Mental and Behavioural Health Clinical Reference Group

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Hi All, 

We've recently received a helpdesk query from the NRC in Sweden. They identified that there are descendants of 5880005 |Physical examination procedure (procedure)| but which contain the word "mental". This seems to go against the definition of that concept "An observation of the body or a body part using one of the five human senses (e.g. inspection, palpation, percussion, auscultation)". 
We discussed this issue at our internal SNOMED editors call and feel that there is probably a need to create a new high level concept for Mental examination (or similar) and have the concepts moved to sit beneath that. However, we also discussed how the lines between a physical examination, which may include recording basic psychiatric findings and a full mental examination aren't clear.
We're keen to know for the below concepts if you think they warrant being a descendant of Physical examination, Mental examination or both. 
It may also be the case that some of the concepts are outdated and can be inactivated or are specific to individual regions, again we would appreciate your input on this.

Thanks,

Mark Banks


ConceptPreferred TermId
Neurological mental status determination (procedure)Neurological mental status determination392257007
Mental Health Act examination (procedure)Mental Health Act examination171423009
Medico-legal mental status determination (procedure)Medico-legal mental status determination42813001
Examination for suspected mental disorder (procedure)Examination for suspected mental disorder171398007
Assessment of mental status by psychiatrist (procedure)Assessment of mental status by psychiatrist392258002
Evaluation for signs and symptoms of mental/emotional health problems (procedure)Evaluation for signs and symptoms of mental/emotional health problems410325007
Initial psychiatric interview with mental status and evaluation (procedure)Initial psychiatric interview with mental status and evaluation79094001
History and physical examination, follow-up for emotional or mental disease (procedure)History and physical examination, follow-up for emotional or mental disease14129001
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11 Comments

  1. Elaine Wooler

    Hi Mark Banks

    The meeting did not have all the necessary people to be able to make a decision so will be carried forward to the next meeting on the 16 August.

  2. Piper Allyn Ranallo

    Mark Banks

    I took a look at the larger  |Action (qualifier value | hierarchy yesterday after our call. I think the larger hierarchy needs review and may need some clean up from a MH perspective.

    A couple of high level:observations from the MH perspective:

    • Many concepts have ambiguous FSNs when evaluated from the perspective of all of healthcare (less ambiguous if making assumptions that all concepts apply to methods involving only anatomic structures and physical entities). For example:

    - Exploration - action (qualifier value)
    - Freeing - action (qualifier value)
    - Connection - action (qualifier value)
    - Decompression - action (qualifier value)
    - Manipulation - action (qualifier value)
    - Removal - action (qualifier value)
    - Restore- action (qualifier value)
    - Structural modfication- action (qualifier value)
    - Measurement - action (qualifier value

    • Concept hierarchy |Functional modification - action | might be particularly worth looking at, since virtually all methods used in MH procedures are  'functional modifications' v. anatomic or structural modification)
    • All concepts enumerated above (in the list you provided) use anatomic structures for defining relationship |Procedure site| or | Procedure site - Direct |.  This isn't appropriate for most mental health procedures. The"mind" (a higher level functional system that can't be neatly reduced to nervous system functional systems) is the finding site, the entity being measured or observed, or the entity being directly  "acted upon" (procedure site) for clinical findings and procedures in SNOMED. This is something we need to address more braodly – not just as it relates to the concepts here.
    IdPreferred TermProcedure SiteProcedure site direct
    171423009Mental Health Act examinationAnatomical or acquired body structure (body structure)]
    171398007Examination for suspected mental disorderAnatomical or acquired body structure (body structure)]
    410325007Evaluation for signs and symptoms of mental/emotional health problemsAnatomical or acquired body structure (body structure)]
    14129001History and physical examination, follow-up for emotional or mental diseaseAnatomical or acquired body structure (body structure)]
    392257007Neurological mental status determination
    		Structure of nervous system (body structure)
    42813001Medico-legal mental status determination
    		Structure of nervous system (body structure)
    392258002Assessment of mental status by psychiatrist
    		Structure of nervous system (body structure)
    79094001Initial psychiatric interview with mental status and evaluation
    		Structure of nervous system (body structure)

    Attachng a spreadsheet with notes here.

