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PubMed2001

Terminology tools: state of the art and practical lessons.

OBJECTIVES: As controlled medical terminologies evolve from simple code-name-hierarchy arrangements, into rich, knowledge-based ontologies of medical concepts, increased demands are placed on both the developers and users of the terminologies. In response, researchers have begun developing tools to address their needs. The aims of this article are to review previous work done to develop these tools and then to describe work done at Columbia University and New York Presbyterian Hospital (NYPH). METHODS: Researchers working with the Systematized Nomenclature of Medicine (SNOMED), the Unified Medical Language System (UMLS), and NYPH's Medical Entities Dictionary (MED) have created a wide variety of terminology browsers, editors and servers to facilitate creation, maintenance and use of these terminologies. RESULTS: Although much work has been done, no generally available tools have yet emerged. Consensus on requirement for tool functions, especially terminology servers is emerging. Tools at NYPH have been used successfully to support the integration of clinical applications and the merger of health care institutions. CONCLUSIONS: Significant advancement has occurred over the past fifteen years in the development of sophisticated controlled terminologies and the tools to support them. The tool set at NYPH provides a case study to demonstrate one feasible architecture.

Computer Systems↗
PubMed2002

Characteristics of consumer terminology for health information retrieval.

OBJECTIVES: As millions of consumers perform health information retrieval online, the mismatch between their terminology and the terminologies of the information sources could become a major barrier to successful retrievals. To address this problem, we studied the characteristics of consumer terminology for health information retrieval. METHODS: Our study focused on consumer queries that were used on a consumer health service Web site and a consumer health information Web site. We analyzed data from the site-usage logs and conducted interviews with patients. RESULTS: Our findings show that consumers' information retrieval performance is very poor. There are significant mismatches at all levels (lexical, semantic and mental models) between the consumer terminology and both the information source terminology and standard medical vocabularies. CONCLUSIONS: Comprehensive terminology support on all levels is needed for consumer health information retrieval.

Adult↗
PubMed2004

Evolving to clinical terminology.

The electronic medical record (EMR) is slowly replacing the paper chart for documenting patient details. As the adoption curve for EMRs rapidly increases, so will the need for clinical terminologies. Currently, administrative classifications such as ICD-9-CM, CPT and HCPCS serve not only billing and reporting purposes, but also are used by healthcare providers for documentation and capturing patient procedures and problem lists. But the use of clinical terminologies, such as SNOMED CT, will assume the interface role in EMRs and thus replace these administrative classifications at the point of care. These billing terminologies will then be relegated back to the coders and payers for use, enabling the clinicians to document using richer and more granular terminologies. During this transition phase to the clinical terminology, training will likely be required as healthcare providers adjust to using terminologies in more robust ways. Clinical informaticists and early adopters will play a role in this training and help to demonstrate the many advantages of richer documentation. The use of clinical standards in EMRs is one of the key evolutions in informatics.

Diffusion of Innovation↗
PubMed2004

U.S. Department of Veterans Affairs Enterprise Reference Terminology strategic overview.

The Veterans Health Affairs (VHA) branch of the Department of Veterans Affairs has undertaken an Enterprise Reference Terminology (ERT). VHA, arguably the largest integrated healthcare provider in the United States, has completely computerized virtually all clinical transactions, including physician orders and documentation. The VA is now integrating its clinical records across hundreds of sites of care by means of a Health Data Repository (HDR) project. ERT has been designed to provide a terminology development environment, terminology services, and maintenance services for the clinical and business content in HDR and other VHA applications. Drug, laboratory observations, and clinical document title files have been developed, and the ERT will encompass all HDR domains by 2008. Commercial tools are used to host the VHA's ERT terminology development and server environments. We will select and adopt both open-source and licensable terminology systems to provide ERT content, as well as reuse existing VA-specific terminology content.

Hospital Information Systems↗
PubMed2004

Overcoming barriers to evaluation of terminological systems.

Evaluation of terminological systems has been demonstrated to be a complicated task. This is due to the broad range of terminological systems, their application, and the clinical contexts in which they can be applied. We propose an evaluation framework that explicitly distinguishes an application-independent description of terminological systems, methods to determine application-dependent requirements, and methods to assess the applicability. In order to support a systematic application-independent description of terminological systems, we present a categorization of characteristics, including explicit questions. The answers to these questions can be mapped to the requirements for a certain application of a terminological system. This framework aims at reducing the efforts for determining which terminological system is applicable for a certain clinical setting.

