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Mayo Foundation: Clinical Perspective on Comparable Data. By Peter L. Elkin, MD Director, Laboratory of Biomedical Informatics Department of Internal Medicine Mayo Clinic. Millions of Documents are Generated by Healthcare Organizations each Year

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Mayo foundation clinical perspective on comparable data

Mayo Foundation: Clinical Perspective on Comparable Data

By Peter L. Elkin, MD

Director, Laboratory of Biomedical Informatics

Department of Internal Medicine

Mayo Clinic


Document management the tip of the iceberg

Millions of Documents are Generated by Healthcare Organizations each Year

All are lost with respect to retrieval purposes (Except by MR#)

Lost Opportunity to Learn about your practice

Lost Opportunity to Manage your practice

Document ManagementThe Tip of the Iceberg


Document management the tip of the iceberg1

Other Applications Organizations each Year

Linking Images to Patient Records

Linking the Literature to Patient Records

Aggregate Retrievals for Research

Cost Justification by Better Documentation (links to Clinical Guidelines, Definitions, etc.)

Linking Documents to Web pages Dynamically

Challenge is that this Linkage must be robust enough to characterize today’s practice of medicine

Document ManagementThe Tip of the Iceberg


Clear return on investment

Automated Vocabulary Management Organizations each Year

Better Asset Management

Automated evaluation of records to see if they meet the E&M coding guidelines?

Expert System to Maximize DRG reimbursement…..

Decision Support (Patient Safety)

Clear Return on Investment


Granular encoding
Granular Organizations each YearEncoding


Mayo technology

Concept Based Indexing Organizations each Year

SNOMED-CT

ACE

ACD

Vocabulary Server

Comparable Data

Mayo Technology


Mayo foundation clinical perspective on comparable data

Colloquial Terminologies Organizations each Year

Local

National

International

Entry

Presentation

Pre-Coordinated Terms

Structure within the

Colloquial Terminology

Context

Coordination

Atomic Reference Terminology

Description Logic

Predicate Logic


System architecture enterprise java beans
System Architecture Organizations each YearEnterprise Java Beans


Mayo foundation clinical perspective on comparable data

EMR Organizations each Year


Mayo foundation clinical perspective on comparable data

Record Entry Organizations each Year

Record Entry

Process

Process

Web Server

Web Server

Enterprise

Enterprise

Transcribed Record

Transcribed Record

Java Bean Container

Java Bean Container

Processed Record

Processed Record

Record to Processor

Record to Processor

to Storage

to Storage

and Return

and Return

Map Text To

Map Text To

Map Text To

Map Text To

Terminology and

Terminology and

Terminology

Terminology

Store

Store

EMR

EMR

Terminology

Terminology

Repository

Repository

Server

Server

Intelligent Query

Intelligent Query

to Database

to Database

Handle Query and

Handle Query and

Explode Matches

Explode Matches

Query to Processor

Query to Processor

and Return

and Return

Query

Query

Record Retrieval

Record Retrieval

Process

Process


Terminology in healthcare

“The nomenclature is of as much importance in this department of inquiry, as weights and measures in the physical sciences, and should be settled without delay.” William Farr, 1839; Regarding the Cullenian system of 1785

First Annual Report of the Registrar-General

of Births,Deaths, and Marriages in England.

London: 1839 p. 99.

Terminology in Healthcare:


Florence nightingale 1893

“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison.”

- Florence Nightingale, 1893


Electronic health record

Comparable Data everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison.”

Granularity C/W the Practice

Outcomes Research

Utilization Review

Managing the Financial Side of the Practice

Controlled Medical Vocabulary

Maintenance

Coverage

Formal Definitions

Unambiguous (Within a Context)

Non-Redundant

Ease of Data Acquisition

Electronic Health Record


Current large vocabulary efforts

SNOMED-RT everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison.”

SNOMED-DICOM Microglossary

Clinical Terms v3 (Read Codes)

SNOMED-CT

UMLS

NIC, NOC, NANDA

NDF-RT

Current Large Vocabulary Efforts


Tommy g thompson secretary of health and human services july 1 2003

I am very excited about the tremendous potential for information systems to improve the quality of health care, and I have been pushing everyone in the Department very hard to move forward as rapidly as possible.

