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RadLex Chair Orientation Meeting July 19, 2005 What is a Controlled Medical Terminology DONALD P. HARRINGTON MD,MA Outline of Discussion Background and Motivation Definition of terms Index’s, Classifications and Terminologies Why do we need a Controlled Medical Terminology

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RadLex Chair Orientation MeetingJuly 19, 2005

What is a Controlled Medical Terminology

DONALD P. HARRINGTON MD,MA


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Outline of Discussion

  • Background and Motivation

    • Definition of terms

    • Index’s, Classifications and Terminologies

    • Why do we need a Controlled Medical Terminology

  • What constitutes a Controlled Medical Terminology

    • Cimino’s desiderata

    • Framework for a Comprehensive Health Terminology Systems. Chute et.al.

  • Sources of terms MedLEE


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Definitions

  • Vocabulary: all the words used by or known to a particular person or group, or contained in a language as a whole

  • Lexicon: the entire stock of words belonging to a branch of knowledge or known by somebody

  • Terminology: the expressions and words, or a set of expressions and words, used by people involved in a specialized activity or field of work


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Definitions

  • Index: 1. An order list of the items that make up a set 2. An alphabetical list, usually at the end of a book, of people places, or topics, giving the numbers of the pages on which they are mentioned

  • Classification: 1. the allocation of items to groups according to type 2. The categorization of organisms into defined groups on the basis of identified characteristics.


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Problem?

  • The English Language is extraordinarily expressive but is by the same token filled with vagueness, ambiguity and ellipsis

  • There is no reporting standard

  • There is no standardized teaching of reporting


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Problem?

  • Radiological reporting is not an exact science

    • Radiological interpretation is a subjective process and this subjectivity compounds the problem of vagueness and ambiguity

    • There is uncertainty in the diagnostic process and this is poorly specified if at all


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Why we need a Controlled Radiology Vocabulary

We need to improve our human to human communication.

We must establish machine to machine communications to take full advantage of PACS and Digital Imaging.

We need a standard vocabulary to accomplish the above


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Why Do we need machine to machine communication

  • To facilitate and to complete the Electronic Medical Record

    • Reduction in Medical Error

    • Facilitates Data Mining

      • Epidemiology studies and bioterrorism detection

      • Teaching file development and use

  • Application of Decision Support to Imaging

    • Image Interpretation

    • Differential Diagnosis


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Terminology Development and Cimino’s Desiderata

  • Content,Content and Content

  • Concept Orientation

  • Concept Permanence

  • Nonsemantic Concept Identifiers


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Cimino’s Desiderata

  • Content,Content and Content

    • This is the focus of the domain experts that make up this group and others that will follow.

    • Curt has included terms from the ACR Index, other knowledge bases such as Medical texts and indices of disease

    • I believe a portion of the terms can come from the output of MedLee from Columbia Radiology reports.


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Cimino’s Desiderata

  • Concept Orientation

    • This means that terms must correspond to at least one meaning (nonvagueness) and no more than one meaning (nonambiguity) and that meanings correspond to no more than one term (nonredundancy)


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Cimino’s Desiderata

  • Concept Permanence

    • Old terms are retired but not dropped

  • Nonsemantic Concept Identifiers


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Cimino’s Desiderata

  • Polyhierarchy

  • Formal Definitions

  • Reject “Not Elsewhere Classified “

  • Multiple Granularities


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Cimino’s Desiderata

  • Polyhierarchy

    • Anatomy and Pathology Fig. 1

  • Formal Definitions

    • “is a “, “part of”. Fig. 2

  • Reject “Not Elsewhere Classified “

  • Multiple Granularities

    • ICD-9 vs. DRG


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Cimino’sDesiderata

  • Multiple Consistent Views

    • Different tracks lead to the same concept

  • Beyond Medical Concepts Representing Context Fig. 2

  • Evolve Gracefully [Things change]

  • Recognize Redundancy [synonyms]


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A Framework for Health Terminology systems in the US

  • General

    • Completeness: Explicit in-depth coverage

    • Comprehensiveness: All aspects of the subject

    • Characteristics of integration: Unique term representation

      • Nonoverlapping: Specialized terminology is nonredundent and interrelates with existing systems

      • Integrated: Cross-referenced to the the point of interdependence


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A Framework for Health Terminology systems in the US

  • General

    • Nonredundent: Internally consistent with one and only one preferred way to represent a concept or idea

    • Mapping: An algorithmic relationship with classifications such as ICD-9 and CPT Codes. This could relate to language translation


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A Framework for Health Terminology systems in the US

  • Structure of the terminology model

    • Atomic base: Root concept

    • Compositional: Root concepts are combinable

    • Synonyms: Are to be made explicit and supported likewise, abbreviations and non-English terms

    • Attributes Time, staging, quantity

      • Inheritance


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A Framework for Health Terminology systems in the US

  • Structure of the terminology model

    • Multiple hierarchies:

      • Terms have multiple semantic parents

      • Lung cancer is a in the neoplasm and the lung disease hierarchy

      • Consistency of views: Both hierarchies lead to the same concept--lung cancer

    • Explicit uncertainty:

      • The lack of expression for uncertainty is a major flaw in Radiology reporting

    • Lexical rules: Spell checking

    • Representation: No restriction on coding of concepts


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A Framework for Health Terminology systems in the US

  • Maintenance

    • Context-free identifiers

    • Unique identifiers

    • Version control

      • Dated

      • Obsolete marking

    • Definitions

    • Language independence

    • Responsiveness


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A Framework for Health Terminology systems in the US

  • Administration

    • Coordination

    • Access

    • Funding


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