment<br /> Type 5:( Oversight):<br /> Input:<br /> 16. Lawton CA, Winter K, Byhardt R, et al. Androgen<br /> suppression plus radiation versus radiation alone for patients<br /> with D1 (pN+) adenocarcinoma of the prostate (results based on<br /> a national prospective trial, RTOG 85-31) Int J Radiat Oncol<br /> Biol Phys 1997; 38(5):931-939.<br /> Output:<br /> AU: Lawton CA, Winter K, Byhardt R, et al<br /> TI: Androgen suppression plus radiation versus radiation<br /> alone for patients with D1 (pN+) adenocarcinoma of the<br /> prostate (results based on a national prospective trial, RTOG<br /> 85-31) Int J Radiat Oncol Biol Phys 1997; 38(5):931-939<br /> JO: NA<br /> <br /> <br /> <br /> <br /> Figure 4-13. Managing Reference Examples Supplement 7:<br /> <br /> Appendix 9 contains sample input and the corresponding output files generated by<br /> <br /> the parser. Appendix 10 contains the source code of the parser.<br /> <br /> The CPT Data<br /> <br /> The CPT data are required for billing of insurance companies. The essential data to<br /> <br /> be captured are the code with the three forms of the CPT text. The CPT database file<br /> <br /> structure hence, includes the code and fields for the three formats of the code. See Figure 4-<br /> <br /> 14. Entries can be in upper, lower, or mixed (sentence) case since Microsoft AccessO<br /> <br /> allows non-case sensitive searching.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 4-14 Screen shot of parser before parsing.<br /> <br /> <br /> Figure 4-14. The CPT Structure<br /> <br /> <br /> CPT Code<br /> CPTText Short<br /> CPTText Med<br /> CPT_Text_Long<br /> <br /> <br /> 14 Parsr to Pase a Rferencefile tothe Reerence anager ormat<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> 1. ..I tI afi t tF<br /> <br /> <br /> Figure 4-15 Screen shot of parser after parsing.<br /> The CPT code is unique to each procedure and serves as a Primary Key.<br /> <br /> <br /> ICD-9 Data<br /> <br /> The ICD-9 data also relates to billing. The ICD-9 text and data are represented in a<br /> <br /> table. Because there are many synonyms for a single ICD-9, a synonyms table was<br /> <br /> developed. In addition to this, it can be noticed that each ICD-9 code includes an ICD-9<br /> <br /> code type (see Appendix 2). A separate table was designed to capture this information. A<br /> <br /> code type is a super-set encompassing many sub types with each subtype, possibly having<br /> <br /> further subtypes. The database structure allows representation of all the different levels of<br /> <br /> subtypes. Figure 4-15 gives the database structure for ICD9.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 4-15. The ICD-9 Structure<br /> Note that the ICD-9 type table allows the representation of many levels of code<br /> <br /> types. A simple search with a code will give a list of all types that the condition fall under as<br /> <br /> shown below with a samplepseudo query.<br /> <br /> The Code_Type field in the ICD-9_Codes table, will refer to only one major code<br /> <br /> type to which the code belongs. Which of the codes are used will depend on specifics to be<br /> <br /> determined by the ACR. For the present, its default value is set to the first upper level in the<br /> <br /> hierarchy<br /> <br /> <br /> Print Code Type, Code Description<br /> From ICD-9 type<br /> Where code>= Start Code and code <= End Code<br /> <br /> <br /> <br /> Figure 4-16. Sample Query: ICD-9 Table<br /> Conditions<br /> <br /> The ACR documents provide analysis of the best way to alleviate certain conditions.<br /> <br /> The condition should be well documented with an ICD-9 code. The specifics of the<br /> <br /> condition and the patient help to determine of the best course of treatment described with<br /> <br /> one or a series of CPT codes. Again as described earlier, all documents form a continuum in<br /> <br /> the ACRAC. The condition table is designed to capture the information on the first page<br /> <br /> dedicated to this condition. See Figure 4-17.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 4-17. Condition Structure<br /> <br /> Figure 4-17 illustrates how the condition is being described. Each variant of each<br /> <br /> condition is given a unique identifier and is linked to its Condition codes(s), and the<br /> <br /> procedures that may be appropriate to alleviate this variant of this condition.<br /> <br /> <br /> Print Original Procedue Name, Approprateness rating<br /> From Condition Procedure<br /> Where Condition ID = Current Condition ID<br /> Sort by Approprateness rating<br /> <br /> <br /> <br /> Figure 4-18. Sample Query: Condition Table<br /> <br /> A samplepseudo query illustrates how a doctor may use this to help determine the best<br /> <br /> course of action. The sample query in Figure 4-18 illustrates the ease with which the doctor<br /> <br /> may obtain help from the system to help prescribe a course of action. This way, the chances<br /> <br /> of a doctor making a mistake by prescribing an inappropriate treatment or prescribing a non-<br /> <br /> reimbursable treatment are greatly reduced, since the results of this search have been pre-<br /> <br /> approved by many levels in the many governing bodies of the American health care<br /> <br /> bureaucracy.<br /> <br /> Procedures<br /> <br /> Procedures are operations used to alleviate or determine a condition. Each procedure<br /> <br /> listed in the database is, as a result linked to a condition. Sometimes the same procedure is<br /> <br /> referred to by different names, which could be confusing. To avoid confusion, a standard<br /> <br /> <br /> ConditionProcedure<br /> <br /> Procedure ID<br /> Condition ID<br /> Appropriateness Rating<br /> Comments<br /> Original Procedure Name<br /> <br /> <br /> Conditions<br /> <br /> Condition ID<br /> Guideline ID<br /> Location_System<br /> Clinical Condition<br /> Variant_Number<br /> Variant_Description<br /> Page_InBook<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> 46<br /> <br /> <br /> should be initiated. The database provides space for procedures to have standardized names<br /> <br /> when they come into force. For the present however, the Original name can be replicated in<br /> <br /> the space for the Standardized name. Figure 4-19 details how procedures are documented.<br /> <br /> <br /> <br /> <br /> Condition Procedure Procedures CPT Procedure<br /> Procedure ID Procedure_ID oc Procedure ID<br /> Condition ID Modality CPT Code<br /> Appropriateness Rating Body_Region<br /> Comments Modifier<br /> Original Procedure Name Standardized_Name<br /> Comments<br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 4-19. Procedure Structure<br /> <br /> The Composite key that consists of two foreign keys Procedure_ID and<br /> <br /> Condition_ID indexes the ConditionProcedure table. Procedure_ID is the primary key that<br /> <br /> refers to each unique procedure hence indexing the Procedures table. As discussed earlier, a<br /> <br /> condition may require multiple procedures resulting in the many to one relationship. A<br /> <br /> procedure may need to be addressed by a series of CPT codes. Hence the relationship. The<br /> <br /> standardization of names is applicable to the individual procedure.<br /> <br /> Ancillary Docs and Definitions<br /> <br /> Ancillary documents are supporting documents that are part of the Guideline. These<br /> <br /> documents may be in any form such as JPEG, PAX images, WordO documents,<br /> <br /> PowerPointO presentations etc. These are present as supporting material and are stored in<br /> <br /> their original form. They usually come with some supporting text explaining their existence.<br /> <br /> The A _)-Docs table will contain details pertaining to all such documents.<br /> <br /> Definitions are part of any publication that help explain parts of the publication. A<br /> <br /> document typically has several definitions and a definition could appear in many Guidelines.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Hence the many to many relationship normalized below. Figure 4-20 illustrates the<br /> <br /> relationship between Ancillary_Docs, Definitions, and Guidelines.<br /> <br /> <br /> <br /> Ancillary Does Definition Guideline Definitions<br /> <br /> Guideline ID Guideline ID Definition ID<br /> Title Text Definition ID IKeyword<br /> SupplementalText Text<br /> File Name<br /> FileType<br /> Supplemental Text<br /> <br /> <br /> Guideline<br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 4-20. Ancillary Docs and Definitions<br /> <br /> Guidelines<br /> <br /> The guideline is the fundamental unit of the ACRAC document set. Each ACRAC<br /> <br /> document is a guideline referring to a specific aspect of Radiology. The Guideline table is<br /> <br /> designed to hold all details relating to the Guideline itself as shown in Figure 4-21.