Evaluation Studies as Topic↗
PubMed2004

Testing the ISO nursing reference terminology model for mapping.

PURPOSE: The ISO IS 18104 is intended for helping the nursing profession to integrate their terminologies into computer systems and into larger health care reference terminologies. One purpose of the standard is to map between different terminologies. METHOD: This mapping was tested, using three terminologies that are relevant for nursing in the Netherlands. Concepts and terms where selected, and their equivalence was determined by experts, and next these were dissected. RESULTS: The dissection revealed that several concepts can easily be interchanged among the three example terminologies, while others cannot, or only for specific purposes. CONCLUSIONS: The ISO IS 18104 fulfills this purpose very well and can be considered the gold standard for mapping of nursing terminologies.

Netherlands↗
PubMed1996

MEME-II supports the cooperative management of terminology.

Health care enterprises need enterprise-wide terminologies to compare, reuse and repurpose health care descriptions. But once they are created, these terminologies need to be maintained and enhanced to sustain their utility and that of the descriptions encoded with them. MEME II (Metathesaurus Enhancement and Maintenance Environment, Version II) supports the required activities and enables enterprises to leverage their investment in terminology and descriptions by permitting remote-extra-enterprise-enhancements to terminology to be incorporated locally, and local-intra-enterprise-enhancements to be shared remotely. MEME II represents all changes to terminologies as data, or "actions," that can be interpreted by an "action engine." These actions, or messages, represent semantic "units of work" that can be interpreted by other copies of MEME II. The exchange of update messages increases the likelihood that the comparability of terminology-based health care descriptions can be sustained.

Information Systems↗
PubMed1995

Development of a controlled medical terminology: knowledge acquisition and knowledge representation.

The creation of controlled medical terminologies is a central challenge in the development of electronic patient records. In the T-Helper patient-record system, designed for the care of patients with HIV disease, the IVORY module allows health-care workers to compose textual progress notes by making selections from menus generated automatically from a controlled medical terminology. Construction of this IVORY terminology required extensive design sessions with a team of computer scientists and an expert physician. Refinement of the terminology was only possible when the design team could envision how the completed T-Helper system would be used in the context of clinical practice. Development of controlled medical terminologies is a significant problem in knowledge acquisition. Techniques used to acquire and represent clinical concepts for the purpose of building decision-support systems also are appropriate for the construction of controlled terminologies such as the one in T-Helper.

Artificial Intelligence↗
PubMed1997

SNOMED RT: a reference terminology for health care.

We describe the framework for SNOMED RT (Reference Terminology), designed to complement the broad coverage of medical concepts in SNOMED with a set of enhanced features that significantly increases its value as a reference terminology for representing clinical data. We describe what is meant by a reference terminology, and differentiate SNOMED RT from specialized terminologies that enable user interfaces, electronic messaging, or natural language processing, as well as from other specialized reference terminologies whose primary purpose is for representing data that is not primarily clinical in nature. We then describe how SNOMED RT represents multiple hierarchies and incorporates description logic. We believe that such a comprehensive set of concepts at multiple levels of granularity, with multiple logic-based subsumption hierarchies can meet the requirements of a reference terminology for health care.

Terminology as Topic↗
PubMed2006

Electrodes and multiple electrode systems for radio frequency ablation: a proposal for updated terminology.

OBJECTIVE: Research on technology for soft tissue radio frequency (RF) ablation is ever advancing. A recent proposal to standardize terminology of RF electrodes only deals with the most frequently used commercial electrodes. The aim of this study was to develop a logical, versatile, and unequivocal terminology to describe present and future RF electrodes and multiple electrode systems. MATERIALS AND METHODS: We have carried out a PubMed search for the period from January 1st 1990 to July 1st 2004 in seven languages and contacted the six major companies that produce commercial RF electrodes for use in the liver. In a first step, names have been defined for the five existing basic designs of single-shaft electrode. These names had to be unequivocal, descriptive of the electrode's main working principle and as short as possible. In a second step, these basic names have been used as building blocks to describe the single-shaft electrodes in combination designs. In a third step, using the same principles, a logical terminology has been developed for multiple electrode systems, defined as the combined use of more than one single-shaft RF electrode. RESULTS: Five basic electrode designs were identified and defined: plain, cooled, expandable, wet, and bipolar electrodes. Combination designs included cooled-wet, expandable-wet, bipolar-wet, bipolar-cooled, bipolar-expandable, and bipolar-cooled-wet electrodes. Multiple electrode systems could be characterized by describing several features: the number of electrodes that were used (dual, triple, etc.), the electric mode (monopolar or bipolar), the activation mode (consecutive, simultaneous or switching), the site of the inserted electrodes (monofocal or multifocal), and the type of single-shaft electrodes that were used. CONCLUSION: In this terminology, the naming ofthe basic electrode designs has been based on objective criteria. The short and unequivocal names of the basic designs can easily be combined to describe current and future combination electrodes. This terminology provides an exact and complete description of the versatile novel multiple electrode systems.

