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PubMed2006

A future vision: A serious attempt to integrate terminologies in nursing practice, a strategy for 2005-2007.

The Norwegian Nurses Association has developed a strategy for the use and development of terminologies in nursing. The proposal for this strategy is that terminologies are important in developing nursing practice. The goal of the strategy is to contribute to the nursing endeavours in documenting, quality insurance and influencing health policies. One method of achieving this is to stimulate the use and further development of terminologies, through structured and standardized documentation. The purpose is to inform and educate clinical practice, education, professional development and research. It is a goal that the strategy will also influence health authorities in the choice and decisions of terminologies that will be used for nursing. The strategy gives an overview of the terminologies that the Norwegian Nurses Association has decide translate and evaluate. In addition, the strategy exemplifies recommendations for status in 2007 for structured documentation and the use of terminologies and how this status should be achieved. This paper will highlight three areas from the strategy that the Norwegian Nurses Association wishes to focus on: 1. Translations of classifications systems and version control. 2. The need for systematic research and evaluation of terminologies in the context of nursing practice and laws in Norway. 3. The challenge of educating nurses in the use of terminologies.

Advisory Committees↗
PubMed2005

TERMTrial--terminology-based documentation systems for cooperative clinical trials.

Within cooperative groups of multi-center clinical trials a standardized documentation is a prerequisite for communication and sharing of data. Standardizing documentation systems means standardizing the underlying terminology. The management and consistent application of terminology systems is a difficult and fault-prone task, which should be supported by appropriate software tools. Today, documentation systems for clinical trials are often implemented as so-called Remote-Data-Entry-Systems (RDE-systems). Although there are many commercial systems, which support the development of RDE-systems there is none offering a comprehensive terminological support. Therefore, we developed the software system TERMTrial which consists of a component for the definition and management of terminology systems for cooperative groups of clinical trials and two components for the terminology-based automatic generation of trial databases and terminology-based interactive design of electronic case report forms (eCRFs). TERMTrial combines the advantages of remote data entry with a comprehensive terminological control.

Clinical Trials as Topic↗
PubMedDate not supplied

Adequacy of evolving national standardized terminologies for interdisciplinary coded concepts in an automated clinical pathway.

PURPOSE: The purpose of this analysis was to determine the adequacy of evolving national standardized terminologies with regard to coded data elements (concepts) in an automated clinical pathway designed to drive adherence with the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Evaluation and Management of Chronic Heart Failure. METHOD: Concepts were identified in a previously developed automated clinical pathway and associated tools. Once identified, concepts were categorized according to the conceptual domains identified by Campbell et al. (1997). A review of evolving national standardized terminologies and coding systems was initiated to determine if the identified concepts had corresponding representation in one of these coding systems. Available codes were then evaluated for adequacy with respect to national guideline adherence measures put forth by the Centers for Medicare/Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO). RESULTS: The concept domain model put forth by Campbell et al. (1997) worked well for organizing concepts and for providing a useful framework for data analysis. Using our method, 260 unique pathway concepts were identified, of which, 91.9% (239) are represented by one or more of the standardized coding systems. Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT alone represented 86.2% of the concepts. Seventy percent (70%) of the clinical pathway concepts are represented using the Health Insurance Portability and Accountability Act (HIPAA) mandated national terminologies alone. Less than 50% of CMS and JCAHO guideline adherence concepts were found to have representation in the HIPAA mandated terminologies. The addition of Logical Observation Identifier Names and Codes (LOINC) and SNOMED CT improved representation up to 86.4%, but did not include representation of all concepts necessary for complete electronic monitoring of guideline adherence. CONCLUSIONS: Evolving national standardized terminologies provided matching terms for the majority of the data elements in the automated clinical pathway. Standard clinical terminologies with granular terms such as LOINC and SNOMED CT are required to represent the depth and detail of certain procedures and guideline-based care. Gaps exist in Health Insurance Portability and Accountability Act (HIPAA) mandated terminologies for representing interdisciplinary concepts in national adherence measures.

Computational Biology↗
PubMedDate not supplied

Terminology. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial.