<br /> <br /> Guidelines are indexed by Guideline-ID which is an automatically generated primary<br /> <br /> key. As mentioned before, the guidelines each form a subset of the ACRAC book. The page<br /> <br /> in book holds the first page in the book that the guideline will appear in. The<br /> <br /> Body_File_name contains the file name where this Guideline appears in its electronic<br /> <br /> version. The Originally_Developed and Review_Date fields will hold dates corresponding to<br /> <br /> the date this document was composed and the date this document will be reviewed.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> 48<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Guidelines<br /> <br /> <br /> Guideline ID<br /> PageInBook<br /> Long_Title<br /> Short Title<br /> BodyFileName<br /> Panel Name<br /> SummaryLiterature<br /> Anticipated Exceptions<br /> C ... .1. Devloped<br /> Review Date<br /> <br /> <br /> <br /> <br /> Figure 4-21. Guidelines Table Structure.<br /> <br /> <br /> <br /> <br /> Chapter 4 discussed the structure of the data in detail and how it will be part of the<br /> <br /> <br /> database. Chapter 5 gives specifics of the database structure including the syntax of the data<br /> <br /> <br /> definition language, the extended ER diagram and a sample of the data definition.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> CHAPTER 5<br /> COMPLETE DATABASE STRUCTURE<br /> <br /> <br /> <br /> The complete database structure was designed to be implemented using Microsoft<br /> <br /> AccessO and later upgraded to run on a Microsoft Sequel server. The initial<br /> <br /> implementation was designed as a feasibility analysis to demonstrate to the American College<br /> <br /> of Radiology how an electronic version of the ACRAC could be implemented. The database<br /> <br /> structure was first built using MS Access 2000 for the Modified ER diagram that is presented<br /> <br /> in this chapter. The complete database structure was designed and presented in a website.<br /> <br /> (http://www.cise.ufl.edu/~gbO/ACR/index.html). The ER Diagram conventions and Data<br /> <br /> definition language used conform to all requirements of the end user and have been<br /> <br /> developed in consultation. The rest of this chapter specifies the database in detail. Figure 5-1<br /> <br /> is the modified ER diagram specifying the database structure. Modified ER Diagram<br /> <br /> (MSSQL conventions)<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> C-3<br /> j 1.<br /> <br /> <br /> Cs)<br /> <br /> * 1'ji'1'- i1:<br /> -.11:1: C.).11:1-<br /> <br /> <br /> ii>CM<br /> <br /> I 'i*,<br /> <br /> <br /> .1)<br /> ii AIPitulD<br /> -JI'': J -iI,<br /> <br /> <br /> <br /> 311"I<br /> <br /> <br /> Figure 5-1. Complete ER Diagram<br /> <br /> <br /> 311<br /> <br /> <br /> <br /> <br /> <br /> AS I S*. h:<br /> <br /> <br /> S11I Jul~<br /> <br /> 311<br /> 3- 1 '<br /> <br /> <br /> <br /> Ii'S111. !J'iiIl:'S I<br /> <br /> <br /> * Oxlfixt _lD<br /> <br /> Ii<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> i'<br /> <br /> <br /> <br /> -I :<br /> -: I -l,<br /> <br /> <br /> <br /> <br /> n-,, j,<br /> <br /> <br /> I- I<br /> <br /> <br /> 11-7 1'- 31 1'<br /> 1 I :<br /> ii j~ :1 Fl'S <br /> I:~ il.-I<br /> <br /> <br /> Ill<br /> <br /> <br /> 'Jl'I'I' I- 'l 31 1<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Data Definition Syntax:<br /> <br /> The data definition was specified using a pre determined data definition language.<br /> <br /> The data definition language (DDL) syntax specified in Figure 5-2 was chosen for two main<br /> <br /> reasons.<br /> <br /> The hierarchically layered bulleted definition format in MS Word allowed for easy<br /> <br /> reading and update.<br /> <br /> The well-structured format allowed easy electronic parsing, should a need arise, at a<br /> <br /> later date.<br /> <br /> In the DDL specification, fields enclosed by square brackets [ ] will be replaced by<br /> <br /> the actual entities. Fields surrounded by "<>"signs are field headers.<br /> <br /> <br /> <br /> <br /> [Table Number] [Table Name]+<br /> O <Description><br /> S[A short description of the table]<br /> O <Attributes><br /> [Attribute Name] +<br /> <Type> [Attribute Type]<br /> <Contents> [What the field contains]<br /> <Constraints> [Constraints if any]<br /> <Details> [Details about the field]<br /> <br /> <br /> <br /> <br /> Figure 5-2 The DDL Description<br /> The DDL specification provides a detailed description of each entity including the<br /> <br /> type of text each entity would contain. This was because MS Office treats text in a<br /> <br /> hierarchical manner making it easy to port to other office / windows applications. For<br /> <br /> instance, a heading is treated to be a higher level than a Body text. Figure 5-3 gives the DDL<br /> <br /> specifications for the needed levels.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Figure 5-3: The DDL Specification<br /> The table name is specified in Heading 2 format, followed by its description and<br /> <br /> attributes in heading 3 format. The individual field attributes are entered in heading 5 format.<br /> <br /> The rest of the chapter gives an example of two table specifications. The entire data<br /> <br /> definition is presented in Appendix 8. The complete DDL specified for an MS Access<br /> <br /> database has a total of 19 tables. The database was specified using the MS Access ER<br /> <br /> diagram along with the Data definition.<br /> <br /> Data Definition<br /> <br /> The following is a short example of the data definition that defines the structure of<br /> <br /> the database, relationships between tables and associated constraints. For the full data<br /> <br /> definition of the ACRAC database refer Appendix 7. The following is the data definition<br /> <br /> specification for two tables contributors and references.<br /> <br /> <br /> * [Heading 2] +<br /> O <Heading 3><br /> > [Heading 4]<br /> O <Heading 3><br /> S[Heading 4] +<br /> <Heading 5><br /> <Heading 5><br /> <Heading 5><br /> <Heading 5><br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Contributors<br /> <br /> <Description><br /> <br /> e This table contains details that pertain to each contributor that was part of<br /> one or more teams, each of which worked on some ACR Guideline document.<br /> In addition to items needed for generating the attributions for the guideline<br /> itself this will hold contact information for administrative purposes.<br /> <br /> <br /> <Attributes><br /> <br /> Contributor ID<br /> <br /> <br /> o <T- > Long Integer<br /> <br /> o <Contents> Auto Number'<br /> <br /> o <Constraints> <Pimary Key> <Unique><br /> o <Details>This feld uniquely identifies this Contributor among<br /> all contributors in the Database. This is only an identifying<br /> number (like most Auto Numbers) and has no other bearing<br /> on the database.<br /> <br /> <br /> > Contributor Name<br /> <br /> <br /> o <Type> String<br /> o <Contents> Author's Name.<br /> o <Constraints> None<br /> o <Details> This contributor will have been part of one or more<br /> teams that have designed an ACR document.<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Data types are with reference to Access / Sequel server conventions.<br /> <br /> 4 An auto number is a Long integer generated automatically by Microsoft Access. It is used to index a table and is usually the<br /> primary key.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> > Institution Name<br /> <br /> <br /> <Tjpe> String<br /> <br /> <Contents> Institution Name<br /> <br /> <Constraints> None<br /> <Details>The institution to which the Contributor belongs.<br /> <br /> <br /> SDepartment_Name<br /> <br /> <br /> <Tjpe><br /> <br /> <Contents><br /> <br /> <Constraints><br /> <Details><br /> <br /> <br /> String<br /> <br /> Department Name<br /> <br /> None<br /> <br /> Department within the institution<br /> <br /> <br /> <Tjpe> String<br /> <br /> <Contents> First line of mailing address<br /> <Constraints> None<br /> <br /> <Details> This field holds the first line of the mailing address.<br /> <br /> <br /> <br /> <Type> String<br /> <br /> <Contents> Second line of mailing address<br /> <Constraints> None<br /> <br /> <Details> This field holds the second line of the mailing<br /> address.<br /> <br /> <br /> <Type><br /> <Contents><br /> <br /> <Constraints> None<br /> <br /> <Details><br /> <br /> <br /> String<br /> Name of a City.<br /> <br /> <br /> City of the contributor's address.<br /> <br /> <br /> > Address 1<br /> <br /> <br /> > Address 2<br /> <br /> <br /> > City<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> o <Tjpe><br /> <br /> o <Contents><br /> <br /> o <Constraints><br /> <br /> <br /> A state.