    Action (qualifier value).xlsx

    Best,

    Piper

  3. Mark Banks

    Hi Piper Allyn Ranallo,

    Thanks very much for looking deeply into that and I don't disagree with any of the points you raised. I absolutely think that looking at the Action hierarchy and editing it from a MH perspective would be beneficial. 

    As it's likely to take some time to determine exactly how the Action hierarchy should be changed to accurately model procedures involving the mind, I wonder if a "quick win" in the meantime which would enable Sweden to continue with their translation would be to edit those specific examination concepts above to remove the Procedure site attributes and assign a different primitive parent, of a new concept "Mental examination" which would be a child of 302199004 |Examination - action (qualifier value)|.
    Doing so would remove the incorrect body structure attributes (which were probably only added to allow the concepts to slot into the hierarchy anyways) and would have that small group of concepts collected together which could be easily identified and changed once a decision on how to logically represent MH procedures has been made. Would you be ok with that in the meantime? 

  4. Piper Allyn Ranallo

    Hi Mark Banks-

    Yes, I think that's a great idea! 

    What are your thoughts about making the concept a child of 129449000 | Functional assessment - action (qualifier value) | rather than a direct child of  |302199004 |Examination - action (qualifier value)|. Or does "functional" have a specific meaning that wold preclude making it an appropriate parent?

    Editing to add this:

    Just to be clear - you are proposing the following:

    • Create new concept | Mental examination (procedure) |  as a child of  |Examination by method (procedure)| 
    • Create new concept | Mental examination - action (qualifier value)| as a child of |Examination - action (qualifier value)|  (or 129449000 | Functional assessment - action (qualifier value) | if you think it may be more appropriate?)

    Here is my reasoning for proposing we make | Mental examination - action (qualifier value)| a child of 129449000 | Functional assessment - action (qualifier value) |

    • There are some concepts in the 252952004 | Child development test (procedure) | sub hierarchy that test both physiologic and mental functional status/functioning
    • If | Mental examination - action (qualifier value)| is a child of 129449000 | Functional assessment - action (qualifier value) | then functional assessment can represent both the physiological and more abstact mental functioning, and | Mental examination - action (qualifier value)| can represent the subset of functions (mental) - which I think is necessary for correct subsumption of concepts in the procedure hiearchy that use these concepts in defining relationships? 

    If you (and Elaine Wooler) can provide your thoughts on this,  I will bounce this off the CRG once more to make sure there is agreement among the SMEs.

    Michael First, Janna Hastings, Laura Fochtmann, Uma Vaidyanathan, Jeffrey Buchhalter

  5. Piper Allyn Ranallo

    Mark Banks, Elaine Wooler-

    We've had some offline discussion. 

    It sounds like 129449000 | Functional assessment - action (qualifier value) | may have a pretty specific meaning that precludes it use an appropriate parent for  | Mental examination - action (qualifier value)|.

    Would it make sense to be really explicit and create a concept for | Physical examiation -action (qualifier value) | as well as | Mental examination - action (qualifier value) |? This would be a simple solution to the larger problem of disambiguating existing 'action' concepts.  Those concepts like |Exploration - action (qualifier value) | that have a different meaning in the context of a physical examination and mental examination would be made clear based on their parent (mental v physical examination). 

    Just a thought.... 

    Piper

  6. Piper Allyn Ranallo

    Here is a graphic of a solution that combines your recommendation, Mark Banks, with a few minor changes that would allow us to disambiguate between concepts that may have different meanings in the context of biomedical v. mental healthcare, e.g., |Exploration - action (qualifier value) |


    Summary:

    Add concept  | Physical examination - action (qualifier value) | with an explicit defintion of  "A physical examination is an action that involves examination of the the entire body and/or one or more (in-vivo) body structures. The action is capable of generating information about anatomic strucutres or physiologic functions, processes, or states" 

    Add concept  | Mental examination - action (qualifier value) | with an explicit defintion (preliminary, needs further MABH-CRG review) of  "A mental examination action is an action that involves direct examination of the entire person, including body structures (physical behavior and appearance) and non-somatic (mental, interpersonal, social, environmental) entities and processes. The action is capable of generating information about mental, cognitive, behavioral, and social functions, processes, or states."