My first charge ……… is to develop incentives for all parts of the health care community to use SNOMED, the electronic medical records, and other standards as they are adopted. We want to see the integration of health information systems through to its logical conclusion.

I challenge you to adopt and use interoperable electronic health records.

TOMMY G. THOMPSON, SECRETARY OF HEALTH AND HUMAN SERVICES July 1, 2003


Mayo foundation clinical perspective on comparable data

Placing a Stake in the Ground information systems to improve the quality of health care, and I have been pushing everyone in the Department very hard to move forward as rapidly as possible.by Don Berwick, MD

Clinicians and Researchers need a comparable mechanism for accessing Medical Record Data.

Let’s place that stake in the ground where we think it Really Ought To Be!!!


Interoperability

Data Exchange Between and Among Computers and Computer Systems

Reliable

Complete

Accurate

Interoperability Standards

HL7

ASTM

ISO

Interoperability


Statement

In Medicine, we will never be able to create a vocabulary, with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.

E.g. Cellulitis, Left foot, with Osteomyelitis of the 3rd Metatarsal.

Statement:


Answer compositionality

Unambiguous with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.

The Composite Term and its formalism should be specified in such a way as not to allow two or more interpretations of the term’s meaning.

Non-Redundant

Normalization of Pre-Coordinated Terms

Normalization of Post-Coordinated Terms

Answer: Compositionality


Glossary

Atomic Concept with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.:

Example: Colon has a unique concept identifier in SNOMED-CT and cannot be represented by combining two or more other codes from within the terminology.

Glossary:


Glossary1

Pre-coordinated Concept with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.:

Example: Colon Cancer is non-atomic, however it has a single unique identifier in SNOMED-CT, which means to the SNOMED that it represents a “single” concept.

Glossary:


Glossary2

Post-coordinated Concepts with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.:

Example: The concept “Status-Post CABG” is not a unique concept within the SNOMED-CT Reference Terminology.

Glossary:


Glossary3

Qualifier: with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary. A string which when added to a term changes the meaning of the term in a Temporal or Administrative sense. For example, “History of” or “Recurrent”.

Modifier: A string which when added to a term changes the meaning of the term in a Clinical sense. For example, clinical stage or severity of illness.

Ontology: An organization of concepts for which one can make a rational argument. Colloquially this term is used to describe a hierarchy constructed for a specific purpose. For example a hierarchy of Qualifiers would be a Qualifier Ontology.

Canonical Term: A preferred atomic or pre-coordinated term for a particular medical concept.

Glossary:


Glossary4

Content Normalization with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary. - When all the Pre-coordinated terms in the Vocabulary are mapped to the combinations of Atomic terms in the same Vocabulary, which can be said to be equivalent in meaning.

Glossary:


If we build it they will come field of dreams early 90 s

Standards with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.

Vocabulary Structure

Semantic Representation

Formalism for Content Representation

Formalism for Composition

Formalism for Medical Knowledge Representation

Reliable Set of Views

Vocabulary Messaging (HL7 CDA and Templates Conformant)

If We Build It, They Will Come Field of Dreams (Early 90’s)


Usability laboratory experience

Compositionality is Essential for a robust and clinically useful Document Retrieval Tool

Modifiers and Qualifiers provided the greatest Utility

The Interface Design is integral to the acceptance of the Search Engine

Designers must work to minimize Cognitive Overhead and potential sources of Disorientation.

Usability Laboratory Experience


Comparable data

SNOMED-CT useful Document Retrieval Tool

Description Logic-Based Terminology

Compositional System

~340,000 Concepts

~800,000 Terms

LBI version adds 400,000 Terms

Over 30,000,000 Indices to the SNOMED-CT Terminology

Comparable Data


Mayo foundation clinical perspective on comparable data

Compositional Systems useful Document Retrieval Tool


Compositional systems

Acute myocardial infarction of the anterolateral wall useful Document Retrieval Tool

Heart attack, Anterolateral cardiac wall, Acute

AMI, Anterolateral Wall

Acute MI of the Anterolateral Wall

Compositional Systems

  • - Myocardial infarction (disorder) [22298006]

    • - [has Finding Site] . Entire myocardium of anterolateral region (body structure) [190762001]