<br /> <br /> <br /> None<br /> <br /> <br /> o <Details> State in which the contributorlives<br /> <br /> <br /> > Zip<br /> <br /> <br /> o <Cope><br /> o <Contents><br /> <br /> o <Constraints><br /> <br /> <br /> Integer<br /> <br /> zO Code.<br /> <br /> None<br /> <br /> <br /> o <Details> Zip code of contributor's address.<br /> <br /> <br /> SE Mail<br /> <br /> <br /> o <Tope><br /> o <Contents><br /> <br /> o <Constraints><br /> <br /> o <Details><br /> <br /> <br /> e-mail address, complete<br /> <br /> None<br /> <br /> <br /> The contributor's e-mail address<br /> <br /> <br /> r Phone Number<br /> <br /> <br /> o <Tope><br /> o <Contents><br /> <br /> o <Constraints><br /> <br /> <br /> o <Details><br /> <br /> <br /> Complete phone number, with area code<br /> <br /> None<br /> <br /> The contributor's telephone number<br /> <br /> <br /> References<br /> <br /> <Description><br /> <br /> e This table will contain details of references that were used in producing<br /> various Guidelines. Note that this is a generic table to accommodate the<br /> largest variance in the reference matter. The table allows a reference to be<br /> anything from a personal communication to a Journal reference to a chapter/<br /> passage in a book.<br /> <br /> <br /> <Attributes><br /> <br /> > Reference ID<br /> <br /> <br /> o <Tjpe><br /> <br /> <br /> > State<br /> <br /> <br /> Long Integer<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> o <Contents> Auto-Number<br /> o <Constraints> <Primary Key> <Unique><br /> o <Details>This number uniquely identifies this reference among<br /> all references in the database. This is only an identifying<br /> number and has no other bearing on the database.<br /> <br /> > PM ID<br /> <br /> <br /> o <Type> String<br /> o <Contents> Medlinepub med ID<br /> o <Constraints> None<br /> o <Details>This feld serves two purposes. Keeping in mind that<br /> some referred material may not appear in Medline, the<br /> following will apply.<br /> If the referred article is in the Medline database, this<br /> field will contain the PM-ID of the referred document.<br /> This ID is an identifier that can be used to locate the<br /> referred document among all those stored in<br /> MEDLINE. This number can be stored with a<br /> hyperlink to MEDLINE so that clicking on it allows<br /> one to obtain an abstract of the reference, and with<br /> authorization even the Full text may be available.<br /> If the referred matter is not present in Medline, a<br /> <br /> suitable and pre-qualifed null and void feld such a 'O'<br /> or "N.A' will appear here. It will signify the reference's<br /> non-existence in the MEDLINE database.<br /> 0<br /> <br /> SReferenceType<br /> <br /> o <Type> String<br /> o <Contents> The kind of reference contained in this record.<br /> o <Constraints>An .:,.i.; .,, reference type. The ,.i., .,1 types have yet to be<br /> decided.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> o <Details>Examples: "JOUR_ART", "BOOK_CHAP",<br /> "PERS_COM" for journal article, book chapter, and personal<br /> communication respectively.<br /> <br /> <br /> r Reference Title<br /> <br /> o <Type> String<br /> o <Contents> Title<br /> o <Constraits> None<br /> o <Details>This field is to take into consideration that a reference<br /> may be a chapter in a book or a specific part of another<br /> <br /> Journal. This feld could contain the Title of the chapter or the<br /> heading of the referred text. The non-existence (or irrelevance<br /> with reference to the current context) of this feld is signifed<br /> by a Null value.<br /> <br /> <br /> > Chapter_Number<br /> <br /> o <Type> String<br /> o <Contents> Chapter identification<br /> o <Constraints> None<br /> o <Details>This field contains the chapter designator (mostly an<br /> Arabic number) if the reference is from a book. It will be blank<br /> if the reference is a journal article.<br /> <br /> <br /> F Journal_Book_Title<br /> <br /> o <Type> String<br /> o <Contents> A Journal/ Book's name.<br /> o <Constraints> None<br /> o <Details>This field will contain a the title of a Journal, the<br /> name of a book or even the subject of a personal<br /> communication (E.g. subject of an Email).<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> - Publisher Name<br /> <br /> <br /> o <Type> String<br /> o <Contents> The publisher name.<br /> o <Constraints> None<br /> o <Details>This field contains the name of the publisher. This<br /> may be left blank for journal articles and is mostly used for<br /> book chapters.<br /> <br /> <br /> > Year Published<br /> <br /> <br /> o <Type> Integer<br /> o <Contents> Year<br /> o <Constraints> None<br /> o <Details>The year the Journal/Book was published. In case of<br /> personal communication, it could similarly contain an<br /> <br /> appropriate date.<br /> <br /> <br /> F Edition Number<br /> <br /> <br /> o <Type> Strng<br /> o <Contents> Edition Number<br /> o <Constraints> None<br /> o <Details>This field contains the book edition number. This<br /> may be left blank for journal articles and is mostly used for<br /> book chapters.<br /> <br /> <br /> F Volume Number<br /> <br /> <br /> o <Type> Strng<br /> o <Contents> Volume Number<br /> o <Constraints> None<br /> o <Details>Most Journals and some Books are printed in<br /> multiple volumes. This number will help identify the Volume<br /> in which the reference was published.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> SStart_Page<br /> <br /> <br /> o <Tjpe> String<br /> o <Contents> Start of a range ofpages.<br /> o <Constraints> None<br /> o <Details>The frst page of the referenced article or chapter.<br /> This needs to be a text feld since sometimes these contain<br /> <br /> alphabetical characters.<br /> <br /> <br /> > End_Page<br /> <br /> <br /> o <Tjpe> String<br /> o <Contents> End of a range ofpages.<br /> o <Constraints> None<br /> o <Details>The last page of the referenced article or chapter.<br /> Needs to be text as sometimes these contain alphabetical<br /> characters.<br /> <br /> <br /> r Abstract<br /> <br /> <br /> o <Type> Memo/Text<br /> o <Contents> Abstract<br /> o <Constraints> None<br /> <br /> o <Details>Contains the Medline abstract of the reference (if<br /> present)<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> CHAPTER 6<br /> CONCLUSIONS AND FUTURE WORK<br /> <br /> Goals Accomplished<br /> <br /> This thesis has accomplished two primary tasks.<br /> <br /> 1) Planning, which included<br /> <br /> An analysis of the problems faced by current radiologists and the best way to fix<br /> these problems.<br /> <br /> An analysis of the ACRAC, CPT and ICD-9 CM code set.<br /> <br /> The scheduling, costing, and planning of an integrated solution for the ACR.<br /> <br /> A discussion and decision on the implementation tools that will be used<br /> <br /> Database design which included<br /> <br /> The decision to implement the database in MS Access.<br /> <br /> A decision on the Data Definition Language.<br /> <br /> A survey of previous work that have implemented portions of the current scope, and<br /> The Data Analysis consisting of<br /> <br /> Study of the ACRAC, CPT and ICD-9 structure,<br /> <br /> Decision to incorporate additional fields into the database to make space for future<br /> variants and standardizations, and<br /> <br /> Design of a sample parser to parse references from an ACRAC document into the<br /> Reference Manager Format.<br /> 2) Design: which included<br /> <br /> The ER Diagram using MSSQL conventions.<br /> <br /> The Data definition using the discussed DDL.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> As noted, this is a pilot project with significantly more work to be done for the<br /> <br /> electronic version of the ACRAC to make a difference to the community of radiologists.<br /> <br /> This work was primarily to demonstrate to the ACRAC the following.<br /> <br /> The need for an Electronic version of the ACRAC that allowed electronic access,<br /> updates, collaboration and distribution,<br /> <br /> The schedule and costs associated with such a venture, and<br /> <br /> The means to achieve this objective.<br /> <br /> These tasks have been successfully executed.<br /> <br /> Future Work<br /> <br /> There is a tremendous amount of future work that must be accomplished before any<br /> <br /> difference can be seen by radiologists. The future phases of the project are illustrated in the<br /> <br /> outline of the plan in Chapter 2. The future phases include<br /> <br /> / Parsing word documents to make plain text tables based on the database<br /> structure of Chapter 5.