Catheter Ablation↗
PubMed1997

Fascia: an illustrative problem in international terminology.

As a result of international nomenclatures being in Latin, with the terms usually being undefined and translated into national vernacular languages, the same terms have been used in different ways in different countries. Fascia is an example of this, the limits of the meaning of the word differing in English-, French- and German-speaking countries. These differences are itemized in a comparative table. In 1989 the General Assembly of the International Federation of Associations of Anatomists [IFAA] created the Federative Committee on Anatomical Terminology [FCAT] with a remit to create a new terminology for the anatomical sciences with full democratic consultation with the member societies of IFAA. The draft recommendations of FCAT on fascia and the reasons for them are given. Problems associated with the use, or lack of use, of international terminologies are illustrated. For the advancement of medical knowledge and understanding, the cooperation of authors, editors and publishers in using the current terminology in the right way remains of critical importance. It is suggested that, after adopting a terminology, IFAA has a responsibility to arrange for technical back-up.

Fascia↗
PubMed2005

Electrodes and multiple electrode systems for radiofrequency ablation: a proposal for updated terminology.

Research on technology for soft tissue radiofrequency (RF) ablation is ever advancing. A recent proposal to standardise terminology of RF electrodes only deals with the most frequently used commercial electrodes. The aim of this study was to develop a logical, versatile and unequivocal terminology to describe present and future RF electrodes and multiple electrode systems. We have carried out a PubMed search for the period from January 1 1990 to July 1 2004 in seven languages and contacted the six major companies that produce commercial RF electrodes for use in clinic. In a first step, names have been defined for the five existing basic designs of single-shaft electrode. These names had to be unequivocal, descriptive of the electrode's main working principle and as short as possible. In a second step, these basic names have been used as building blocks to describe the single-shaft electrodes in combination designs. In a third step, using the same principles, a logical terminology has been developed for multiple electrode systems, defined as the combined use of more than one single-shaft RF electrode. Five basic electrode designs were identified and defined: plain, cooled, expandable, wet and bipolar electrodes. Combination designs included cooled-wet, expandable-wet, bipolar-wet, bipolar-cooled, bipolar-expandable and bipolar-cooled-wet electrodes. Multiple electrode systems could be characterised by describing several features: the number of electrodes that were used (dual, triple, ...), the electric mode (monopolar or bipolar), the activation mode (consecutive, simultaneous or switching), the site of the inserted electrodes (monofocal or multifocal), and the type of single shaft electrodes that were used. In this terminology, the naming of the basic electrode designs has been based on objective criteria. The short and unequivocal names of the basic designs can easily be combined to describe current and future combination electrodes. This terminology provides an exact and complete description of the versatile novel multiple electrode systems.

Catheter Ablation↗
PubMed2005

From concepts to clinical reality: an essay on the benchmarking of biomedical terminologies.

It is only by fixing on agreed meanings of terms in biomedical terminologies that we will be in a position to achieve that accumulation and integration of knowledge that is indispensable to progress at the frontiers of biomedicine. Standardly, the goal of fixing meanings is seen as being realized through the alignment of terms on what are called 'concepts.' Part I addresses three versions of the concept-based approach--by Cimino, by Wüster, and by Campbell and associates--and surveys some of the problems to which they give rise, all of which have to do with a failure to anchor the terms in terminologies to corresponding referents in reality. Part II outlines a new, realist solution to this anchorage problem, which sees terminology construction as being motivated by the goal of alignment not on concepts but on the universals (kinds, types) in reality and thereby also on the corresponding instances (individuals, tokens). We outline the realist approach and show how on its basis we can provide a benchmark of correctness for terminologies which will at the same time allow a new type of integration of terminologies and electronic health records. We conclude by outlining ways in which the framework thus defined might be exploited for purposes of diagnostic decision-support.