    • - [is Modified By] . Acute (qualifier value) [53737009]


An evaluation of the content coverage of snomed ct for clinical problem lists

By useful Document Retrieval Tool

Peter L. Elkin, MD1, Steven H. Brown, MD2, Casey Husser, MD1, Brent A. Bauer, MD1, Dietlind Wahner-Roedler, MD1, S. Trent Rosenbloom, MD2, Ted Speroff, PhD2

1. Mayo Foundation for Medical Education and Research

2. Vanderbilt University

An Evaluation of the Content Coverage of SNOMED-CT for Clinical Problem Lists


Methods

4,996 Most Common Unique Mastersheet Index Entries were Mapped to SNOMED-CT

Two expert reviewers (Consultants) independently graded the mappings (using the automated mappings plus a SNOMED-CT browser)

Disagreements were adjudicated by a third reviewer

Methods


Results
Results Mapped to SNOMED-CT


Results1

The sensitivity of SNOMED-CT without the use of composition was only 51.4%. Using the McNemar Chi-Square Test there was a significant difference between the sensitivity of SNOMED-CT with and without using composition (51.4% vs. 92.3%; p<0.001).

Results


Conclusions regarding medical knowledge representation using snomed ct

SNOMED-CT has good coverage of the terms used commonly in medical problem lists.

Improvements to synonymy and the addition of missing modifiers would lead to the greatest return on investment toward improved coverage of common problem statements.

Compositional expressions are required to exactly represent a significant portion of common problem statements (p<0.001).

Conclusions Regarding Medical Knowledge Representation using SNOMED-CT


Mayo foundation clinical perspective on comparable data

Representational Complexity medical problem lists.


Variable complexity
Variable Complexity medical problem lists.



Ambiguous representation

“Hepatoma Metastatic to the Lungs” medical problem lists.

Malignant neoplastic disease (disorder) [363346000]

Entire liver (body structure) [181268008]

Entire lung (body structure) [181216001]

Secondary malignant neoplastic disease (disorder) [128462008]

“Liver Cancer”  “Lung” or

“Lung Cancer”  “Liver”

Ambiguous Representation


Inter semantic relationships

Dx = (defconcept medical problem lists.Hepatoma Metastatic to the Lung

(and disease

(and (some Assoc-Morphology “Metastatic Neoplasm”)

(some Assoc-Topography “Lung”))

(and (some Assoc-Etiology “Malignant Neoplasm”)

(some Assoc-Topography “Liver”))))

Inter-Semantic Relationships


Generic rule

Dx = (defconcept Dxxxxxx medical problem lists.

(and disease

(and (some Assoc-Morphology x)

(some Assoc-Topography (at least 1 Topography {or t1, t2 ,t3, …tm (m1)}))

(and (some Assoc-Etiology y)

(some Assoc-Topography (at least 0 Topography {or t1, t2, t3, …tn (n1))))))

Generic Rule


Conceptual relativity

Level 1 - Diseases medical problem lists.

| Distance 1.0

Level 2 - Cardiovascular Diseases (2000 Siblings)

| Distance = (((256/2000) * (5-2)) * 1.0) = 0.384

Level 3 - Congestive Heart Failure (250 Siblings)

| Distance = (((6/250) * (5-3) * .384) = 0.0399

Level – 4 LV Systolic Dysfunction (5 Siblings)

| Distance = (((1/5) * (5-4) * 0.0399) = 0.008

Level 5 - LV Systolic Dysfunction, Class III HF (1 Sibling)

Generalization:

((ScT/Sp * (LevelT-Levelp)) * DistLevel –1)

Conceptual Relativity


Semantic distance from feature set recognition

Myocardial Infarction medical problem lists.

HasMorphology Infarct

HasFindingSite Myocarium

And

Heart Attack

HasMorphology Infarct

HasFindingSite Myocarium

Semantic Distance from Feature Set Recognition

Acute Myocardial Infarction

HasMorphology Infarct

HasFindingSite Myocarium

HasModifier Acute


Level one ontology

HEALTH LEVEL 7 medical problem lists.