<br /> <br /> / Implementing the complete set of Database tables which involves:<br /> <br /> o The implementation of the database structure and constraints on a<br /> MSSQL server, and<br /> <br /> o Populating the database with data from the plain text tables<br /> <br /> / Implementing of a user interface that will allow radiologists to<br /> <br /> o Access data and perform searches,<br /> <br /> o Collaboratively perform updates to the database by entering new<br /> values or changing old ones, and<br /> <br /> / Establish a distribution system for sale / Distribution of the product<br /> <br /> / Implementing a Windows CE or other PDA compatible version of the<br /> database and application along with all related synching software.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> 62<br /> <br /> <br /> The design of this system has been done under the guidance of Dr. Sistrom. Dr.<br /> <br /> Sistrom will coordinate with the ACR for any future effort. Since the final product will be<br /> <br /> implemented under the direction of a radiologist (Dr. Sistrom) its potential benefits are<br /> <br /> great. Figure 6-1 best demonstrates the scope of the current work(follow-up of this Thesis).<br /> <br /> <br /> H :A p It --<br /> <br /> <br /> S L_<br /> <br /> <br /> Bill<br /> <br /> <br /> I --- _. .I<br /> <br /> <br /> I' u_ __... :- :-<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> I F' t.' -I' 1<br /> <br /> <br /> Figure 6-1. Proposed Hospital Procedure<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> Potential Benefits of the Application<br /> <br /> Figure 6-1 shows some of the simplifications to the billing process that would result.<br /> <br /> The whole process should result in significant financial savings insurance companies and<br /> <br /> indirectly the Taxpayers. It should be noticed from the Figure that one expensive entity is<br /> <br /> missing. The HSP no longer needs to employ the ICD-9 coder. The Doctors will simply<br /> <br /> specify the codes on their terminal appending these codes it to the report. This would both<br /> <br /> achieve standardization and efficiency.<br /> <br /> In the "current" system the ordering physician identifies the test (coded by CPT) by<br /> <br /> specifying the examination and a reason (usually a minimal sentence or phrase). The coders<br /> <br /> (or radiologists in this case) then did their best to determine the ICD-9 code that details the<br /> <br /> primary need for care. This is called "back-end" coding because it is done after the<br /> <br /> examination has been ordered, scheduled, performed, and interpreted. The current system is<br /> <br /> represented by Figure 2-3. The second-generation system (described in Chapter 3) aids order<br /> <br /> entry by allowing a simpler addition of the ICD-9 codes.<br /> <br /> <br /> <br /> The "new" system places the specification of the examination justification (ICD-9<br /> <br /> code) at the "front end". That means that at either the ordering or scheduling stage a correct<br /> <br /> and appropriate reason (ICD-9 code) must be assigned or the test will not be done. A "third<br /> <br /> generation" solution that might be called "assisted order entry" used the appropriateness<br /> <br /> criteria. In this scheme the ordering physician does not order a specific test but specifies a<br /> <br /> reason for the test (coded by ICD-9) and is prompted with the appropriate list of tests after<br /> <br /> referencing the appropriateness criteria. So in this "third generation" system we get an ICD-<br /> <br /> 9 code, CPT code, AND the assurance that the ICD-9 code is a good match for the CPT<br /> <br /> code (and thus will be likely to be reimbursed by insurance). In the "front end coding"<br /> <br /> <br /> <br /><br /> <br /> <br /> 64<br /> <br /> <br /> mechanism we get ICD-9 and CPT codes but NO assurance that the ICD-9 code will be<br /> <br /> appropriate for the CPT code. With the "current" system we only get the CPT code and<br /> <br /> must generate the ICD-9 code after the test has already been performed.<br /> <br /> The potential benefits of this application are immense. Ignoring the substantial<br /> <br /> monetary impact of the final application, the benefits include standardization and hence<br /> <br /> enhanced safety in health care.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 1<br /> ICD 9 CODE SET EXAMPLE<br /> <br /> <br /> <br /> * INFECTIOUS AND PARASITIC DISEASES (001-139)<br /> * NEOPLASMS (140-239)<br /> * ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES, AND IMMUNITY DISORDERS (240279)<br /> * DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (280-289)<br /> * MENTAL DISORDERS (290-319)<br /> * DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS (320-389)<br /> * DISEASES OF THE CIRCULATORY SYSTEM (390-459)<br /> * DISEASES OF THE RESPIRATORY SYSTEM (460-519)<br /> * DISEASES OF THE DIGESTIVE SYSTEM (520-579)<br /> * DISEASES OF THE GENITOURINARY SYSTEM (580-629)<br /> * COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM (630677)<br /> * DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE (680-709)<br /> * DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE (710-739)<br /> * CONGENITAL ANOMALIES (740-759)<br /> * CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD (760-779)<br /> * SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS (780-799)<br /> * INJURY AND POISONING (800-999)<br /> * PERSONS WITH POTENTIAL HEALTH HAZARDS RELATED TO COMMUNICABLE DISEASES (V01-V06)<br /> * PERSONS WITH NEED FOR ISOLATION, OTHER POTENTIAL HEALTH HAZARDS AND PROPHYLACTIC MEASURES<br /> (V07-V09)<br /> * PERSONS WITH POTENTIAL HEALTH HAZARDS RELATED TO PERSONAL AND FAMILY HISTORY (V10V19)<br /> * PERSONS ENCOUNTERING HEALTH SERVICES IN CIRCUMSTANCES RELATED TO REPRODUCTION AND<br /> DEVELOPMENT (V20 V29)<br /> * LIVEBORN INFANTS ACCORDING TO TYPE OF BIRTH (V30V39)<br /> * PERSONS WITH A CONDITION INFLUENCING THEIR HEALTH STATUS (V40 V49)<br /> * PERSONS ENCOUNTERING HEALTH SERVICES FOR SPECIFIC PROCEDURES AND AFTERCARE (V50 V59)<br /> * PERSONS ENCOUNTERING HEALTH SERVICES IN OTHER CIRCUMSTANCES (V60 V68)<br /> * PERSONS ENCOUNTERING HEALTH SERVICES DUE TO PROBLEMS RELATED TO LIFESTYLE (V69)<br /> * PERSONS WITHOUT REPORTED DIAGNOSIS ENCOUNTERED DURING EXAMINATION AND INVESTIGATION OF<br /> INDIVIDUALS AND POPULATIONS (V70-V82)<br /> * RAILWAY ACCIDENTS (E800-E807)<br /> * MOTOR VEHICLE TRAFFIC ACCIDENTS (E810-E819)<br /> * MOTOR VEHICLE NONTRAFFIC ACCIDENTS (E820-E825)<br /> * OTHER ROAD VEHICLE ACCIDENTS (E826-E829)<br /> * WATER TRANSPORT ACCIDENTS (E830-E838)<br /> * AIR AND SPACE TRANSPORT ACCIDENTS (E840-E845)<br /> * VEHICLE ACCIDENTS NOT ELSEWHERE CLASSIFIED (E846-E848)<br /> * PLACE OF ACCIDENT OCCURRENCE (E849)<br /> * ACCIDENTAL POISONING BY DRUGS, MEDICINAL SUBSTANCES, AND BIOLOGICALS (E850-E858)<br /> * ACCIDENTAL POISONING BY OTHER SOLID AND LIQUID SUBSTANCES, GASES, AND VAPORS (E860-E869)<br /> * MISADVENTURES TO PATIENTS DURING SURGICAL AND MEDICAL CARE (E870E876)<br /> * SURGICAL AND MEDICAL PROCEDURES AS THE CAUSE OF ABNORMAL REACTION OF PATIENT OR LATER<br /> COMPLICATION, WITHOUT MENTION OF MISADVENTURE AT THE TIME OF THE PROCEDURE (E878-E879)<br /> * ACCIDENTAL FALLS (E880-E888)<br /> * ACCIDENTS CAUSED BY FIRE AND FLAMES (E890-E899)<br /> * ACCIDENTS DUE TO NATURAL AND ENVIRONMENTAL FACTORS (E900-E909)<br /> * ACCIDENTS CAUSED BY SUBMERSION, SUFFOCATION, AND FOREIGN BODIES (E910-E915)<br /> * OTHER ACCIDENTS (E916-E928)<br /> * LATE EFFECTS OF ACCIDENTAL INJURY (E929)<br /> * DRUGS MEDICINAL AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE (E930<br /> E949)<br /> * SUICIDE AND SELF-INFLICTED INJURY (E950-E959)<br /> * HOMICIDE AND INJURY PURPOSELY INFLICTED BY OTHER PERSONS (E960-E969)<br /> * LEGAL INTERVENTION (E970E978)<br /> * INJURY UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED (E980-E989)<br /> * INJURY RESULTING FROM OPERATIONS OF WAR (E990-E999) [5]<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 2<br /> THE ICD-9-CM INDEX TO DISEASES: A<br /> <br /> <br /> <br /> * AAV (disease) (illness) (infection)=see Human immunodeficiency virus (disease) (illness) (infection)<br /> <br /> <br /> * Abactio=see Abortion, induced<br /> <br /> <br /> * Abactus venter=see Abortion, induced<br /> <br /> <br /> * Abarognosis 781.9<br /> <br /> <br /> * Abasia (-astasa) 307.9<br /> <br /> O atactica 781.3<br /> <br /> O choreic 781.3<br /> <br /> O hysterical 300.11<br /> <br /> <br /> 0 paroxysmal trepidant 781.3<br /> <br /> O spastic 781.3<br /> <br /> O trembhng 781.3<br /> <br /> O trepidans 781.3<br /> <br /> <br /> * Abderhalden-Kaufmann-Lignac syndrome (cystinosis) 270.0<br /> <br /> <br /> * Abdomen, abdominal=see also condition<br /> <br /> O accordion 306.4<br /> <br /> O acute 789.0<br /> <br /> 0 angina 557.1<br /> <br /> O burst 868.00<br /> <br /> O convulsive equivalent (see also Epilepsy) 345.5<br /> <br /> O heart 746.87<br /> <br /> O muscle deficiency syndrome 756.7<br /> <br /> O obstipum 756.7<br /> <br /> <br /> * Abdominalgia 789.0<br /> <br /> <br /> 0 periodic 277.3<br /> <br /> * Abduction contracture, hip or other joint=see Contraction, point<br /> <br /> <br /> * Abercromble's syndrome (amyloid degeneration) 277.3<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> * Aberrant (congenital)see also Malposition, congenital<br /> <br /> <br /> O adrenal gland 759.1<br /> <br /> O blood vessel NEC 747.60<br /> <br /> <br /> O artenovenous NEC 747.60<br /> <br /> O cerebrovascular 747.81<br /> <br /> <br /> O gastrointestinal 747.61<br /> <br /> O lower hmb 747.64<br /> <br /> O renal 747.62<br /> <br /> <br /> O spinal 747.82<br /> <br /> O upper limb 747.63<br /> <br /> O breast 757.6<br /> <br /> O endocnne gland NEC 759.2<br /> <br /> <br /> O gastrointestinal vessel (penpheral) 747.61<br /> <br /> <br /> O hepatic duct 751.69<br /> <br /> O lower limb vessel (penpheral) 747.64<br /> <br /> <br /> O pancreas 751.7<br /> <br /> O parathyroid gland 759.2<br /> <br /> <br /> O penpheral vascular vessel NEC 747.60<br /> <br /> <br /> O pituitary gland pharyngeall) 759.2<br /> <br /> O renal blood vessel 747.62<br /> <br /> <br /> O sebaceous glands, mucous membrane, mouth 750.26<br /> <br /> O spinal vessel 747.82<br /> <br /> <br /> O spleen 759.0<br /> <br /> O testis (descent) 752.5<br /> <br /> <br /> O thymus gland 759.2<br /> <br /> <br /> O thyroid gland 759.2<br /> <br /> O upper hmb vessel (penpheral) 747.63<br /> <br /> <br /> * Aberration<br /> <br /> <br /> O lactis 757.6<br /> <br /> O testis 752.5<br /> <br /> <br /> * Aberration=see also Anomaly<br /> <br /> <br /> O chromosome=see Anomaly, chromosomes)<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> 68<br /> <br /> <br /> <br /> O distantial 368.9<br /> <br /> O mental (see also Disorder, mental, nonpsychotic) 300.9<br /> <br /> <br /> * Abetalipoprotenemia 272.5<br /> <br /> <br /> * Abionarce 780.7<br /> <br /> <br /> * Abiotrophy 799.8<br /> <br /> <br /> * Ablatio<br /> <br /> <br /> O placentae=see Placenta, ablatio<br /> <br /> O retinae (see also Detachment, retina) 361.9<br /> <br /> <br /> * Ablation<br /> <br /> <br /> O pituitary (gland) (with hypofunction) 253.7<br /> <br /> O placenta see Placenta, ablatio<br /> <br /> O uterus 621.8<br /> <br /> <br /> * Ablephana, ablepharon, ablephary 743.62<br /> <br /> <br /> * Ablepsia=see Blindness<br /> <br /> <br /> * Ablepsy=see Blindness<br /> <br /> <br /> * Ablutomania 300.3<br /> <br /> <br /> * Abnormal, abnormality, abnormalties=see also Anomaly<br /> <br /> <br /> 0 acid-base balance 276.4<br /> <br /> O fetus or newborn=see Distress, fetal<br /> <br /> 0 adaptation curve, dark 368.63<br /> <br /> 0 alveolar ndge 525.9<br /> <br /> 0 amnion 658.9<br /> <br /> <br /> 0 affecting fetus or newborn 762.9<br /> <br /> 0 anatomical relationship NEC 759.9<br /> <br /> 0 apertures, congenital, diaphragm 756.6<br /> <br /> 0 auditory perception NEC 388.40<br /> <br /> 0 autosomes NEC 758.5<br /> <br /> 0 13 758.1<br /> <br /> 0 18758.2<br /> <br /> <br /> 0 21 or 22 758.0<br /> <br /> 0 D1 758.1<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> 69<br /> <br /> <br /> <br /> 0 E3 758.2<br /> <br /> 0 G 758.0<br /> <br /> 0 balhstocardiogram 794.39<br /> <br /> 0 basal metabolic rate (BMR) 794.7<br /> <br /> 0 biosynthesis, testicular androgen 257.2 [26,5]<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 3<br /> THE CPT DATA FILE DETAIL: 2001 SHORT DESCRIPTION UPPER CASE(17)<br /> <br /> <br /> <br /> <br /> Layout<br /> <br /> All records are 80 characters in length, fixed-field format. Short<br /> CPT code descriptions do not exceed 28 characters in length. Blank<br /> space will fill records through position 80. Record content<br /> includes:<br /> <br /> CPT Code position 1 through 5 (numeric)<br /> Blank space position 6<br /> CPT Short Description position 7 up to 34 (alpha/numeric)<br /> Blank space through position 80<br /> <br /> Sample<br /> <br /> 00100 ANESTH, SALIVARY GLAND<br /> 00102 ANESTH, REPAIR OF CLEFT LIP<br /> 00103 ANESTH, BLEPHAROPLASTY<br /> 00104 ANESTH, ELECTROSHOCK<br /> 00120 ANESTH, EAR SURGERY<br /> 00124 ANESTH, EAR EXAM<br /> 00126 ANESTH, TYMPANOTOMY<br /> 00140 ANESTH, PROCEDURES ON EYE<br /> 00142 ANESTH, LENS SURGERY<br /> 00144 ANESTH, CORNEAL TRANSPLANT<br /> 00145 ANESTH, VITRECTOMY<br /> 00147 ANESTH, IRIDECTOMY<br /> 00148 ANESTH, EYE EXAM<br /> 00160 ANESTH, NOSE/SINUS SURGERY<br /> 00162 ANESTH, NOSE/SINUS SURGERY<br /> 00164 ANESTH, BIOPSY OF NOSE<br /> 00170 ANESTH, PROCEDURE ON MOUTH<br /> 00172 ANESTH, CLEFT PALATE REPAIR<br /> 00174 ANESTH, PHARYNGEAL SURGERY<br /> 00176 ANESTH, PHARYNGEAL SURGERY<br /> 00190 ANESTH, FACIAL BONE SURGERY<br /> 00192 ANESTH, FACIAL BONE SURGERY<br /> 00210 ANESTH, OPEN HEAD SURGERY<br /> 00212 ANESTH, SKULL DRAINAGE<br /> 00214 ANESTH, SKULL DRAINAGE<br /> 00215 ANESTH, SKULL FRACTURE<br /> 00216 ANESTH, HEAD VESSEL SURGERY<br /> 00218 ANESTH, SPECIAL HEAD SURGERY<br /> 00220 ANESTH, SPINAL FLUID SHUNT<br /> 00322 ANESTH, BIOPSY OF THYROID<br /> 00350 ANESTH, NECK VESSEL SURGERY [26,5]<br /> C Copyright 1995-2000 American Medical Association All nights reserved<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 4<br /> CPT DATA FILE DETAIL: 2001 MEDIUM DESCRIPTION UPPER CASE<br /> <br /> <br /> Layout<br /> <br /> All records are 106 characters in length. Medium CPT code descriptions<br /> do not exceed 100 characters in length. Blank space will fill records<br /> through position 106 if record descriptions are less than 100 characters<br /> in length. The truncation convention list developed for the medium<br /> descriptions is provided for your information. Record content includes:<br /> <br /> CPT Code position 1 through 5 (numeric)<br /> Blank space position 6<br /> CPT Medium Description position 7 through 106 (alpha/numeric)<br /> <br /> Truncation Conventions Used in the Medium Descriptions<br /> <br /> * The substitution of "with" with "W/";<br /> * The substitution of "without" with "W/O";<br /> * The substitution of "including" with "W/";<br /> * The substitution of "biopsy" with "BX";<br /> * The substitution of "procedure" with "PROC";<br /> * The substitution of "Magnetic resonance imaging" with "MRI";<br /> * The substitution of "Magnetic resonance angiography" with "MRA";<br /> * The substitution of "or" with a slash (/) (eg, foot or leg foot/leg);<br /> * The substitution of "and" with "&";<br /> * The substitution of "and/or" with "&/OR"<br /> * The substitution of the words "or more" with a "+" (eg, two or more 2+)<br /> * The substitution of "Supervision and Interpretation" with "S & I";<br /> * The substitution of the word "examination" with "EXAM";<br /> * The substitution of "greater than" or "more than" with ">";<br /> * The substitution of "less than" with "<";<br /> * The substitution of "with and without" with "W/WO"<br /> * The substitution of "additional" with "ADD'L";<br /> * The substitution of "computerized axial tomography" and "computerized<br /> tomography" with "CT";<br /> * The substitution of "history" with "HX";<br /> * The substitution of intramuscularr" with "IM";<br /> * The substitution of "intravenous" with "IV";<br /> * The substitution of "subcutaneous" with "SUBQ";<br /> * The substitution of the prepositions "of, by, from, for" with a comma (,);<br /> * The substitution of "(separate procedure)" with "(SEP PROC)";<br /> * The substitution of "diagnostic" with "DX";<br /> * The substitution of "gastrointestinal" with "GI";<br /> * The substitution of "fracture" with "FX";<br /> * The substitution of "internal" or "external" with "INT" or "EXT";<br /> * The substitution of "interphalangeal" with "IP";<br /> * The substitution of "metacarpalphalangeal" with "MCP";<br /> * The substitution of "foreign body" with "FB";<br /> * The substitution of "minutes" with "MIN";<br /> * The substitution of "weight" with "WT";<br /> * The substitution of "identification" with "ID";<br /> * The substitution of "material" with "MATL";<br /> * The substitution of "unilateral/bilateral" with "UNILAT/BILAT";<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> 72<br /> <br /> <br /> * The deletion of "(eg)" and "(ie)";<br /> * The deletion of all eponyms;<br /> * Fractions to be spelled out (eg, 2/3 TWO THIRDS);<br /> * Delete years and if necessary replace with age (ie, AGE 2);<br /> <br /> General Rules<br /> * Consistency of parent code language in all indented codes where the parent<br /> and child code descriptions are under 100 characters;<br /> * Attempt to replicate as closely as possible (ie, with 100 characters) the<br /> original language of the CPT long description.