Animals↗
PubMed2006

Demystifying medication safety: making sense of the terminology.

BACKGROUND: Although there is a growing interest in medication safety, there remains much confusion about the terminology used to describe the problem. Some have described the classification of medication safety terminology as haphazard. OBJECTIVE: The purpose of this commentary is to help provide some direction by clarifying the terminology. METHODS: A review of the medication safety literature was performed. A description of commonly used terms is provided and the implications of the misuse of terminology are discussed. RESULTS: There are inconsistencies in the definitions of commonly used terms that may affect the accuracy of event rates. This may have an adverse impact on the establishment of medication safety priorities and on the validity of cross-jurisdictional comparisons. CONCLUSIONS: As the medication safety literature continues to expand, it is imperative that standardized terminology be adopted and used consistently.

Adverse Drug Reaction Reporting Systems↗
PubMed1999

Representation of change in controlled medical terminologies.

Computer-based systems that support health care require large controlled terminologies to manage names and meanings of data elements. These terminologies are not static, because change in health care is inevitable. To share data and applications in health care, we need standards not only for terminologies and concept representation, but also for representing change. To develop a principled approach to managing change, we analyze the requirements of controlled medical terminologies and consider features that frame knowledge-representation systems have to offer. Based on our analysis, we present a concept model, a set of change operations, and a change-documentation model that may be appropriate for controlled terminologies in health care. We are currently implementing our modeling approach within a computational architecture.

Artificial Intelligence↗
PubMed1998

The minimal standard terminology for digestive endoscopy: introduction to structured reporting.

The wider use of computers for the management of endoscopic data and the use of electronic endoscopes for the production of high quality endoscopic images has made the standardization of terminology and images formats necessary in digestive endoscopy reports. The European Society for Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy have combined their efforts to propose a Minimal Standard Terminology for Computerized Databases in Endoscopy. This terminology is based on the following principles: no term describing findings less frequent than 1%, of the daily practice, and no term based on subjective impressions. The Minimal Standard Terminology has been developed according to the natural process of constructing an endoscopic report in natural language and deals with the following: reasons for performing the examination, endoscopic findings, endoscopic diagnosis, additional therapeutic and diagnosis procedures (biopsies, etc.). It is subdivided according to the main organs examined with an endoscopy. Until now, the Minimal Standard Terminology was tested in many centers and was shown to accurately cover 95% of routine examinations for the upper gastrointestinal tract, colonoscopy and cholangio-pancreatography. It is currently being tested in an a prospective way in several centers in Europe (with a grant from the European Commission DGXIII-C4) and in the USA (with grant from the AHDHF).

Endoscopy, Digestive System↗
PubMedDate not supplied

Formal nursing terminology systems: a means to an end.

In response to the need to support diverse and complex information requirements, nursing has developed a number of different terminology systems. The two main kinds of systems that have emerged are enumerative systems and combinatorial systems, although some systems have characteristics of both approaches. Differences in the structure and content of terminology systems, while useful at a local level, prevent effective wider communication, information sharing, integration of record systems, and comparison of nursing elements of healthcare information at a more global level. Formal nursing terminology systems present an alternative approach. This paper describes a number of recent initiatives and explains how these emerging approaches may help to augment existing nursing terminology systems and overcome their limitations through mediation. The development of formal nursing terminology systems is not an end in itself and there remains a great deal of work to be done before success can be claimed. This paper presents an overview of the key issues outstanding and provides recommendations for a way forward.

Information Systems↗
PubMed2003

Recognizing specialized terminology presented through different modes.

In the present study, the authors examined how previous experience and modes of presenting information affect the recognition of terms in new, specialized terminologies. The specialized terminology used was related to orienteering. Orienteering concepts representing features found in the woods may be communicated verbally (as definitions or words) or symbolically. There were 225 participants (101 reported no orienteering experience and 122 reported varying amounts of orienteering experience; 2 did not respond to that question) who tried to identify which of 5 entities was an orienteering definition, word, or symbol. Those with orienteering experience found that recognizing the specialized terminology was significantly easier than for those without experience. Recognizing symbols was significantly more difficult than recognizing definitions or words, particularly for non-orienteers. Performance of the orienteers was similar for the three modes. Within the orienteering group, the number of years of experience and usual course difficulty attempted were significant predictors of overall test success. Applications to training of both low-level specialized terminology (e.g., used in algebra), and higher level terminology (e.g., used in computer science) are discussed.

Adult↗