Concept addition from Concept addition from conception to deliveryconception to delivery

OrOrWhy does it take so @#$% long?Why does it take so @#$% long?

You can’t always get what you wantYou can’t always get what you want

Not all medical terms can or should be Not all medical terms can or should be represented “as is” in SNOMED represented “as is” in SNOMED The terminology should not aid and abet the The terminology should not aid and abet the

use of imprecise, inaccurate, or erroneous use of imprecise, inaccurate, or erroneous termsterms

Not all nuances of medical circumstances can Not all nuances of medical circumstances can be captured and defined within the be captured and defined within the nomenclaturenomenclature

Over-reliance on precoordination invites Over-reliance on precoordination invites combinatorial explosion and limits expressivitycombinatorial explosion and limits expressivity

...but if you try sometimes, you can ...but if you try sometimes, you can get what you needget what you need

The requirements of a controlled medical The requirements of a controlled medical nomenclature restrict the addition of nomenclature restrict the addition of contentcontent

My job is to determine what content can My job is to determine what content can be added, and to add it in a form that does be added, and to add it in a form that does not introduce error or ambiguity to the not introduce error or ambiguity to the nomenclaturenomenclature

GoalsGoals

Avoid adding redundant or duplicate Avoid adding redundant or duplicate concepts to SNOMEDconcepts to SNOMED

Avoid adding ambiguous, obsolete, or Avoid adding ambiguous, obsolete, or incorrect terms as fully specified namesincorrect terms as fully specified names

Accurately define all new conceptsAccurately define all new concepts

Preadmission questions Preadmission questions

Do we need this concept?Do we need this concept? What does the concept mean?What does the concept mean? In what context will the concept be used?In what context will the concept be used? Can the concept be defined in SNOMED?Can the concept be defined in SNOMED?

Where’s Waldo?Where’s Waldo?

Does SNOMED already contains the concept, Does SNOMED already contains the concept, sometimes under another wording, or a usable sometimes under another wording, or a usable equivalent?equivalent?

Ex: request for UroabdomenEx: request for Uroabdomen SNOMED already has an equivalent concept, Urine SNOMED already has an equivalent concept, Urine

ascites, not found by searching for uroabdomenascites, not found by searching for uroabdomen Adding Uroabdomen would create redundancyAdding Uroabdomen would create redundancy Request addition of Uroabdomen as synonym insteadRequest addition of Uroabdomen as synonym instead

Say what?Say what?

In a controlled medical terminology, each concept In a controlled medical terminology, each concept must represent a single idea, and the concept must represent a single idea, and the concept FSN should clearly state that idea…BUTFSN should clearly state that idea…BUT

Human and veterinary medical language Human and veterinary medical language contains many terms whose meaning is not contains many terms whose meaning is not evident from the wording or which convey evident from the wording or which convey multiple meaningsmultiple meanings Downer cowDowner cow White line diseaseWhite line disease Overeating diseaseOvereating disease

What this means:What this means:

Even “accepted” medical terms must often Even “accepted” medical terms must often be translated, not transcribed, into be translated, not transcribed, into SNOMEDSNOMED

Just because “the clinician said so” does Just because “the clinician said so” does not mean SNOMED will—or can--“say so”not mean SNOMED will—or can--“say so”

Say what you mean…Say what you mean…

If commonly accepted term is ambiguous, If commonly accepted term is ambiguous, but conveys a commonly accepted but conveys a commonly accepted meaning:meaning:

=> add concept=> add concept=> give concept unambiguous FSN=> give concept unambiguous FSN=> add common name as description=> add common name as description

Example 1:Example 1:

Sweeney Sweeney = neurogenic atrophy of shoulder muscles= neurogenic atrophy of shoulder muscles

Mean what you say:Mean what you say:

If commonly used medical term conveys If commonly used medical term conveys more than one meaning:more than one meaning:

=> create separate concepts for each => create separate concepts for each meaningmeaning

=> give each concept unambiguous => give each concept unambiguous FSNFSN

=> assign commonly used term as => assign commonly used term as synonym for each conceptsynonym for each concept