<br /> Sample<br /> <br /> 00100 ANESTHESIA FOR PROC ON SALIVARY GLANDS, W/ BX<br /> 00102 ANESTHESIA FOR PROC ON PLASTIC REPAIR, CLEFT LIP<br /> 00103 ANESTHESIA FOR RECONSTRUCTIVE PROC, EYELID<br /> 00104 ANESTHESIA, ELECTROCONVULSIVE THERAPY<br /> 00120 ANESTHESIA, EAR PROC/BX; NOS<br /> 00124 ANESTHESIA, PROC ON EXT, MIDDLE, & INNER EAR W/ BX; OTOSCOPY<br /> 00126 ANESTHESIA, PROC ON EXT, MIDDLE, & INNER EAR W/ BX; TYMPANOTOMY<br /> 00140 ANESTHESIA, PROC ON EYE; NOS<br /> 00142 ANESTHESIA, PROC ON EYE; LENS SURGERY<br /> 00144 ANESTHESIA, PROC ON EYE; CORNEAL TRANSPLANT<br /> 00145 ANESTHESIA, PROC ON EYE; VITRECTOMY<br /> 00147 ANESTHESIA, PROC ON EYE; IRIDECTOMY<br /> 00148 ANESTHESIA, PROC ON EYE; OPHTHALMOSCOPY<br /> 00160 ANESTHESIA, PROC ON NOSE & ACCESSORY SINUSES; NOS<br /> 00162 ANESTHESIA, PROC ON NOSE & ACCESSORY SINUSES; RADICAL SURGERY<br /> 00164 ANESTHESIA, PROC ON NOSE & ACCESSORY SINUSES; BX, SOFT TISSUE<br /> 00170 ANESTHESIA, INTRAORAL PROC, W/ BX; NOS<br /> 00172 ANESTHESIA, INTRAORAL PROC, W/ BX; REPAIR, CLEFT PALATE<br /> 00174 ANESTHESIA, INTRAORAL PROC, W/ BX; EXCISION, RETROPHARYNGEAL TUMOR<br /> 00176 ANESTHESIA, INTRAORAL PROC, W/ BX; RADICAL SURGERY<br /> 00190 ANESTHESIA, PROC ON FACIAL BONES; NOS<br /> 00192 ANESTHESIA, PROC ON FACIAL BONES; RADICAL SURGERY (W/ PROGNATHISM)<br /> 00210 ANESTHESIA, INTRACRANIAL PROC; NOS<br /> 00212 ANESTHESIA, INTRACRANIAL PROC; SUBDURAL TAPS<br /> 00214 ANESTHESIA, INTRACRANIAL, BURR HOLES, VENTRICULOGRAPHY [26,5]<br /> <br /> <br /> Copynght 1995-2000 Amencan Medical Association All nghts reserved<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 5<br /> THE CPT DATA FILE DETAIL: 2001 LONG DESCRIPTION UPPER CASE(19)<br /> <br /> Layout<br /> <br /> All records are 80 characters in length, fixed-field format. When<br /> long CPT code descriptions exceed 72 characters, the CPT code is<br /> repeated and the sequence number (2-digit counter) is increased by<br /> one (eg, 01, 02, 03, etc). Blank space will fill records through<br /> position 80 if record descriptions are less than 72 characters in<br /> length. Record content includes:<br /> <br /> CPT Code position 1 through 5 (numeric)<br /> Sequence Number position 6 though 7 (numeric)<br /> Blank space position 8<br /> CPT Long Description position 9 through 80 (alpha/numeric)<br /> Sample<br /> <br /> 0010001 ANESTHESIA FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING BIOPSY<br /> 0010201 ANESTHESIA FOR PROCEDURES ON PLASTIC REPAIR OF CLEFT LIP<br /> 0010301 ANESTHESIA FOR RECONSTRUCTIVE PROCEDURES OF EYELID (EG, BLEPHAROPLASTY,<br /> 0010302 PTOSIS SURGERY)<br /> 0010401 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY<br /> 0012001 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING<br /> 0012002 BIOPSY; NOT OTHERWISE SPECIFIED<br /> 0012401 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING<br /> 0012402 BIOPSY; OTOSCOPY<br /> 0012601 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING<br /> 0012602 BIOPSY; TYMPANOTOMY<br /> 0014001 ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED<br /> 0014201 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY<br /> 0014401 ANESTHESIA FOR PROCEDURES ON EYE; CORNEAL TRANSPLANT<br /> 0014501 ANESTHESIA FOR PROCEDURES ON EYE; VITRECTOMY<br /> 0014701 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY<br /> 0014801 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY<br /> 0016001 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; NOT OTHERWISE<br /> 0016002 SPECIFIED<br /> 0016201 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; RADICAL SURGERY<br /> 0016401 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; BIOPSY, SOFT<br /> 0016402 TISSUE<br /> 0017001 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE<br /> 0017002 SPECIFIED<br /> 0017201 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; REPAIR OF CLEFT<br /> 0017202 PALATE<br /> 0017401 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; EXCISION OF<br /> 0017402 RETROPHARYNGEAL TUMOR<br /> 0017601 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; RADICAL SURGERY<br /> 0019001 ANESTHESIA FOR PROCEDURES ON FACIAL BONES; NOT OTHERWISE SPECIFIED<br /> 0019201 ANESTHESIA FOR PROCEDURES ON FACIAL BONES; RADICAL SURGERY (INCLUDING<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> 74<br /> <br /> <br /> 0019202 PROGNATHISM)<br /> 0021001 ANESTHESIA FOR INTRACRANIAL PROCEDURES; NOT OTHERWISE SPECIFIED<br /> 0021201 ANESTHESIA FOR INTRACRANIAL PROCEDURES; SUBDURAL TAPS [26,5]<br /> <br /> C Copynght 1995-2000 Amencan Medical Association All nghts reserved<br /> <br /> 73<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 6<br /> THE CPT DATA FILE DETAIL: 2001 LONG DESCRIPTION UPPER(20)<br /> <br /> <br /> <br /> Layout<br /> <br /> All records are 80 characters in length, fixed-field format. When<br /> long CPT code descriptions exceed 72 characters, the CPT code is<br /> repeated and the sequence number (2-digit counter) is increased by<br /> one (eg, 01, 02, 03, etc). Blank space will fill records through<br /> position 80 if record descriptions are less than 72 characters in<br /> length. Record content includes:<br /> <br /> CPT Code position 1 through 5 (numeric)<br /> Sequence Number position 6 though 7 (numeric)<br /> Blank space position 8<br /> CPT Long Description position 9 through 80 (alpha/numeric)<br /> Sample<br /> <br /> 0010001 Anesthesia for procedures on salivary glands, including biopsy<br /> 0010201 Anesthesia for procedures on plastic repair of cleft lip<br /> 0010301 Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty,<br /> 0010302 ptosis surgery)<br /> 0010401 Anesthesia for electroconvulsive therapy<br /> 0012001 Anesthesia for procedures on external, middle, and inner ear including<br /> 0012002 biopsy; not otherwise specified<br /> 0012401 Anesthesia for procedures on external, middle, and inner ear including<br /> 0012402 biopsy; otoscopy<br /> 0012601 Anesthesia for procedures on external, middle, and inner ear including<br /> 0012602 biopsy; tympanotomy<br /> 0014001 Anesthesia for procedures on eye; not otherwise specified<br /> 0014201 Anesthesia for procedures on eye; lens surgery<br /> 0014401 Anesthesia for procedures on eye; corneal transplant<br /> 0014501 Anesthesia for procedures on eye; vitrectomy<br /> 0014701 Anesthesia for procedures on eye; iridectomy<br /> 0014801 Anesthesia for procedures on eye; ophthalmoscopy<br /> 0016001 Anesthesia for procedures on nose and accessory sinuses; not otherwise<br /> 0016002 specified<br /> 0016201 Anesthesia for procedures on nose and accessory sinuses; radical surgery<br /> 0016401 Anesthesia for procedures on nose and accessory sinuses; biopsy, soft<br /> 0016402 tissue<br /> 0017001 Anesthesia for intraoral procedures, including biopsy; not otherwise<br /> 0017002 specified<br /> 0017201 Anesthesia for intraoral procedures, including biopsy; repair of cleft<br /> 0017202 palate<br /> [26,5]<br /> Copynght 1995-2000 Amencan Medical Association All nights reserved<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 7<br /> SAMPLE ACR DOCUMENT; ROLE OF IMAGING IN CANCER OF THE CERVIX [7]<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Of<br /> .. ... Criteria<br /> <br /> <br /> lxpert IPanI oni Womie's Imaging: Hedvig Hricak, MD, PhD; Ellen Mi<br /> MDI; Robert Bree, MD4, Hiarris MDu; Elliot K. Fish man, MiDu;<br /> Thurmond1 MD MDi)."<br /> <br /> <br /> lin,o11 fia Mertea lab F \ kc<br /> rN) lX aia Sarltoll 441<br /> <br /> <br /> Irvsv 12 vica F 11,<br /> II 1)1? bofli<br /> tit ill ivevi FFV<br /> <br /> ta RiI to u dlr<br /> dlnii 1< ().<br /> <br /> <br /> cer is the fhird ,<br /> <br /> <br /> and one of tU<br /> <br /> <br /> It (5,800 new case.<br /> Between 1939 61 : ', in the mortality)<br /> This improvement in has been attributed to the development of th<<br /> and only minor improvement has been achieved in the survival of invasive cervica<br /> <br /> <br /> 7hF p~olnof of cc 1 ct kal tn m 40141 piI aiiy doet 170in dc by Itt I re of dliiac, 1 1111? oi 161' Fi4Far<br /> IUIIIF; 11 a nd (iiini Irir ho Inrait Idl icrlla o 11110 017 rlo 0 0d tl)~itbljlrI(1k(;)) 10ia<br /> 1.11 11714 1 ltca Itd~ Fig b'IItFIIOIV 1u dIFIIca 1110icm 70se '1 t (ol ph-yia u ed dFidh~lin,<br /> loitosp,F p hfgiziosoy Iniatru 110 O I IIUI I) faphy 0 lnt hal- 1111<br /> 'ruma f12). I i ;2<br /> 1nsi~ 4141 diifes 0 d 50 -ii i 11. a-ll 1111 (14eds 0410dca ~lait lltiiidlstma Ih<br /> <br /> d dbuil 10 It6 II: ,'tti4Ol p111 Fla tnlrsalidn 171) Itno ItIV 111 I II<br /> p Il)i 1 v~~stm io Fn Fll'I 1 f 1)00 ni t ~IUntlliia I n Illica II Is 11 1412 III 111<br /> due~~ It li~i~ite 414 114 110dbar~o iii paalidlail 144i .iiwi ivsu .h vliio 11 I<br /> I4p1iur cderIcd Iuor t~tllallol tr lIydttC 1gIIg I00('111Fs Inipria<br /> <br /> iI~tIV 01 114 ti~i 71141 IafbX 11417 Framel (Ft'Suig Fidl lI "~ I )b V 0ylti (10<br /> 1 sil~oft igiis ctbi~r(o No lI' lltbiipll' lidR IIgig glifr 1 41) Ibt<br /> hicrorir Wnr lImiedt-i 4 ~g (3)ao FImtIlg 111114 17 4)tMil<br /> <br /> <br /> ima1gig studies have been of limited value in it-ie<br /> t r ot..