REFERENCE INFORMATION MODEL

RIM_0100

released January 2001 reflects RIM changes through

Harmonization on 11/17/2000

Enitites

Acts (Services)

Participation

Roles

0..*

0..*

Message_control

Act

has_as_participant

Entity

1

1

type_cd : CS

Act_relationship

Role

participates_in

id : SET<II>

tmr : IVL<TS>

id : SET<II>

is_played_by

plays_a_role

type_cd : CS

type_cd : cc

note_text : ED

mood_cd : CS

Entity_name

type_cd : CC

is_source_of

effective_tmr : IVL<TS>

inversion_ind : BL

0..*

0..*

signature_cd : CV

is_source_for

has_source

0..1

0..1

type_cd : CC

determiner_cd : CS

Role-role relationships

Appointments &

has

addr : SET<AD>

is_target_for

for

sequence_nbr : INT

effective_tmr : IVL<TS>

1

1

1

1

function_cd : CD

importance_status_txt : ED

txt : ED

scheduling

telecom : SET<TEL>

priority_nbr : INT

nm : EN

1

1

1

1

0..*

0..*

awareness_cd : CV

qty

status_cd : CS

is_for

0..*

0..*

purpose_cd : CV

has

pause_qty : PQ

signature_txt : ED

telecom : SET<TEL>

activity_time : GTS

checkpoint_cd : CS

encounter_accommodation_cd : CV

Healthcare_finances

desc

0..*

0..*

1

1

critical_time : GTS

is_target_for

split_cd : CS

Billboard produced by:

has_target

status_cd : CS

status_cd : CS

confidentiality_cd : SET<CV>

Rochester Outdoor Advertising

join_cd : CS

sends

1..1

1..1

1

1

max_repeat_nmr : IVL<INT>

0..*

0..*

negation_ind : BL

shall_receive

1..*

1..*

interruptible_ind : BL

conjunction_cd : CS

priority_cd : SET<CV>

orderable_ind : BL

originates_in_context_of

1..*

1..*

Military_person

availability_dttm : TS

Healthcare_provider

Notary_public

military_branch_of_service_cd : CV

specialty_cd : CV

military_rank_nm : ST

notary_county_cd : CE

Act

Act

military_status_cd : CV

notary_state_cd : CE

Place

gps_txt : ST

position_txt

addr : AD

Health_chart

directions_txt

1

1

Financial_act

0..*

0..*

provides_context_for

Individual_healthcare_practitioner

has_an_assessment_of

effective_tmr : IVL<TS>

fellowship_field_cd : CE

reason_cd : CE

Medication

Act_context

Living_subject

graduate_school_nm : ON

Working_list

status_dttm

form_cd : CD

level_cd

birth_dttm : TS

graduation_dttm : TS

ownership_level_cd

route_cd : CD

Patient_encounter

deceased_dttm : TS

board_certified_ind : BL

dose_qty : PQ

Material

deceased_ind : BL

discharge_disposition_cd : CV

strength_qty : PQ

is_assessed_against

administrative_gender_cd : CE

Organization

form_cd : CV

acuity_level_cd : CV

rate_qty : PQ

Referral

organ_donor_ind : BL

danger_cd : CE

0..*

0..*

org_nm : SET<ON>

birth_encounter_ind : BL

dose_check_qty : PQ

Supply

multiple_birth_ind : BL

effective_tmr : IVL<TS>

authorized_visits_qty : REAL

standard_industry_class_cd : CE

status_reason_cd : CV

Consent

Health_chart_deficiency

method_cd : SET<CV>

Healthcare_facility

handling_cd : CE

Healthcare_benefit_product_policy

qty : PQ

desc : ED

addr : SET<AD>

classification_cd : CV

body_site_cd : SET<CD>

Diagnostic_related_group_definition

assessment_dttm : TS

licensed_bed_nbr : REAL

reason_txt : ED

Patient_billing_account

assignment_of_benefits_ind : BL

encounter_classification_cd : CV

substitution_cd : CV

desc : ED

base_rate_qty : MO

mobile_ind : BL

benefit_product_desc : ED

adjustment_cd : CV

practice_setting_cd : CV

Healthcare_benefit_coverage_item

level_cd : CV

capital_reimbursement_qty : MO

benefit_product_nm : ST

certification_required_ind : BL

valuables_desc : ED

type_cd : CV

cost_weight_qty : MO

service_category_cd : CV

1

1

benefit_product_type_cd : CE

current_unpaid_balance_qty : MO

1

1

pre_admit_test_ind : BL

major_diagnostic_category_cd : CE

service_cd : CE

is_site_for

is_utilized_during

Transportation

benefits_coordination_ind : BL

expected_insurance_plan_qty : REAL

Procedure

1

1

Document_service

source_cd : CV

operating_reimbursement_qty : MO

0..*

0..*

service_modifier_cd : CE

utilizes

Role_relationship

cob_priority_nbr : REAL

expected_payment_source_cd : CV

Message_interaction

special_courtesies_cd : CV

entry_site_cd : SET<CD>

completion_cd : CV

0..*

0..*

reimbursement_qty : MO

authorization_ind : BL

has_parts

type_cd : CC

combine_baby_bill_ind : BL

notice_of_admission_dttm : TS

valuables_location_desc : ED

method_cd : SET<CV>

set_id : II

standard_day_qty : PQ

network_ind : BL

effective_tmr : IVL<TS>

notice_of_admission_ind : BL

group_benefit_ind : BL

effective_tmr

has_as_target

1

1

body_site_cd : SET<CD>

storage_cd : CV

0..1

0..1

standard_total_charge_qty : MO

assertion_cd : CE

id : SET<II>

uses

patient_financial_class_cd : CV

mail_claim_party_cd : CE

version_nbr : INT

Person

trim_high_day_qty : PQ

is_communicated_as

covered_parties_cd : CE

status_cd : CS

price_schedule_id : II

release_information_cd : CE

copy_dttm : TS

Non_Person_living_subject

trim_low_day_qty : PQ

disability_cd : CE

qty : REAL

is_authorized_by

responsibility_cd : SET<CE>

report_of_eligibility_dttm : TS

status_cd : CS

origination_dttm : TS

ethnic_group_cd : CE

taxonomic_classification_cd : CE

quantity_qualifier_cd : CE

is_part_of

position_nbr : LIST<INT>

coverage_type_cd : CE

retention_ind : BL

has_as_source

race_cd : CE

breed_cd : CE

1

1

time_period_qualifier_cd : CE

defines

qty : PQ

agreement_type_cd : CE

signature_on_file_dttm : TS

ambulatory_status_cd : CV

strain_txt : ED

0..*

0..*

0..*

0..*

range_low_qty : PQ

certificate_txt : ED

policy_category_cd : CE

special_program_cd : CV

birth_order_nbr : INT

Diet

euthanasia_ind : BL

is_defined_by

range_high_qty : PQ

Observation

access_protocol_desc : ED

stoploss_limit_ind : BL

0..*

0..*

education_level_cd : CV

production_class_cd : CE

energy_qty : PQ

range_units_cd : CV

value : ANY

suspend_charges_ind : BL

Encounter_drg

living_arrangement_cd : CV

gender_status_cd : CE

