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Clinical Vocabularies

Clinical Vocabularies. James J. Cimino, M.D. Columbia University. March, 1997: The Needs for Coding and Classification Systems. Multiple needs for controlled vocabulary Capturing clinical data for multiple purposes (In)adequacy of current systems Some desired characteristics

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Clinical Vocabularies

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  1. Clinical Vocabularies James J. Cimino, M.D. Columbia University

  2. March, 1997: The Needs for Coding and Classification Systems • Multiple needs for controlled vocabulary • Capturing clinical data for multiple purposes • (In)adequacy of current systems • Some desired characteristics • A model for the future

  3. Capturing Clinical Data for Multiple Purposes: Now Recode Patient Data Collect Patient Data Collect Patient Data Financial Database Clinical Repository Research Database

  4. Capturing Clinical Data for Multiple Purposes: Future Recode Patient Data Collect Patient Data Collect Patient Data Financial Database Clinical Repository Research Database

  5. Concept Orientation • One meaning meaning per code • Clear semantics • Meaning never changes • Concept permanence

  6. Structural Aspects: Don’ts • Don’t limit breadth or depth of hierarchy • Don’t limit to a strict hierarchy • Don’t put meaning in the codes

  7. NEC

  8. Content: Do’s • Do strive for content that matches the needs of the primary creators of the data • Do develop a feedback mechanism to include creators and users in content development • Do develop a timely, concept-oriented update process

  9. Lessons to Learn • ICD - Not! • SNOMED • LOINC

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