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Controlled Terminology in Clinical Practice

A comprehensive guide to controlled terminology in clinical practice, including definitions, uses, features, and examples of terminologies such as ICD-9/10-CM, SNOMED, MeSH, and UMLS.

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Controlled Terminology in Clinical Practice

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  1. Controlled Terminology in Clinical Practice James J. Cimino, M.D. Department of Medical InformaticsColumbia University

  2. Definition Terminology: A finite, enumerated set of terms intended to convey information unambiguously

  3. Some General Classes of Terms • Diagnostic Procedures • Therapeutic Procedures • Medications • Diagnoses • Findings • Organisms • Anatomy

  4. Uses of Terminology • Storing in database • Querying database • Transfering data • Billing • Monitoring data

  5. Term - Basic Features • Unique Identifier (Code) • 12345 • Official Name • aspirin • Synonyms • ASA • Translations • NDC: 5502; UMLS: C0004057

  6. Term - Advanced Features • Classes • antipyretic, anti-inflammatory, analgesic • Semantic Links • CAUSES: gastritis • TREATS: arthritis • Attributes • UNITS: mg

  7. Desiderata for Terminology • Content • Concept Orientation • Nonredundant • Nonambiguous • Permanent • Nonsemantic Concept Identifiers • Polyhierarchy • Semantic relationships

  8. heart disease lung disease heart attack arrhythmia pneumonia Strict Hierarchy disease

  9. heart disease lung disease infectious disease heart attack arrhythmia pneumonia Polyhierarchy disease

  10. specimen test substance is_a is_a is_a serum potassium Semantic Network has_specimen measures_substance serum potassium test

  11. ICD-9/10 and -CM • 9th International Classification of Diseases • WHO for collecting health statistics • Clinical Modifications added • 10th edition • Clinical modifications under construction • Strict hierarchy • Synonyms and “index” terms • Code determines place in hierarchy

  12. ICD9-CM Examples ------Diseases----- 003. @ OTHER SALMONELLA INFECTIONS 003.0 SALMONELLA GASTROENTERITIS 003.2 @ LOCALIZED SALMONELLA INFECTIONS 003.20 LOCALIZED SALMONELLA INFECTION, UNSPECIFIED 003.21 SALMONELLA MENINGITIS 003.29 OTHER LOCALIZED SALMONELLA INFECTIONS ------Procedures----- 01. @ INCISION AND EXCISION OF SKULL, BRAIN,... 01.0 @ CRANIAL PUNCTURE 01.01 CISTERNAL PUNCTURE 01.09 OTHER CRANIAL PUNCTURE

  13. SNOMED • Systematized Nomenclature of Medicine • College of American Pathologists • Organized into axes • Synonyms • Assemble complex terms from axes • SNOMED-RT (Reference Terminology) under development

  14. SNOMED - Axes • D - Diseases • C - Drugs • F - Function • L - Living Organisms • X - Manufacturers • G - Modifiers • M - Morphology • J - Occupations • A - Physical Agents • P - Procedures • S - Social Context • T - Topography

  15. SNOMED - Examples "D3-15000" "01" "Myocardial infarction, NOS" "(T-32020) (M-54700)" "D3-15000" "02" "Infarction of heart, NOS" "(T-32020) (M-54700)" "D3-15000" "02" "Cardiac infarction, NOS" "(T-32020) (M-54700)” "D3-15000" "02" "Heart attack, NOS” "(T-32020) (M-54700)" "D3-15010" "01" "Microinfarct of heart” "(T-32000) (M-54701)” "C-C137A" "01" "Bufferin Analgesic Tablets" "C-C137B" "01" "Bufferin Analgesic Caplets" "M-54700" "01" "Infarct, NOS" “M-54700" "02" "Infarction, NOS" "M-54700" "05" "Infarcted" "M-54701" "01" "Focal infarct" "M-54701" "02" "Microscopic infarct" "S-10120" "01" "Mother, NOS"

  16. MeSH • Medical Subject Headings • National Library of Medicine • Indexing the medical literature • Multiple hierarchy • Synonyms

  17. MeSH Example D011014: Pneumonia D018410: Pneumonia, Bacterial D007877: Legionnaires' Disease D011018: Pneumonia, Pneumococcal D011019: Pneumonia, Mycoplasma D009175: Mycoplasma Infections D011002: Pleuropneumonia, Contagious D011022: Pneumonia, Rickettsial D011023: Pneumonia, Staphylococcal D001996: Bronchopneumonia D009956: Ornithosis D011001: Pleuropneumonia D011015: Pneumonia, Aspiration D011017: Pneumonia, Lipid D011020: Pneumonia, Pneumocystis carinii D011024: Pneumonia, Viral

  18. Nursing Terminologies

  19. UMLS • Unified Medical Language System • National Library of Medicine • Metathesaurus groups terms under single concept id • No new hierarchy • Translation of terms

  20. Metathesaurus • 80+ sources • 1,358,891 strings • 626,893 concepts • Strings have attributes • Concepts have attributes, including Relations

  21. Concept Lexical group String String Concept Lexical group Lexical group String String String String Metathesaurus Lexical group String String

