Concept addition from conception to delivery

1. Concept addition from conception to delivery Or Why does it take so @#$% long?

2. You can’t always get what you want • Not all medical terms can or should be represented “as is” in SNOMED • The terminology should not aid and abet the use of imprecise, inaccurate, or erroneous terms • Not all nuances of medical circumstances can be captured and defined within the nomenclature • Over-reliance on precoordination invites combinatorial explosion and limits expressivity

3. ...but if you try sometimes, you can get what you need • The requirements of a controlled medical nomenclature restrict the addition of content • My job is to determine what content can be added, and to add it in a form that does not introduce error or ambiguity to the nomenclature

4. Goals • Avoid adding redundant or duplicate concepts to SNOMED • Avoid adding ambiguous, obsolete, or incorrect terms as fully specified names • Accurately define all new concepts

5. Preadmission questions • Do we need this concept? • What does the concept mean? • In what context will the concept be used? • Can the concept be defined in SNOMED?

6. Where’s Waldo? Does SNOMED already contains the concept, sometimes under another wording, or a usable equivalent? • Ex: request for Uroabdomen • SNOMED already has an equivalent concept, Urine ascites, not found by searching for uroabdomen • Adding Uroabdomen would create redundancy • Request addition of Uroabdomen as synonym instead

7. Say what? In a controlled medical terminology, each concept must represent a single idea, and the concept FSN should clearly state that idea…BUT • Human and veterinary medical language contains many terms whose meaning is not evident from the wording or which convey multiple meanings • Downer cow • White line disease • Overeating disease

8. What this means: • Even “accepted” medical terms must often be translated, not transcribed, into SNOMED • Just because “the clinician said so” does not mean SNOMED will—or can--“say so”

9. Say what you mean… If commonly accepted term is ambiguous, but conveys a commonly accepted meaning: => add concept => give concept unambiguous FSN => add common name as description

10. Example 1: Sweeney = neurogenic atrophy of shoulder muscles

11. Mean what you say: If commonly used medical term conveys more than one meaning: => create separate concepts for each meaning => give each concept unambiguous FSN => assign commonly used term as synonym for each concept

12. Example 2 Overeating disease = Type C Enterotoxemia = Type D Enterotoxemia = Grain Overload

13. Saying 1 + 2 to mean 3 If common term has complex meaning that can be best be captured by post-coordinating existing concepts => Deny concept request => Supply guidance to use of existing SNOMED concepts

14. Example 3 Pigeon fever • misleading name—pigeons do not get or carry it • variable presentation—+/- pectoral abscess = Abscess of pectoral region 76035004 + Causative agent Corynebacterium pseudotuberculosis OR = Infection due to Corynebacterium pseudotuberculosis

15. Say…what did you mean? Requested term obscure, outdated, inherently vague or meaning is impossible to determine from information given • seek clarification from requestor • determine if concept warranted

16. Just the facts, ma’am When requesting a concept, you may be asked to: • Seek clarification from a clinician • Supply background information • Explain the concept’s projected use • Discuss whether existing SNOMED concept(s) can be used instead • Accept a refusal 

17. Request: Myelocytoma Problem: Myelocytoma can refer to Multiple myeloma Chronic myelogenous leukemia A discrete tumor esp. of fowl, composed of myelocytes Need to know: which meaning is intended

18. Request: Proliferative thrombovascular necrosis Problem: References lacking Need to know: --is this an accepted medical term? --what is the pathophysiology? --what is the etiology, if known?

19. Request: Delayed weaning Problem: Context unclear Procedure or finding? If finding—necessarily abnormal? Need to know: context, to determine hierarchy to which concept belongs

20. Request: Ringwomb Problem: User requests new concept or guidance to appropriate existing concept Need to know: exact nature of “ringwomb” to find if perfect match exists in SNOMED (yes).

21. Request: Chronic moist dermatitis Problem: Concept irredeemably ambiguous Need to know: how to break clinicians of using pseudodiagnoses!

22. And finally…. • Sliced, diced, buffed and polished concept submitted to SNOMED with suggested FSN, synonyms, and definitions • CAP modeler reviews submission—may reject, query, or accept concept • If accepted, new concept is created and assigned codes in TDE • New concept appears in next database release