CHAPTER 18: Advanced Terminology Systems

Primary motivation for standardized terms in nursing is the need for valid, comparable data that can be used across information system applications to support clinical decision-making and the evaluation of processes and outcomes of care. Vocabulary problem failure to achieve a single, integrated terminology with broad coverage of the healthcare domain Reasons for Vocabulary Problem: 1) Development of multiple specialized terminologies has resulted in areas of overlapping content, areas of which no content exists, and large numbers of codes and terms 2) Existing terminologies are most often developed to provide sets of terms and definitions of concepts for human interpretation, with computer interpretation as only a secondary role

Evaluation Criteria related to Concept-oriented Approaches a) Atomic-based concepts must be separable into constituent components b) Compositionality ability to combine simple concepts into composed concepts, e.g., pain + acute = acute pain c) Concept permanence once a concept is defined it should not be deleted from a terminology d) Language independence support for multiple linguistic expressions e) Multiple hierarchy accessibility of concepts through all reasonable hierarchal paths with consistency of views f) Nonambiguity explicit definition for each term g) Nonredundancy one preferred way of representing a concept or idea h) Synonymy support for synonyms and consistent mapping of synonyms within and among terminologies *A single concept may be associated with multiple terms, but a term should represent only one concept.

Concept Orientation Concept-oriented approaches are needed to support the data needs of todays complex, knowledge-driven healthcare and health management environment. In order to appreciate the significance of concept-oriented approaches, it is important to first understand the definitions of and relationships among things in the world (objects), our thoughts about things in the world (concepts), and the labels we use to represent and communicate our thoughts about things in the world (terms). These relationships are depicted by a model called semiotic triangle.

Components of Advanced Terminology Systems A. Terminology Model a concept-based representation of a collection of domain-specific terms that is optimized for the management of terminological definitions. a) Schemata incorporate domain-specific knowledge about the typical constellations of entities, attributes, and events in the real world and, as such, reflect plausible combinations of concepts. Ex. dyspnea may be combined with severe to make severe dyspnea. b) Type definitions obligatory conditions that state only the essential properties of a concept. Ex. A nursing activity must have a recipient, an action, and a target. B. Representation Language - terminology models may be formulated and elucidated in an ontology language. - Ontology Language represents classes (concepts, categories, or types) and their properties (relations, slots, roles, or attributes) - Able to support, through explicit semantics, the formal definition of concepts in terms of their relationships with other concepts, and facilitate reasoning about those concepts C. Computer-Based Tools A representation language may be implemented using description logic within a software system or by a suite of software tools.

Semiotic Triangle

The triangle of reference (also known as the triangle of meaning and the semantic triangle) is a model of how linguistic symbols are related to the objects they represent. The triangle was published in The Meaning of Meaning (1923) by Ogden and Richards. International Organization for Standardization (ISO) international standard ISO 1087-1:2000 provides definitions for elements that correspond to each vertex of the triangle: a) Concept unit of knowledge created by a unique combination of characteristics a characteristic is an abstraction of a property of an object of a set of objects. b) Object anything perceivable or conceivable c) Term verbal designation of a general concept in a specific subject field a general concept corresponds to two or more objects which form a group by reason of common properties

Classifications of Terminology Systems: a) First-generation terminology systems consist of a list of enumerated terms, possibly arranged as a single hierarchy. - Serve a single purpose or a group of closely related purposes and allow minimal computer processing - North American Nursing Diagnosis Association (NANDA) professional organization of nurses standardized nursing terminology that develops, researches, disseminates, and refines the nomenclature, criteria, and taxonomy of nursing diagnoses.

CHAPTER 18: Advanced Terminology Systems

- Nursing Interventions Classification (NIC) - a comprehensive, standardized system to classify treatments performed by nurses. b) Second-generation terminology systems include an abstract terminology model or terminology model schema that describes the organization of the main categories used in a particular terminology or set of terminologies. - Can be used for a range of purposes, but they allow only limited computer processing; automatic classification of composed concepts is not possible - Beta 2 version of the International Classification for Nursing Practice (ICNP) Abstract terminology model complemented by a thesaurus of elementary descriptors (terms) and templates or rules (grammar) c) Third-generation systems support sufficient formalisms to enable computer-based processing - Include grammar that defines the rules for automated generation and classification of new concepts. - Also referred to as formal concept representation systems or reference terminologies.

