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Desirable Clinical Terminology Characteristics and Present Adherence. James J. Cimino. Defining the Need for a Controlled Vocabulary. Recording primary clinical information Multipurpose (re-use) Sharing data Maintenance. 1: Content. Must seek to be provide breadth and depth

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defining the need for a controlled vocabulary
Defining the Need for a Controlled Vocabulary
  • Recording primary clinical information
  • Multipurpose (re-use)
  • Sharing data
  • Maintenance
1 content
1: Content
  • Must seek to be provide breadth and depth
  • Atoms versus molecules
  • A formal methodology is needed
  • Structure must not limit size
2 concept orientation
2: Concept Orientation
  • Concepts, not terms
  • One meaning (nonvague)
  • No more than one meaning (nonambiguous)
  • Higher-level ¹ ambiguous
  • One concept per meaning (nonredundant)
  • May have multiple context-dependent meanings
3 concept permanence
3: Concept Permanence
  • Old concepts can't be deleted
  • Example: non-A-non-B hepatitis
  • Names can be changed as long as meaning doesn't change (retronyms)
  • Example: transvenous pacemaker
4 nonsemantic concept identifiers
4: Nonsemantic Concept Identifiers
  • Don't use the name
  • Don't use a code that will run out of room
  • Don't use a hierarchical code
  • Meaningless integer (+/- check digit)
5 polyhierarchy
5: Polyhierarchy
  • Needed for tree walking
  • Needed for inferencing
  • Needed for "essence"
  • Example: diseases of the liver which also involve the kidney
6 formal definitions
6: Formal Definitions
  • Support understanding
  • Support maintenance
  • Structured and controlled (not narrative)
  • Represented through relationships within the vocabulary
  • Defintional versus assertional knowledge
  • Additional effort minimal and will pay off
7 reject not elsewhere classified
7: Reject "Not Elsewhere Classified"
  • Can never have a formal definition
  • Vocabulary changes induce semantic drift
8 multiple granularities
8: Multiple Granularities
  • Different levels for different purposes
  • Uncertainty is allowed, imprecision is not
  • We must be precise about our uncertainty
9 multiple consistent views
9: Multiple Consistent Views
  • Multiple views for multiple purposes
  • Must not lead to inconsistency
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10 representing context
10: Representing Context
  • Needed: a grammar to show usage
  • "What is sensible to say"
  • Consider modeling "events"
slide22

Controlled Medical Vocabulary

Definitional Knowledge

(how concepts define each other)

Pathologic

Function

Finding

Body Site

is -a

has-

site

is -a

is -a

Joint

Joint

Swelling

Swelling

is -a

has-

abnormality

Right Knee

slide23

Controlled Medical Vocabulary

Assertional Knowledge

Definitional Knowledge

(how concepts combine)

(how concepts define each other)

Pathologic

Function

Finding

Body Site

modifies

is -a

has-

site

Finding

Body Site

is -a

is -a

Joint

Joint

Swelling

Swelling

is -a

has-

abnormality

Right Knee

slide24

Controlled Medical Vocabulary

Contextual Knowledge

Assertional Knowledge

Definitional Knowledge

(how concepts are used)

(how concepts combine)

(how concepts define each other)

Pathologic

Function

Finding

Body Site

part-of

Physical Exam

Finding

modifies

is -a

has-

site

Finding

Body Site

part -of

is -a

is -a

Joint

Joint

Swelling

Hospital

Progress

Swelling

is -a

Admission

Note

has-

abnormality

part-of

Right Knee

slide25

Controlled Medical Vocabulary

Contextual Knowledge

Assertional Knowledge

Definitional Knowledge

(how concepts are used)

(how concepts combine)

(how concepts define each other)

Pathologic

Function

Finding

Body Site

part-of

Physical Exam

Finding

modifies

is -a

has-

site

Finding

Body Site

part -of

is -a

is -a

Joint

Joint

Swelling

Hospital

Progress

Swelling

is -a

Admission

Note

has-

abnormality

part-of

Right Knee

Hospital Admission

Progress Note

Physical Exam

Progress Note

Progress Note

[Joint Swelling [Right Knee]]

Electronic Medical Record

11 graceful evolution
11: Graceful Evolution
  • Will always need to fix mistakes
  • Medical knowledge will grow
  • Bad reasons
  • Good reasons
11 graceful evolution1
11: Graceful Evolution
  • Bad reasons:

- Redundancy

- Major name changes

- Code reuse

- Changed codes

11 graceful evolution2
11: Graceful Evolution
  • Good reasons:

- Simple addition

- Refinement

- Precoordination

- Disambiguation

- Obsolescence

- Discovered redundancy

- Minor name changes

12 recognize redundancy
12: Recognize Redundancy
  • Synonyms are good
  • Redundant concepts are bad
  • Redundant expressions are inevitable
  • Example:

- Year 1: "Pneumonia", "Left Lower Lobe"

- Year 2: "Left Lower Lobe Pneumonia"

12 recognize redundancy1

Finding

Pneumonia

Left Lower Lobe

12: Recognize Redundancy
12 recognize redundancy2

Finding

Pneumonia

Left Lower Lobe

12: Recognize Redundancy

Left Lower Lobe Pneumonia

12 recognize redundancy3

Finding

Pneumonia

Left Lower Lobe

12: Recognize Redundancy

Left Lower Lobe Pneumonia

is-a: Pneumonia

12 recognize redundancy4

Finding

Pneumonia

Left Lower Lobe

12: Recognize Redundancy

Left Lower Lobe Pneumonia

is-a: Pneumonia

has-site: Left Lower Lobe

12 recognize redundancy5

Finding

Pneumonia

Left Lower Lobe

12: Recognize Redundancy

Left Lower Lobe Pneumonia

is-a: Pneumonia

has-site: Left Lower Lobe

participates-in: Finding

12 recognize redundancy6

Finding

Pneumonia

Left Lower Lobe

12: Recognize Redundancy

Left Lower Lobe Pneumonia

is-a: Pneumonia

has-site: Left Lower Lobe

participates-in: Finding

what s here today
What's Here Today?

1: Content

4: Nonsemantic Concept Identifiers

8: Multiple Granularities

10: Multiple Consistent Views

what may be here soon
What May Be Here Soon?

2: Concept Orientation

3: Concept Permanence

5: Polyhierarchy

6: Formal Definitions

7: Reject "Not Elsewhere Classified"

what s left
What's Left?

10: Representing Context

11: Graceful Evolution

12: Recognize Redundancy

keep your eye on the goal
Keep Your Eye on the Goal
  • Recording primary clinical information
  • Multipurpose (re-use)
  • Sharing data
  • Maintenance