ISSUES: Differences in type, structure, quality of health care systems and availability of resources influence reporting systems. In most countries, individual systems have a long history of usage that might preclude adoption of a uniform terminology worldwide. CONSENSUS POSITION: It is desirable but unrealistic at this time to aim for a unified terminology worldwide. It should be the stated objective of the International Academy of Cytology to serve as an umbrella organization for various terminologies and enhance mutual understanding and cooperation. Translation tables of equivalent terms have been created to allow increased communication. Consensus has been achieved in defining essential elements required of any terminology system: (1) the report must be text based: numerical Papanicolaou class designations alone are inadequate; (2) an assessment of the adequacy of the sample should be included; and (3) the diagnosis must address the primary purpose of cervical cytology: to indicate the presence or absence of epithelial abnormalities. Incorporating additional elements within a terminology system may be more or less appropriate, depending on the setting in which the system is used. ONGOING ISSUES: Despite the cited problems in adopting a uniform terminology worldwide, a single system would have many advantages in terms of communication and research and may be a long-term goal worth pursuing. Countries are invited to present their individual national terminology systems and participate in an ongoing dialogue, critically evaluating the advantages and disadvantages of all systems.

Cervix Uteri↗
PubMed2001

Partitioning an object-oriented terminology schema.

Controlled medical terminologies are increasingly becoming strategic components of various healthcare enterprises. However, the typical medical terminology can be difficult to exploit due to its extensive size and high density. The schema of a medical terminology offered by an object-oriented representation is a valuable tool in providing an abstract view of the terminology, enhancing comprehensibility and making it more usable. However, schemas themselves can be large and unwieldy. We present a methodology for partitioning a medical terminology schema into manageably sized fragments that promote increased comprehension. Our methodology has a refinement process for the subclass hierarchy of the terminology schema. The methodology is carried out by a medical domain expert in conjunction with a computer. The expert is guided by a set of three modeling rules, which guarantee that the resulting partitioned schema consists of a forest of trees. This makes it easier to understand and consequently use the medical terminology. The application of our methodology to the schema of the Medical Entities Dictionary (MED) is presented.

Humans↗
PubMed2005

Terminological system maintenance: a procedures framework and an exploration of current practice.

The use of electronically stored data requires that the data is recorded in a structured and standardized manner. This has led to the development of terminological systems. The content of these medical terminological systems is subject to continuing changes as a consequence of the developments in the field of medicine.By means of a literature study criteria were obtained for the maintenance of terminological systems. The criteria are used to develop a framework for the management of the maintenance process. The current practice of terminology maintenance was explored in a survey of twenty-seven organizations that currently maintain a terminological system. The results of the survey reveal the diversity and suboptimality of the current maintenance processes. The framework for the management of the maintenance process can be used to eliminate deficiencies in this process. This framework for terminology maintenance is an important step towards standardization of the maintenance of medical terminological systems.

Disease Management↗
PubMed1989

[Historical research on international medical terminology].

The history of medical terminology is part of the history of medicine. Historical study of medical terminology involves the following aims: 1. to investigate the role of Latin and Greek in medical terminology; 2. to study changes and trends in terminology, such as changes induced by better insight into certain phenomena, narrowing and broadening of the content of terms, development of models and of special means of word formation, fight against foreign elements in terminology, and the existence of synonyms and eponyms; 3. research into the origin and development of individual terms; 4. to establish the use of terms by individual authors; 5. to study trends towards unification of terminology; 6. to investigate theoretical views of physicians on medical terminology in the past. (Ref. 93.).

History, 16th Century↗
PubMed1998

Synchronization of diverging versions of a controlled medical terminology.

To share clinical data and to build interoperable computer systems that permit data entry, data retrieval, and data analysis, users and systems at multiple sites need a shared clinical terminology. However, local sites that adopt a shared terminology have local needs that prompt local-terminology maintainers to make changes to the local version. Meanwhile, maintainers of the shared terminology make changes to the shared version, and the two terminologies diverge. I propose a formal model for managing change, with additional features included for the local site. If terminology maintainers follow such a model, the local-terminology maintainer can synchronize the local version with the shared version at periodic intervals. I am implementing a prototype, which I will use to assess the model and to study the synchronization process.

