Clinical Vocabularies

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Clinical Vocabularies

• James J. Cimino, M.D.
• Columbia University

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March, 1997 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

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Capturing Clinical Data for Multiple Purposes
Now
Recode Patient Data
Collect Patient Data
Collect Patient Data
Financial Database
Clinical Repository
Research Database
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Capturing Clinical Data for Multiple Purposes
Future
Recode Patient Data
Collect Patient Data
Collect Patient Data
Financial Database
Clinical Repository
Research Database
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Concept Orientation

• One meaning meaning per code
• Clear semantics
• Meaning never changes
• Concept permanence

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Structural Aspects Donts

• Dont limit breadth or depth of hierarchy
• Dont limit to a strict hierarchy
• Dont put meaning in the codes

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NEC
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Content Dos

• Do strive for content that matches the needs of
  the primary creators of the data
• Do develop a feedback mechanism to include
  creators and users in content development
• Do develop a timely, concept-oriented update
  process

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Lessons to Learn

• - Not!
• SNOMED
• LOINC

• ICD

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