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The Needs for Coding and Classification Systems

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. Multiple Needs. Electronic record keeping Decision support

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The Needs for Coding and Classification Systems

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  1. 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

  2. Multiple Needs • Electronic record keeping • Decision support • Reviewing patient data • Alerts and reminders • Access to on-line information resources • Billing • Management • Case management • QA • Clinical research • Epidemiology

  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. Some Desired Characteristics • Synonymy • Concept-oriented (one term = one meaning) • Clear semantics • No limits on number, depth, breadth of terms • Multiple hierarchies • Multiple granularity • Sensible compositionality • Interchangeable constructs

  6. Synonymy • Many names for the same concept is good... • ... but they must be recognized as synonyms • This is easy

  7. Concept-Oriented: One Term = One Meaning) • No ambiguity • Concept permanence • Easy to say, not so easy to do

  8. Clear Semantics • What does the term really mean? • How is it meant to be used? • Example: Penicillin • The chemical? • The pill? • Example: Gunshot • The act? • The injury?

  9. Gunshot in atrium.

  10. No Limits on:Number, Depth, Breadth of Terms • No limits imposed by coding scheme • No limits posed by computer limitations

  11. Multiple Hierarchies • Medicine is multihierarchic • Organ system vs. etiology • Macro vs. micro • Each user of data will want their own view

  12. Multiple Granularity • Clinical users will want fine-grained terms • Epidemiologists and payors will want coarse-grained terms • Decision support and research will want something in between

  13. Sensible Compositionality • Users will always need to record at a finer level of detail • Need to be able to combine coded terms • Need rules for combining them • Need to be able to recognize synonymy

  14. Finding Pneumonia Left Lower Lobe Interchangeable Constructs Left Lower Lobe Pneumonia is-a: Pneumonia has-site: Left Lower Lobe participates-in: Finding

  15. NEC

  16. (In)adequacy of Current Systems ICD9-CM SNOMED CPT4 Read Gabrieli Synonymy Concept-oriented Clear semantics No limits Multhierarchies Granularity Compositionality Interchangeable - + - + +/- - + - + ? - - - ? ? - - + + - - - - + - - + - + - - + - + - - - - - -

  17. A Model for the Future • Meaningless codes • Semantic network • Grammar • Definitional information • Reject "Other" terms

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