<br /> <br /> <br /> 111,471 41 41 lodtu l 41 1<br /> <br /> <br /> 1:, lic Netr ic ur Y'dn<br /> Iii i~ i~ii ~iimih ii:iionx<br /> <br /> <br /> incer of the Cervix<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> 78<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Whiie IVU is a sensitive itst in the detection of urinary obstruction, a<br /> obstruction in stage Tb disease argues against the routine use of this te<br /> routine use of BI, cystOscopy and sigtmoidoscopy has been suggested previt<br /> <br /> <br /> i'ransrcial and endovagina sonugriphy has<br /> value has yet to be evaluated<br /> staging and CL' in the differentia tio of from stage lib disease<br /> limited by operator poor soft tissue contrast, and a smali field c<br /> <br /> <br /> Computed<br /> The staging accuracy of CT ranges f<br /> from 17%-100% with an average o<br /> *re is a consensus in ihe<br /> limited value (a positive ,<br /> (30 37). value<br /> <br /> <br /> <br /> IThe staging accuracy ranges<br /> parametral invasion is 69%, and ithe s<br /> evaluation of pirametrial invasion,. M<br /> sensitivity and of MRI, 5i<br /> assessment of local tumor invasion,<br /> <br /> <br /> <br /> Although iymphangingraphy has bee<br /> node melastasesi its has been mostly r<br /> *alnd CT<br /> modalities CT may<br /> [ympharngiography<br /> disease ( ii49), A meta-analysis corn<br /> cervica<br /> overall perfoEnrmance of lAGC CT and<br /> LAG or CT (50),<br /> <br /> <br /> rom 32% -80 (23 37), The<br /> ages from 5(<br /> CT increases<br /> value of 58%) in thii evaa<br /> of CT for nodal involvetme il is 65% i<br /> <br /> <br /> <br /> s front 75%-90% (33-43). The sensitiv<br /> pecificity is 93% (33-43)<br /> IRI was superior io CT i). In th<br /> 0% and 95% respectively, are srida<br /> T2-weighted images are superior it<br /> <br /> <br /> <br /> n routinely used in Lhe past for ihe i '<br /> placed, in this role, and MRI.<br /> ,eshov . 72%-91%<br /> <br /> <br /> par<br /> <br /> <br /> red the of lymphangiograpl<br /> characteristics rev'<br /> RI, there was a trend toward beif<br /> <br /> <br /> This guideline was in 1996 A complete review<br /> approved in 1990. 'he next review will be completed in 20021<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> 79<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> --, cancer of the Cervix<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> htt r sie i2 Fc<br /> <br /> <br /> Variant 2:<br /> <br /> <br /> s i maingg<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> 80<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> tnvsivt Ccner o: le Cervix<br /> <br /> Wv ( r sizre >3 cm.<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> greatk tha lb<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> indU i;,Ancrsii U<br /> Spt~el ui i""<br /> <br /> <br /> i~r~i t t crin<br /> <br /> <br /> rodanmi M.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX 8<br /> COMPLETE DATA DEFINITION<br /> <br /> Contributors<br /> <br /> <Description><br /> <br /> e This table will contain details that pertain to each contributor that was part of<br /> one or more teams, each of which worked on some ACR Guideline document.<br /> In addition to items needed for generating the attributions for the guideline<br /> itself this will hold contact information for administrative purposes.<br /> <br /> <br /> <Attributes><br /> <br /> Contributor ID<br /> <br /> <br /> o <Type5><br /> <br /> o <Contents><br /> <br /> o <Constraints><br /> <br /> <br /> Long Integer<br /> Auto Number<br /> <br /> <Pnmagy Key> <Unique><br /> <br /> <br /> o <Details>This feld will uniquely identify this Contributors<br /> <br /> among all contributors in the Database. This is only an<br /> <br /> identifying number (like mostAuto Numbers) and has no<br /> <br /> other bearing on the database.<br /> <br /> <br /> r Contributor Name<br /> <br /> <br /> o <Tjpe><br /> <br /> o <Contents><br /> <br /> o <Constraints><br /> <br /> <br /> String<br /> <br /> Author's Name.<br /> <br /> <br /> None<br /> <br /> <br /> o <Details> This contributor will have been part of one or more<br /> <br /> teams that have designed an ACR document.<br /> <br /> <br /> <br /> <br /> Data types are with reference to Access / Sequel server conventions.<br /> <br /> 6 An auto number is a Long integer generated automatically by Microsoft Access. It is used to index a table and is usually the<br /> primary key.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> > Institution Name<br /> <br /> <br /> <Tjpe> String<br /> <br /> <Contents> Institution Name<br /> <br /> <Constraints> None<br /> <br /> <Details>The institution the Contributor belongs to.<br /> <br /> <br /> SDepartment_Name<br /> <br /> <br /> <Tjpe><br /> <br /> <Contents><br /> <br /> <Constraints><br /> <br /> <Details><br /> <br /> <br /> String<br /> <br /> Department Name<br /> <br /> None<br /> <br /> Department within the institution<br /> <br /> <br /> <Tjpe> String<br /> <br /> <Contents> First line of mailing address<br /> <br /> <Constraints> None<br /> <br /> <Details> This field holds a part of the mailing address.<br /> <br /> <br /> <br /> <Tjpe> String<br /> <br /> <Contents> Second line of mailing address<br /> <br /> <Constraints> None<br /> <br /> <Details> This feld holds the second part of the mailing<br /> <br /> address.<br /> <br /> <br /> <Tjpe><br /> <br /> <Contents><br /> <br /> <Constraints> None<br /> <br /> <Details><br /> <br /> <br /> String<br /> <br /> Name of a City.<br /> <br /> <br /> City in the contributor's address.<br /> <br /> <br /> > Address 1<br /> <br /> <br /> > Address 2<br /> <br /> <br /> > City<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> > State<br /> <br /> <br /> <Tjpe> String.<br /> <br /> <Contents> A state.<br /> <br /> <Constraints> None<br /> <br /> <Details> State in the contributor's address. State that the<br /> <br /> above City is in.<br /> <br /> <br /> > Zip<br /> <br /> <br /> <Type> Integer<br /> <br /> <Contents> Zip Code.<br /> <br /> <Constraints> None<br /> <br /> <Details> Zip code at contributor's address.<br /> <br /> <br /> SE Mail<br /> <br /> <br /> <Tjpe><br /> <br /> <Contents><br /> <br /> <Constraints><br /> <br /> <Details><br /> <br /> <br /> String<br /> <br /> e-mail address, complete<br /> None<br /> <br /> The contributor's e-mail address<br /> <br /> <br /> r Phone Number<br /> <br /> <br /> <Tjpe><br /> <br /> <Contents><br /> <br /> <Constraints><br /> <br /> <Details><br /> <br /> <br /> String<br /> <br /> Complete phone number, with area code<br /> <br /> None<br /> <br /> The contributor's telephone number<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> References<br /> <br /> <Description><br /> <br /> e This table will contain details of references that were used in producing<br /> various Guidelines. The point to be noted here is the generic nature of this<br /> table to accommodate the largest variance in the referred matter. The table<br /> has accommodations to take into account that a reference may be anything<br /> from personal communication to a Journal reference to a chapter/ passage in<br /> a book.<br /> <br /> <Attributes><br /> <br /> r Reference ID<br /> <br /> o <Type> Long Integer<br /> o <Contents> Auto-Number<br /> o <Constraints> <Primary Key> <Unique><br /> o <Details>This number will uniquely identify this reference<br /> among all references in the database. This is only an<br /> identifying number and has no other bearing on the database.<br /> <br /> > PM ID<br /> <br /> o <Tpe> String<br /> o <Contents> Medlinepub med ID<br /> o <Constraints> None<br /> o <Details>This feld serves two purposes. Keeping in mind that<br /> some referred material may not appear in Medline, the<br /> following will apply.<br /> SIf the referred article is in the Medline database, this<br /> field will contain the PM-ID of the referred document.<br /> This ID is an identifer that can be used to identify the<br /> referred document among all those stored in<br /> MEDLINE. This number can be stored with a<br /> hyperlink to MEDLINE so that clicking on it will allow<br /> one to obtain an abstract of the reference, and with<br /> authorization even the Full text may be available.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> *If the referred matter is not present in Medline, a<br /> suitable and pre-qualifed null and void feld such a 'O'<br /> or "N.A' will appear here. It will signify the reference's<br /> non-existence in the MEDLINE database.<br /> <br /> 0<br /> <br /> > ReferenceType<br /> <br /> <br /> o <Type> String<br /> o <Contents> The kind of reference contained in this record.<br /> o <Constraints>An .', ,-, J reference type. The ...;, ,/ types -.'.' have to be<br /> <br /> decided.