carbohydrate_qty : PQ

eligibility_cd : CE

derivation_expr : ST

Inpatient_encounter

total_adjustment_qty : MO

marital_status_cd : CV

approval_ind : BL

policy_source_cd : CE

method_cd : SET<CV>

total_charge_qty : MO

religious_affiliation_cd : CV

confidential_ind : BL

length_of_stay_qty : PQ

eligibility_source_cd : CE

body_site_cd : SET<CD>

student_cd : CV

total_payment_qty : MO

cost_outlier_qty : MO

copay_limit_ind : BL

credit_rating_cd : CV

Access

interpretation_cd : SET<CS>

separate_bill_ind : BL

desc : ED

Clinical_document_header

0..1

0..1

addr : SET<AD>

bad_debt_recovery_qty : MO

grouper_review_cd : CE

gauge_qty : PQ

availability_status_cd : CV

Specimen

Champus_coverage

special_accommodation_cd : SET<CV>

grouper_version_id : II

bad_debt_transfer_qty : MO

entry_site_cd : CD

change_reason_cd : CV

body_site_cd : CE

Manufactured_material

handicapped_program_cd : CE

outlier_days_nbr : REAL

completion_status_cd : CV

body_site_cd : CD

outlier_reimbursement_qty : MO

non_avail_cert_on_file_ind : BL

expiration_dttm : TS

confidentiality_status_cd : CV

Schedule

1

1

Public_health_case

outlier_type_cd : CV

retirement_dttm : TS

lot_nbr : ST

content_presentation_cd : CV

status_cd : CS

station_id : II

detection_method_cd

document_creation_dttm : TS

communicates_in

slot_size_increment_qty

transmission_mode_cd

file_nm : ST

disease_imported_cd

last_edit_dttm : TS

is_communicated_by

Financial_transaction

1

1

reporting_priority_cd : CE

manages

results_report_dttm : TS

extended_qty : MO

Practitioner_Certifier

Unmapped_financial_classes

storage_status_cd : CV

0..*

0..*

fee_schedule_cd : CE

board_certification_type_cd : CV

(from RIM_Healthcare_finances)

Employee_Employer

Person_Language

transcription_dttm : TS

insurance_qty : MO

certification_dttm : TS

document_change_cd : CV

Patient_Provider

posting_dttm : TS

addr : SET<AD>

recertification_dttm : TS

Outbreak

version_nbr : INT

hazard_exposure_txt : ED

qty : MO

1

1

residency_field_cd : CE

version_dttm : TS

tmr

job_class_cd : CV

transaction_batch_id : II

is_specified_by

job_title_nm : ST

unit_qty : MO

is_managed_by

telecom : SET<TEL>

unit_cost_qty : MO

0..*

0..*

Insurance_certification

0..*

0..*

1

1

has_coverage_affirmed_by

Billing_information_item

protective_equipment_txt : ED

Guarantor_contract

0..*

0..*

specifies_ability_in

Resource_slot

certification_duration_qty : PQ

salary_qty : MO

condition_cd : CE

billing_hold_ind : BL

Language_ability

effective_tmr : IVL<TS>

status_cd : CS

salary_type_cd : CV

occurrence_cd : CE

Preauthorization

Practitioner_provider

billing_media_cd : CE

affirms_insurance_coverage_for

mode_cd : CV

id : II

time_slot : GTS

status_cd : CS

occurrence_dttm : TS

charge_adjustment_cd : CE

authorized_encounters_qty : REAL

position_cd : CV

proficiency_level_cd : CV

insurance_verification_dttm : TS

job_cd : CE

Container

0..*

0..*

occurrence_span_cd : CE

contract_duration_cd : CE

authorized_period_begin_tmr : IVL<TS>

primary_care_ind : BL

modification_dttm : TS

occurrence_span_from_dttm : TS

capacty_qty : PQ

is_sited_at

contract_type_cd : CE

id : II

Device

Clinical_document

non_concur_cd : CE

occurrence_span_thru_dttm : TS

height_qty : PQ

effective_tmr : IVL<TS>

issued_dttm : TS

manufacturer_model_nm : ST

non_concur_effective_dttm : TS

quantity_nbr : REAL

diameter_qty : PQ

Encounter_facility_association

interest_rate_nbr : REAL

requested_dttm : TS

last_calibration_dttm : TS

0..1

0..1

penalty_qty : MO

quantity_type_cd : CV

barrier_delta_qty : PQ

effective_tmr : IVL<TS>

periodic_payment_qty : MO

restriction_desc : ED

software_nm : ST

report_of_eligibility_dttm : TS

value_amt

bottom_delta_qty : PQ

is_used_by

authorizes

status_cd : CS

priority_ranking_cd : CV

local_remote_control_state_cd : CE

status_cd : CS

value_cd : CE

report_of_eligibility_ind : BL

separator_type_cd : CD

transfer_reason_cd : CV

alert_level_cd : CE

status_change_dttm : TS

cap_type_cd : CD

0..*

0..*

Level One Ontology

Entity

Entity

Role

Role

Participation

Participation

Act

Relationship

Act

Relationship

Role

Relationship

Role

Relationship


Level two ontology
Level Two Ontology medical problem lists.


Level three ontology

Fully Encoded Health Record medical problem lists.

Consistent with the Level One and Two Ontologies for Health

Compositional Expressions are assigned Automagically

No Human effort is needed so that the practice of Medicine does not have to be shaped around information systems but instead the Information Systems can unobtrusively improve Patient Care.

Example…………..

Level Three Ontology