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 Atoms versus molecules A formal methodology is needed Structure must not limit size

2: Concept Orientation Concepts, not terms One meaning (nonvague) No more than one meaning (nonambiguous) Higher-level  ambiguous One concept per meaning (nonredundant) May have multiple context-dependent meanings

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 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 Needed for tree walking Needed for inferencing Needed for "essence" Example: diseases of the liver which also involve the kidney

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

NEC

7: Reject "Not Elsewhere Classified" Can never have a formal definition Vocabulary changes induce semantic drift

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 Multiple views for multiple purposes Must not lead to inconsistency

A B C D E F H G I

A B C D E F H G I A B C D E F (G,H) (I)

A D E F H G I A B C D E F H G I

A B C D E F H G I A B C D E F H G I

A B C D F I E H G A B C D E F H G I E H G

A B C D E F H G I E A B C D E F H G I

A B C D E F H G I E A B C D E F H G I

10: Representing Context Needed: a grammar to show usage "What is sensible to say" Consider modeling "events"

Controlled Medical Vocabulary Definitional Knowledge (how concepts define each other) Body Site Joint is -a Finding Joint Swelling Pathologic Function Swelling is -a Right Knee is -a has- abnormality has- site

Controlled Medical Vocabulary Definitional Knowledge (how concepts define each other) Assertional Knowledge (how concepts combine) Body Site Finding modifies Joint is -a Finding Joint Swelling Pathologic Function Swelling is -a Right Knee is -a has- abnormality has- site

Controlled Medical Vocabulary Definitional Knowledge (how concepts define each other) Assertional Knowledge (how concepts combine) Contextual Knowledge (how concepts are used) Body Site Finding Physical Exam Progress Note Hospital Admission part-of modifies Joint is -a Finding Joint Swelling Pathologic Function Swelling is -a Right Knee is -a has- abnormality has- site

Electronic Medical Record Controlled Medical Vocabulary Definitional Knowledge (how concepts define each other) Assertional Knowledge (how concepts combine) Contextual Knowledge (how concepts are used) Body Site Finding Physical Exam Progress Note Hospital Admission part-of modifies Hospital Admission Progress Note Physical Exam [Joint Swelling [Right Knee]] Joint is -a Finding Joint Swelling Pathologic Function Swelling is -a Right Knee is -a has- abnormality has- site

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

11: Graceful Evolution Bad reasons: - Redundancy - Major name changes - Code reuse - Changed codes

11: Graceful Evolution Good reasons: - Simple addition - Refinement - Precoordination - Disambiguation - Obsolescence - Discovered redundancy - Minor name changes

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 Redundancy Pneumonia Finding Left Lower Lobe

12: Recognize Redundancy Left Lower Lobe Pneumonia Pneumonia Finding Left Lower Lobe

12: Recognize Redundancy Left Lower Lobe Pneumonia is-a: Pneumonia Pneumonia Finding Left Lower Lobe

12: Recognize Redundancy Left Lower Lobe Pneumonia is-a: Pneumonia has-site: Left Lower Lobe Pneumonia Finding Left Lower Lobe

12: Recognize Redundancy Left Lower Lobe Pneumonia is-a: Pneumonia has-site: Left Lower Lobe participates-in: Finding Pneumonia Finding Left Lower Lobe

12: Recognize Redundancy Left Lower Lobe Pneumonia is-a: Pneumonia has-site: Left Lower Lobe participates-in: Finding Pneumonia Finding Left Lower Lobe

What's Here Today? 1: Content 4: Nonsemantic Concept Identifiers 8: Multiple Granularities 10: Multiple Consistent Views

What May Be Here Soon? 2: Concept Orientation 3: Concept Permanence 5: Polyhierarchy 6: Formal Definitions 7: Reject "Not Elsewhere Classified"

What's Left? 10: Representing Context 11: Graceful Evolution 12: Recognize Redundancy

Keep Your Eye on the Goal Recording primary clinical information Multipurpose (re-use) Sharing data Maintenance