Computer Systems↗
PubMed1998

The SNOMED DICOM microglossary: controlled terminology resource for data interchange in biomedical imaging.

This paper describes an authoritative, non-proprietary information resource that provides an efficient mechanism for embedding specialized clinical knowledge into the design of healthcare telecommunications systems. The resource marries two types of data interchange standards, a message/electronic-document standard and a terminology standard. In technical terms, it is part protocol and part database. Industry, academia, professional specialty societies, and the federal government participated in its development. The development of multi-specialty content has broadly engaged biomedical domain experts to an unprecedented degree in voluntary, non-proprietary message/document-standards development. The resource is the SNOMED DICOM Microglossary (SDM), a message-terminology (or document-content) mapping resource. The message/electronic-document standard is DICOM (Digital Imaging and Communications in Medicine). The terminology standard is SNOMED, (Systematized Nomenclature of Human and Veterinary Medicine). The SDM specifies the mapping of multi-specialty imaging terminology from SNOMED to DICOM data elements. DICOM provides semantic constraints and a framework for discourse that are lacking in SNOMED. Thus the message standard and the computer-based terminology both depend upon and complete each other. The combination is synergistic. By substitution of different templates of specialty terminology from the SDM, a generic message template, such as the DICOM Visible Light (Color Diagnostic) Image or the DICOM Structured Reporting specification can be reconfigured for diverse applications. Professional societies, with technical assistance from the College of American Pathologists, contribute and maintain their portions of the terminology, and can use SDM templates and term lists in clinical practice guidelines for the structure and content of computer-based patient records.

Artificial Intelligence↗
PubMed1998

Standards to support development of terminological systems for healthcare telematics.

The Technical Committee on "Medical Informatics" of the European Committee for Standardization (CEN/TC251) is supporting developers of terminological systems in healthcare by a series of standards. The dream of "universal" coding system was abandoned in favor of a coherent family of terminologies, diversified according to tasks; two ideas were introduced: (1) the "categorical structure", i.e. a model of semantic categories and their relations within a subject field and (2) the "cross-thesaurus", i.e. a system of descriptors to build a systematic representation (called here "dissection") for each terminological phrase, coherent across diverse terminologies on a given subject field. The goal is to assure coexistence and interoperability (and reciprocal support for development and maintenance) to three generations of systems: (1) traditional paper-based systems (first generation); (2) compositional systems built according to a categorical structure and a cross-thesaurus (second generation) and (3) formal models (third generation). Various scenarios are presented, on the exploitation of computer-based terminological systems. The idea of "operational meaning" of terminological phrases within administrative and organizational contexts and the idea of "task-oriented details" are also introduced, to justify and exploit design constraints on terminological systems.

Europe↗
PubMed2005

Ontology integration: experience with medical terminologies.

To build a common controlled vocabulary is a formidable challenge in medical informatics. Due to vast scale and multiplicity in interpretation of medical data, it is natural to face overlapping terminologies in the process of practicing medical informatics [A. Rector, Clinical terminology: why is it so hard? Methods Inf. Med. 38 (1999) 239-252]. A major concern lies in the integration of seemingly overlapping terminologies in the medical domain and this issue has not been well addressed. In this paper, we describe a novel approach for medical ontology integration that relies on the theory of Algorithmic Semantic Refinement we previously developed. Our approach simplifies the task of matching pairs of corresponding concepts derived from a pair of ontologies, which is vital to terminology mapping. A formal theory and algorithm for our approach have been devised and the application of this method to two medical terminologies has been developed. The result of our work is an integrated medical terminology and a methodology and implementation ready to use for other ontology integration tasks.

Algorithms↗
PubMed2006

Terminology model discovery using natural language processing and visualization techniques.

Medical terminologies are important for unambiguous encoding and exchange of clinical information. The traditional manual method of developing terminology models is time-consuming and limited in the number of phrases that a human developer can examine. In this paper, we present an automated method for developing medical terminology models based on natural language processing (NLP) and information visualization techniques. Surgical pathology reports were selected as the testing corpus for developing a pathology procedure terminology model. The use of a general NLP processor for the medical domain, MedLEE, provides an automated method for acquiring semantic structures from a free text corpus and sheds light on a new high-throughput method of medical terminology model development. The use of an information visualization technique supports the summarization and visualization of the large quantity of semantic structures generated from medical documents. We believe that a general method based on NLP and information visualization will facilitate the modeling of medical terminologies.

