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The Needs for Coding and Classification Systems

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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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