Controlled Vocabularies for Capturing Clinical Encounters

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Presentation transcript:

Controlled Vocabularies for Capturing Clinical Encounters James J. Cimino, M.D. Department of Medical Informatics Columbia University

Why Use a Controlled Vocabulary? Efficient storage Anticipatory data capture Record abstraction for billing, reporting, research... Automated decision support

What are the Options? ICD-9-CM ICD-10 ICPC NANDA DSM-IV MeSH UMLS Gabrieli Nomenclature Read Clinical Codes SNOMED International

Why Aren’t We Using Them? Abstracting systems provide insufficient detail Comprehensive vocabularies may be too expressive Organizational mismatch between developers and users Adaptation of legacy systems to standard vocabularies

Possible Solution: Collaborative Vocabulary Construction Users contribute to design and content Content drawn from legacy systems Contributions made via the Internet Updates in near-real time

The InterMed Collaboratory HPCC Project from NLM Multiple investigator groups Columbia University Harvard University Stanford University University of Utah Net-based collaborative research

The Collaborative Approach Agree on a domain of interest Model the domain Hierarchies Semantic attributes Contribute content

Browsers and Editors Ontolingua K-Rep AccessMED Web MED Browser

Contributions to the InterMed MED Find a class for your term in the Web browser Click on the “Add” button Enter the name Add other parents and children Refine semantic attributes Click on “UMLS” button

Outcomes Exploration of Internet-based vocabulary collaboration Expansion of domain coverage Vocabulary that fits user needs Contributions to the UMLS http://www.cpmc.columbia.edu/intermed_proj.html

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