  22. Metathesaurus - MRCON C0153957|ENG|P|L0180790|PF|S1084242|benign neoplasm of heart C0153957|ENG|P|L0180790|VC|S0245316|Benign neoplasm of heart C0153957|ENG|P|L0180790|VO|S1446737|Benign neoplasm of heart, NOS C0153957|ENG|S|L0524277|PF|S0599118|Benign tumor of heart C0153957|ENG|S|L0524278|PF|S0599510|Benign tumour of heart C0153957|ENG|s|L0018787|PF|S0900815|Heart <3> C0153957|ENG|s|L0018787|VO|S0047194|Heart C0153957|GER|P|L1258174|PF|S1500120|Gutartige Neubildung: Herz

  23. Metathesaurus - MRSO C0153957|L0018787|S0047194|ICD10|PS|D15.1|3| C0153957|L0018787|S0900815|MTH|MM|U003158|0| C0153957|L0180790|S0245316|ICD10|PX|D15.1|3| C0153957|L0180790|S0245316|ICD99|PT|212.7|0| C0153957|L0180790|S0245316|RCD98|SY|B727.|3| C0153957|L0180790|S1084242|MTH|PN|U001287|0| C0153957|L0180790|S1446737|SNMI98|PT|D3-F0100|3| C0153957|L0524277|S0599118|RCDAE|PT|B727.|3| C0153957|L0524278|S0599510|RCD98|PT|B727.|3| C0153957|L1258174|S1500120|DMDICD|PT|D15.1|1|

  24. Metathesaurus - MRSTY C0153957|T191|Neoplastic Process|

  25. Metathesaurus - MRREL C0002871|CHD|C0002891|isa|MSH99|MTH|| C0002871|CHD|C0002892||CSP98||| C0002871|CHD|C0002893||RCD98||| C0002871|RB|C0221016||MTH|MTH|| C0002871|RL|C0002886|mapped_to|SNMI98|SNMI98||

  26. MED • Medical Entities Dictionary • CPMC • Multiple hierarchy • Synonyms • Translations • Semantic links • Attributes • 60,000 concepts

  27. Central Controlled Vocabulary

  28. Substance Laboratory Specimen Event Chemical Anatomic Substance Plasma Specimen Diagnostic Procedure Substance Sampled Plasma Laboratory Test Laboratory Procedure Has Specimen Carbo- hydrate Bioactive Substance Part of Glucose Substance Measured MED Structure Medical Entity CHEM-7 Plasma Glucose

  29. What do we want to do with these data? • Primary use • Other patient care reuse • Financial • Management • Information transfer (messaging) • Clinical research • Expert systems • Information retrieval • Vocabulary discovery

  30. Primary Use of Data • Spit back the reports

  31. Other Patient Care Reuse • Summaries • Comparability of data • Trending of data • Time representation

  32. Retrieving Results Individually K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 K#3 = 2.6 K#1 K#2 K#3

  33. K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 K#3 = 2.6 K Retrieving Results by Class K#1 K#2 K#3

  34. Lab Display Lab Test Intravascular Glucose Test Case Study:Summaries in the MED Chem20 Display Fingerstick Glucose Test Serum Glucose Test Plasma Glucose Test

  35. DOP Summary

  36. WebCIS Summary

  37. Financial • Reporting • Accounting • Inventory

  38. Case Study:Orderable Tests • HCFA won’t pay for lab batteries • Individual tests now treated as orderable procedures • Need to appear in database as procedures and as tests

  39. Case Study:Orderable Tests Lab Procedure Lab Test Intravascular Glucose Test Chem 7 Fingerstick Glucose Test Serum Glucose Test Plasma Glucose Test

  40. Case Study:Orderable Tests Lab Procedure Lab Test Orderable Test Intravascular Glucose Test Chem 7 Fingerstick Glucose Test Serum Glucose Test Plasma Glucose Test

  41. Management • Quality assurance • Case management

  42. Information Transfer (messaging) • Transfer to repository • State reporting

  43. Clinical Research • Epidemiology - symptoms, incidence, history of disease • Outcomes - effectiveness of therapy, ideal length of stay

  44. Expert systems • Knowledge base construction • Case abstraction • Automated decision support

  45. Terminology and Automated Decision Support • Data monitor checks for triggering conditions • Medical Logic Modules decide if warning conditions are present • Message sent to appropriate channel • Example: Tuberculosis culture result

  46. Decision Support Example: TB • Monitors for delayed culture results • Sends message if result not equal to the code “No growth” • One day, dozens of alerts about positive results but no organism was reported • What happened?

  47. How the Lab Fooled the Alert • Alert looked for results = “No Growth” • Lab started reporting “No Growth to Date” • “No Growth to Date” = “No Growth” • Solution: Use the controlled terminology to map all No-Growth-like lab terms into a single class, and have the alert logic refer to the class.

  48. How We Outsmarted the Lab(Before) Medical Logic Module No Growth to Date No Growth

  49. “No Growth” Results No Growth after 24 Hours No Growth after 48 Hours No Growth after ... No Growth after 72 Hours How We Outsmarted the Lab(After) Medical Logic Module No Growth to Date No Growth

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