Facilitate the representation of nursing diagnosis and nursing action concepts and their relationships in a manner suitable for computer processing Provide a framework for the generation of compositional expressions from atomic concepts within a reference terminology Facilitate the mapping among nursing diagnosis and nursing action concepts from various terminologies Enable the systematic evaluation of terminologies and associated terminology models for purpose of harmonization Provide a language to describe the structure of nursing diagnosis and nursing action concepts to enable appropriate integration with information models GALEN - A concept-oriented approach developed within the GALEN Program - Used in a range of ways, from directly supporting clinical applications to supporting the authoring, maintenance, and quality assurance of other kinds of terminologies - GRAIL is an ontology language for representing concepts and their interrelationships the source material for construction of terminology models. Two integrated sets of tools used in development of GRAIL Model: a) Computer-based modeling environment facilitates the collaborative formulation of models Allows authoring of clinical knowledge at different levels of abstraction b) Terminology server a software system that implements GRAIL - A major motivation for applying GALEN to nursing was the desire to meet the requirements of users of clinical applications, and the need to provide a reusable and extensible model of nursing terminology - GALEN does not seek to replace existing nursing terminologies; rather it seeks to contribute to the development of those terminologies, to supplement them, to allow comparisons among them, and to make them available for describing day-to-day nursing care. GALEN advocates five fundamental paradigm shifts to resolve the fundamental dilemmas that face traditional terminologies, coding, and classification systems. In the user interface, to shift from selecting codes to describing conditions. Interfaces using GALEN technology allow a central concept to be described through simple forms. In the structure, to shift from enumerated codes to composite descriptions. Correspondingly, GALEN handles terminology internally analogously to a dictionary and a grammar so that indefinitely many descriptions can be composed from a manageable number of base concepts. Traditional coding systems are more like a phrase book; each sentence must be listed separately. In establishing standards, to shift from a standard coding system to a standard reference model. Existing coding and classifications differ because they are used for different purposes. Finding a single fixed set of codes for all diseases, procedures, etc. which will serve all purposes is a chimera. The GALEN Common Reference Model provides a common means of representing coding and classification systems so that they can be inter-related a common dictionary and grammar.

ADVANTAGES OF ADVANCED TERMINOLOGY SYSTEMS - Allow much greater granularity through controlled composition, while avoiding a combinatorial explosion of precoordinated terms. - Facilitate two important facets of knowledge representation for computer-based systems that support clinical care: 1) Describing concepts Nonambiguous representation of concepts Facilitation of data abstraction or de-abstraction without loss of original data Nonambiguous mapping of terminologies Data reuse in different contexts 2) Manipulating and reasoning about those concepts using computer-based tools Automated classification of new concepts Ability to support multiple inheritance of defining characteristics ADVANCED TERMINOLOGICAL APPROACHES IN NURSING ISO 18104:2003 - Developed by ISO Technical Committee 215 (Health Informatics) Working Group 3 (Health Concept Representation) under the collaborative leadership of the International Medical Informatics Association Nursing Special Interest Group (IMIANI) and the International Council of Nurses - Approved in 2003 - Covers reference terminology models for nursing diagnoses and nursing actions - The model built on work origination within the European Committee for Standardization - Development was partly motivated by a desire to harmonize the plethora of nursing terminologies in use around the world - Development was intended to be consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model - Potential uses identified for the terminology models include to:

CHAPTER 18: Advanced Terminology Systems

In delivery, to shift from static coding systems as data to dynamic terminology services as software. Terminology is now at the heart of clinical software. GALEN originated the idea of a terminology server and is participating actively in the CorbaMed effort at standardising the software interface. In presentation, to shift from translations of monolingual terminologies to multilingual terminologies. Functions include: Internally managing and representing the mode Testing the validity of combinations of concepts Constructing valid composed concepts Transforming composed concepts into canonical form Automatically classifying composed concepts into the hierarchy Deliver the model for use by clinical applications and other kinds of authoring environments

Benefits of clinical approach: Facilitation of evidence-based practice Matching of potential research subjects to research protocols for which they are potentially eligible. Detection of and prevention of potential adverse drug effects Linking online information resources Increased reliability and validity of data for quality evaluation Data mining for purposes such as clinical research, health services research, or knowledge discovery.

SNOMED Reference Technology (SNOMED RT) - An alternative concept-oriented approach; developed through the collaboration between the College of American Pathologists and Kaiser Permanente, based on SNOMED International. - Is a reference terminology optimized for clinical data retrieval and analysis - Concepts and relationships are represented using modified KRSS rather than GRAIL - Functions: - Acronym resolution, word completion, term completion, spelling correction, display of the authoritative form of the term entered by the user, and decomposition of unrecognized input - Automated classification - Conflict management, detection, and resolution SNOMED Clinical Terms (SNOMED CT) developed by College of American Pathologists and UK National Health Service - Possesses both reference terminology properties and user interface terms. EMERGING APPROACHES Web Ontology Language (OWL) intended for use where applications, rather than humans, are to process information. As such, it should be able to meet the requirements of advanced terminology systems that support contemporary healthcare. By providing additional vocabulary and a formal semantics, OWL builds on existing recommendations such as: a) eXtensible Markup Language (XML) surface syntax for structured documents b) Resource Description Framework (RDF) a data model for resources c) RDF Schema a vocabulary for describing the properties and classes of resources Summary and Implications for Nursing: Provide for nonambiguous concept definitions Facilitate composition of complex concepts from more primitive concepts Support mapping among terminologies.