Example 2Example 2

Overeating diseaseOvereating disease= Type C Enterotoxemia = Type C Enterotoxemia = Type D Enterotoxemia = Type D Enterotoxemia = Grain Overload = Grain Overload

Saying 1 + 2 to mean 3Saying 1 + 2 to mean 3

If common term has complex meaning that If common term has complex meaning that can be best be captured by post-can be best be captured by post-coordinating existing conceptscoordinating existing concepts=> Deny concept request=> Deny concept request

=> Supply guidance to use of existing => Supply guidance to use of existing SNOMED conceptsSNOMED concepts

Example 3Example 3Pigeon feverPigeon fever misleading name—pigeons do not get or carry itmisleading name—pigeons do not get or carry it variable presentation—+/- pectoral abscessvariable presentation—+/- pectoral abscess

= Abscess of pectoral region 76035004= Abscess of pectoral region 76035004 + Causative agent Corynebacterium + Causative agent Corynebacterium

pseudotuberculosispseudotuberculosis OROR= Infection due to Corynebacterium = Infection due to Corynebacterium

pseudotuberculosispseudotuberculosis

Say…what did you mean?Say…what did you mean?

Requested term obscure, outdated, Requested term obscure, outdated, inherently vague or meaning is impossible inherently vague or meaning is impossible to determine from information givento determine from information given

seek clarification from requestorseek clarification from requestor determine if concept warranteddetermine if concept warranted

Just the facts, ma’amJust the facts, ma’am

When requesting a concept, you may be When requesting a concept, you may be asked to:asked to:

Seek clarification from a clinician Seek clarification from a clinician Supply background information Supply background information Explain the concept’s projected useExplain the concept’s projected use Discuss whether existing SNOMED Discuss whether existing SNOMED

concept(s) can be used insteadconcept(s) can be used instead Accept a refusal Accept a refusal

Request: MyelocytomaRequest: Myelocytoma

Problem: Problem: Myelocytoma can refer toMyelocytoma can refer to• Multiple myelomaMultiple myeloma• Chronic myelogenous leukemiaChronic myelogenous leukemia• A discrete tumor esp. of fowl, composed of A discrete tumor esp. of fowl, composed of

myelocytesmyelocytes

Need to know: which meaning is intendedNeed to know: which meaning is intended

Request: Proliferative thrombovascular Request: Proliferative thrombovascular necrosisnecrosis

Problem: Problem: References lackingReferences lacking

Need to know:Need to know:--is this an accepted medical term?--is this an accepted medical term?--what is the pathophysiology?--what is the pathophysiology?--what is the etiology, if known?--what is the etiology, if known?

Request: Delayed weaningRequest: Delayed weaning

Problem: Problem: Context unclearContext unclear• Procedure or finding? Procedure or finding? • If finding—necessarily abnormal? If finding—necessarily abnormal?

Need to know: context, to determine Need to know: context, to determine hierarchy to which concept belongshierarchy to which concept belongs

Request: RingwombRequest: Ringwomb

Problem: Problem: User requests new concept or User requests new concept or guidance to appropriate existing conceptguidance to appropriate existing concept

Need to know: exact nature of “ringwomb” Need to know: exact nature of “ringwomb” to find if perfect match exists in SNOMED to find if perfect match exists in SNOMED (yes).(yes).

Request: Chronic moist dermatitisRequest: Chronic moist dermatitis

Problem: Concept irredeemably ambiguousProblem: Concept irredeemably ambiguous

Need to know: how to break clinicians of Need to know: how to break clinicians of using pseudodiagnoses!using pseudodiagnoses!

And finally….And finally…. Sliced, diced, buffed and polished concept Sliced, diced, buffed and polished concept

submitted to SNOMED with suggested submitted to SNOMED with suggested FSN, synonyms, and definitionsFSN, synonyms, and definitions

CAP modeler reviews submission—may CAP modeler reviews submission—may reject, query, or accept conceptreject, query, or accept concept

If accepted, new concept is created and If accepted, new concept is created and assigned codes in TDEassigned codes in TDE

New concept appears in next database New concept appears in next database releaserelease