Automation↗
PubMed1999

Disability terminology in the media: a comparison of newspaper reports in Canada and Israel.

The terminology used to refer to persons with disability may both reflect and influence attitudes towards them. Negative references may perpetuate negative attitudes and stereotypes. This is of particular importance in the mass media which reaches a broad spectrum of the population. This study looked at disability terminology used in major newspapers in Canada and Israel. It focused on the nature of that terminology and whether its use was related to other factors, such as the disability model reflected in the article, the content of the article (e.g. attributes of the disabled person) and its context (e.g. type of newspaper, feature versus news items). Overall, the use of inappropriate terminology of varying types was quite prevalent in both countries. In addition, in Canada there were a considerable number of articles which had no direct reference to the disability. In general, the terminology used was considerably more positive in articles dealing with individual persons with disabilities (as opposed to groups), with disabled children and with problems of mobility and rights. The results of the study indicate that the choice of terminology cannot be explained by journalistic expedience and conciseness alone.

Attitude to Health↗
PubMedDate not supplied

Structural validation of nursing terminologies.

OBJECTIVE: The purpose of the study is twofold: 1) to explore the applicability of combinatorial terminologies as the basis for building enumerated classifications, and 2) to investigate the usefulness of formal terminological systems for performing such classification and for assisting in the refinement of both combinatorial terminologies and enumerated classifications. DESIGN: A formal model of the beta version of the International Classification for Nursing Practice (ICNP) was constructed in the compositional terminological language GRAIL (GALEN Representation and Integration Language). Terms drawn from the North American Nursing Diagnosis Association Taxonomy I (NANDA taxonomy) were mapped into the model and classified automatically using GALEN technology. MEASUREMENTS: The resulting generated hierarchy was compared with the NANDA taxonomy to assess coverage and accuracy of classification. RESULTS: In terms of coverage, in this study ICNP was able to capture 77 percent of NANDA terms using concepts drawn from five of its eight axes. Three axes-Body Site, Topology, and Frequency-were not needed. In terms of accuracy, where hierarchic relationships existed in the generated hierarchy or the NANDA taxonomy, or both, 6 were identical, 19 existed in the generated hierarchy alone (2 of these were considered suitable for incorporation into the NANDA taxonomy and 17 were considered inaccurate), and 23 appeared in the NANDA taxonomy alone (8 of these were considered suitable for incorporation into ICNP, 9 were considered inaccurate, and 6 reflected different, equally valid perspectives). Sixty terms appeared at the top level, with no indenting, in both the generated hierarchy and the NANDA taxonomy. CONCLUSIONS: With appropriate refinement, combinatorial terminologies such as ICNP have the potential to provide a useful foundation for representing enumerated classifications such as NANDA. Technologies such as GALEN make possible the process of building automatically enumerated classifications while providing a useful means of validating and refining both combinatorial terminologies and enumerated classifications.

Nursing↗
PubMed2004

Terminological mapping for high throughput comparative biology of phenotypes.

Comparative biological studies have led to remarkable biomedical discoveries. While genomic science and technologies are advancing rapidly, our ability to precisely specify a phenotype and compare it to related phenotypes of other organisms remains challenging. This study has examined the systematic use of terminology and knowledge based technologies to enable high-throughput comparative phenomics. More specifically, we measured the accuracy of a multi-strategy automated classification method to bridge the phenotype gap between a phenotypic terminology (MGD: Phenoslim) and a broad-coverage clinical terminology (SNOMED CT). Furthermore, we qualitatively evaluate the additional emerging properties of the combined terminological network for comparative biology and discovery science. According to the gold standard (n = 100), the accuracies (precision / recall) of the composite automated methods were 67% / 97% (mapping for identical concepts) and 85% / 98% (classification). Quantitatively, only 2% of the phenotypic concepts were missing from the clinical terminology, however, qualitatively the gap was larger: conceptual scope, granularity and subtle yet significant, homonymy problems were observed. These results suggest that, as observed in other domains, additional strategies are required for combining terminologies.