<br /> o <Details>Examples: "JOUR_ART", "BOOK_CHAP",<br /> "PERS_COM" for journal article, book chapter, and personal<br /> communication respectively.<br /> <br /> <br /> r Reference Title<br /> <br /> <br /> o <Type> String<br /> o <Contents> Title<br /> o <Constraints> None<br /> o <Details>This field is to take into consideration that a reference<br /> may be a chapter in a book or a specific part of another<br /> <br /> Journal. This feld could contain the Title of the chapter or the<br /> heading of the referred text. The non-existence (or irrelevance<br /> with reference to the current context) of this feld is signifed<br /> by a Null value.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Chapter_Number<br /> <br /> o <T pe> String<br /> o <Contents> Chapter identification<br /> o <Constraints> None<br /> o <Details>This field will contain the chapter designator (mostly<br /> an Arabic number) if the reference is from a book. It will be<br /> blank if the reference is a journal article.<br /> <br /> <br /> - Journal_Book_Title<br /> <br /> <br /> o <Tpe> String<br /> o <Contents> A Journal/ Book's name.<br /> o <Constraints> None<br /> o <Details>This field will contain a the title of a Journal, the<br /> name of a book or even the subject of a personal<br /> communication (Eg-: Subject of an Email).<br /> <br /> <br /> SPublisher Name<br /> <br /> <br /> o <T pe> String<br /> o <Contents> The publisher name.<br /> o <Constraints> None<br /> o <Details>This field will contain the name of the publisher. This<br /> may be left blank for journal articles and is mostly used for<br /> book chapters.<br /> <br /> <br /> SYear Published<br /> <br /> <br /> o <Tpe> Integer<br /> o <Contents> Year<br /> o <Constraints> None<br /> o <Details>The year the Journal/Book was published. In case of<br /> personal communication, it could similarly contain an<br /> <br /> appropriate date.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> - Edition Number<br /> <br /> <br /> o <Tpe> String<br /> o <Contents> Edition Number<br /> o <Constraints> None<br /> o <Details>This feld will contain the book edition number. This<br /> may be left blank for journal articles and is mostly used for<br /> book chapters.<br /> <br /> <br /> r Volume Number<br /> <br /> <br /> o <Tpe> String<br /> o <Contents> Volume Number<br /> o <Constraints> None<br /> o <Details>Most Journals and some Books are printed in<br /> multiple volumes. This number will help identify the Volume<br /> that the reference was published in.<br /> <br /> <br /> - Start_Page<br /> <br /> <br /> o <Tpe> String<br /> o <Contents> Start ofa range ofpages.<br /> o <Constraints> None<br /> o <Details>The frst page of the referenced article or chapter.<br /> <br /> Needs to be text as sometimes these contain alphabetical<br /> characters.<br /> <br /> <br /> > End_Page<br /> <br /> <br /> o <Type> String<br /> o <Contents> End of a range ofpages.<br /> o <Constraints> None<br /> <br /> o <Details>The last page of the referenced article or chapter.<br /> Needs to be text as sometimes these contain alphabetical<br /> characters.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> Abstract<br /> <br /> o <Tjpe> Memo/Text<br /> o <Contents> Abstract<br /> o <Constraints> None<br /> o <Details>Contains the Medline abstract of the reference (if<br /> present)<br /> Guideline Reference<br /> <br /> <Description><br /> <br /> SThis table is used to link each Guideline to its list of References (primarily).<br /> Since the linking is many to many, for the sake of analysis, one may also look<br /> up all the guidelines that a reference was used in.<br /> <br /> <br /> <Attributes><br /> <br /> <br /> <br /> <br /> > Guideline ID<br /> <br /> <br /> o <Tjpe> Long Integer<br /> o <Contents> Foreign Key<br /> o <Constraints> <Foreign Key> <Exists in Guidelines Table><br /> o <Details>This value is a link/index to the Guideline table that<br /> links each reference to one or more Guidelines.<br /> <br /> <br /> r Reference ID<br /> <br /> o <Tjpe> Long Integer<br /> o <Contents> Foreign Key<br /> o <Constraints> <Foreign Key> <Exists in References Table><br /> o <Details> Reference ID of the reference.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> 90<br /> <br /> <br /> r Number in Guideline<br /> <br /> o <Tjpe> Sting<br /> o <Contents> Number<br /> o <Constraints> None<br /> o <Details>Lists the numerical place (Index) of a Reference<br /> among references of a Guideline.<br /> Condition Procedure<br /> <br /> <Description><br /> <br /> This table is used to link each condition to one or more<br /> procedures that may be used to alleviate the condition.<br /> <Attributes><br /> <br /> <br /> <br /> <br /> > Procedure ID<br /> <br /> <br /> o <Type> Long Integer<br /> o <Contents> Foreign Key<br /> o <Constraints> <Foreign Key> <Exists in Procedures Table><br /> o <Details>The procedure ID of the procedure that may<br /> <br /> apply to the below condition.<br /> <br /> <br /> r Condition ID<br /> <br /> o <Tjpe> Long Integer<br /> o <Contents> Foreign Key<br /> o <Constraints> <Foreign Key> <Exists in Conditions Table><br /> o <Details>The Condition ID of the condition being<br /> referred to.<br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> v Appropriateness_Rating<br /> <br /> o <Type> <Integer><br /> o <Contents> Rating no (x)<br /> o <Constraints> <= x <=10<br /> o <Details>Rates on a scale of to 10 the appropriateness<br /> <br /> / applicability of the procedure to the condition.<br /> Comments<br /> <br /> <br /> o <Tjpe> Text<br /> o <Contents> Comments<br /> o <Constraints> None<br /> o <Details> Comments regarding the applicability or<br /> other details regarding the condition and procedure.<br /> <br /> SOriginalProcedure_name<br /> <br /> o <Type> Sting<br /> <br /> o <Contents> Va'd procedure name<br /> o <Constraints> None<br /> o <Details> Each procedure could be referred to by many<br /> names depending on various factors such as<br /> conventions used by the committee, context etc. This<br /> field will contain the procedure name used by the<br /> committee in the Guideline. This will be linked to a<br /> <br /> procedure table that contains a standardized name for<br /> this procedure that may even be the same name used<br /> herein.<br /> Procedures<br /> <br /> <Description><br /> <br /> > This table contains a list of procedures, and other required details. This table<br /> serves to offer a level of standardization in the naming of procedures by<br /> standardizing names and linking them to their alternate names as in the<br /> Guideline.<br /> <br /> <br /> <Attributes><br /> <br /> <br /> <br /><br /> <br /> <br /> <br /> <br /> <br /> <br /> > Procedure ID<br /> <br /> <br /> <Tjpe> Long Integer<br /> <br /> <Contents> (Auto Number)<br /> <br /> <Constraints> <Pimary Key> <Unique><br /> <Details>This number uniquely identifes this procedure<br /> <br /> among all others in the system.<br /> <br /> <br /> > Modality<br /> <br /> <br /> <Tjpe><br /> <br /> <Contents><br /> <br /> <Constraints><br /> <br /> <Details> Modality ofthe procedure.<br /> <br /> <br /> String<br /> <br /> Modality<br /> 0 Exhibit 127<br /> <br /> <br /> > BodyRegion<br /> <br /> <br /> <Tjpe> String<br /> <br /> <Contents> Body Region.<br /> <Constraints> 0 Exhibit 12s<br /> <br /> <Details>Information on the body region where the procedure<br /> <br /> may be applied/ conducted.<br /> <br /> <br /> 7A modality specified, may only be a member of a set of allowed modalities as set forth by the ACR. A sample set of allowed<br /> Modalities is shown in Exhibit 12. Exhibit 12 will subsequently be expanded to hold all allowed modalities.<br /> <br /> 8 A body region may only be a member of a set of allowed regions as set forth by the ACR. A sample set of allowed regions is<br /> shown in Exhibit 12. Exhibit 12 will subsequently be expanded to hold all allowed Body Regions.<br /> <br /> <br /> <br /><br /> </div> </td> </tr> </table> </td> </tr> </table> <!-- Footer divisions complete the web page --> <div id="footer"> <p><a href="http://ufdc.ufl.educontact">Contact Us</a> | <a href="http://ufdc.ufl.edupermissions">Permissions</a> | <a href="http://ufdc.ufl.edupreferences">Preferences</a> | <a href="http://digital.uflib.ufl.edu/sobekcm/">Technical Aspects</a> | <a href="http://ufdc.ufl.edustats">Statistics</a> | <a href="http://ufdc.ufl.eduinternal">Internal</a> | <a href="http://www.uflib.ufl.edu/privacy.html">Privacy Policy</a></p> </div> <div id="UfdcWordmark"> <a href="http://www.ufl.edu"><img src="http://www.uflib.ufl.edu/images/smallWordmark.gif" alt="University of Florida Home Page" title="University of Florida Home Page" width="151" height="37" border="0" id="UfdcWordmarkImage" /></a> </div> <div id="UfdcCopyright"> <a href="http://www.uflib.ufl.edu/rights.html"> © 2004 - 2010 University of Florida George A. 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