Animals↗
PubMed2003

Integrating nursing diagnostic concepts into the medical entities dictionary using the ISO Reference Terminology Model for Nursing Diagnosis.

OBJECTIVE: The purposes of the study were (1) to evaluate the usefulness of the International Standards Organization (ISO) Reference Terminology Model for Nursing Diagnoses as a terminology model for defining nursing diagnostic concepts in the Medical Entities Dictionary (MED) and (2) to create the additional hierarchical structures required for integration of nursing diagnostic concepts into the MED. DESIGN AND MEASUREMENTS: The authors dissected nursing diagnostic terms from two source terminologies (Home Health Care Classification and the Omaha System) into the semantic categories of the ISO model. Consistent with the ISO model, they selected Focus and Judgment as required semantic categories for creating intensional definitions of nursing diagnostic concepts in the MED. Because the MED does not include Focus and Judgment hierarchies, the authors developed them to define the nursing diagnostic concepts. RESULTS: The ISO model was sufficient for dissecting the source terminologies into atomic terms. The authors identified 162 unique focus concepts from the 266 nursing diagnosis terms for inclusion in the Focus hierarchy. For the Judgment hierarchy, the authors precoordinated Judgment and Potentiality instead of using Potentiality as a qualifier of Judgment as in the ISO model. Impairment and Alteration were the most frequently occurring judgments. CONCLUSIONS: Nursing care represents a large proportion of health care activities; thus, it is vital that terms used by nurses are integrated into concept-oriented terminologies that provide broad coverage for the domain of health care. This study supports the utility of the ISO Reference Terminology Model for Nursing Diagnoses as a facilitator for the integration process.

Dictionaries, Medical as Topic↗
PubMed1993

Use of uniform terminology by occupational therapists.

Uniform Terminology for Occupational Therapy-Second Edition (American Occupational Therapy Association, 1989b) was published to foster consistency in terminology among occupational therapists. In this study, agreement between occupational therapists and Uniform Terminology about the definition and categorization of 15 terms was examined. Agreement was measured on 113 responses from a randomly selected sample of 180 occupational therapists. Low levels of agreement were found on both definition of terms (71.9 mean percentage of agreement, SD = 12.4) and categorization of terms into larger conceptual categories (34.9 mean percentage of agreement, SD = 11.7). Therapists selected an alternative definition more often than the one given by Uniform Terminology on 2 of 15 terms and selected an alternative categorization more often than the one given in Uniform Terminology on 8 of 15 terms. These results indicate that therapists do not agree with many Uniform Terminology definitions and categorizations.

Humans↗
PubMed1999

Evaluation of a type definition for representing nursing activities within a concept-based terminologic system.

A terminology model is a conceptual representation that is optimized for the management of terminologic definitions. The purpose of this study was to evaluate one component of a terminology model, a type definition for nursing activity concepts. Two research questions were examined: 1) What percentage of nursing activity terms includes the three essential properties of the type definition (Delivery Mode, Activity Focus, and Recipient)? and 2) Can the nursing activity terms be reliably decomposed into the three elements of the type definition? The sample comprised 1039 non-redundant nursing activity terms collected from the health records of patients hospitalized for an AIDS-related condition. Each nursing activity term was decomposed into the three elements of the type definition by three raters. Percent agreement among the raters ranged from 91.5% to 96.2%. All terms included either an Explicit (82.0%) or Implicit (18.0%) Delivery Mode. Activity Focus was present in 95.1% of the terms in the sample. Recipient was coded as Explicit in 19.2%, Implicit in 75.9%, and Ambiguous in 4.8% of the nursing activity terms in the data set. Mapping among nursing terminologies and convergence of nursing terms within large concept-based health care terminologies has been hindered by the lack of a robust concept representation. A type definition is an essential component of such a representation. Further research is needed to refine the type definition and to incorporate it within a terminology model for nursing concepts.

Humans↗