    Move the actions that are subtypes of physical examination under  | Physical examination - action (qualifier value) |

    MABH-CRG would identify and add specific types of actions used in mental examinations as a future piece of work


  7. Elaine Wooler

    Adding my reply to the email discussion:

    I think we have two options:

    1. The simplest solution for the immediate problem is to move the affected concepts up a level in the hierarchy. So they would no longer be subtypes of 5880005 |Physical examination procedure (procedure)| but subtypes of 315306007 |Examination by method (procedure)|. They would have no body sites specified and the action would be Examination action.

    2. We could create a new concept for Mental examination (procedure) to group the concepts and a Mental examination action (qualifier value) but I thought from our discussion there was a reluctance to have a mind/body separation as there will be elements of both physical and mental examination in most mental health exams.

    There is also an existing SNOMED International content tracker relating to the Actions hierarchy which needs clinical input from a number of domains so hence my reluctance to make changes to this hierarchy at present. We wouldn’t be able to create a Physical examination action as this requires input and much work to assess the impact on the 2000 plus concepts currently subtypes of 5880005 |Physical examination procedure (procedure)|.

    Appreciate your input in to these two options.

  8. Piper Allyn Ranallo

    Couple of thoughts:

    • Putting aside the issue of mind v. body, creating a parent concept for |Mental examination (procedure)| allows us to capture an important real-world concept of performing an examination focused on assessing "psychological" (mental, cognitive, social, emotional) status or functioning
    • I do think it will be quicker and easier to avoid attempting to make a distinction between mental and phyical exam by just not explicitly defining either of them and not creating a separate concept for mental examination, but I also worry that by doing that we are perpetuating the situation that created the issues we currently have in SNOMED – mental health content continues to be nebulous, and the quality of the MH content suffers b/c with so few concepts fully defined, none of the terminology QA processes can tell us much when run against this content...

    I'm biased towards making the time to do the hard work and analysis that needs to be done when these kinds of issues arise.  I agree with holding off on major changes to the Actions sub hierarchy until we're ready to do a compete and thorough review with other CRGs. However, I think it will pay off for us  in the long run if we make the time now to add both |Mental examination (procedure)| and  | Mental examination - action (qualifier value) | and make the minimal changes necessary to accomondate these.

    Just some thoughts. I'm interested in what others think, Laura Fochtmann, Michael First, Uma Vaidyanathan, Darrel Regier ?

    Piper


  9. Piper Allyn Ranallo

    I see we have not addressed the initial question about  "the lines between a physical examination, which may include recording basic psychiatric findings and a full mental examination aren't clear".  

    Thoughts:

    • Modeling these distinctions would be similar to modeling the distinctions between a skin examination performed as part of a routine physical exam (as one of many systems in the ROS) and one performed by a dermatologist,  i.e. use of different methods and instruments aimed at identifying more granular findings with greater precision and certaintly, and being perofrmed by a healthcare professional with specialized training and knowlege
    • Would it make sense to add concept | Health examination (procedure) | to explicilty represent those examination procedures that include an explicit assessment of both physical (somatic) states/processes/functions/findings along with an assessment of social and psychological health states/processes/functions/findings (this will cover routine health exams that include assessments of phyiscal health, mental health, food security, safety of living envronment, etc.).

    Regarding the question about "whether the initial set of concepts should be descendants of Physical examination, Mental examination or both." 

    Jeffrey Buchhalter , Michael First , Laura Fochtmann - could you weigh in on the types of findings or disorders being targeted by the examinations listed by Mark Banksabove (and whether these may have different meanings in different countries' health systems?).

    Based on responses from SMEs above, maybe we could add defining relationship | has focus (attribute)|  to capture the types of findings or disorders that are the focus of the  examination  (this could be a good work around to not having a defining attribute analogous to 'procedure site')

    • Neurocognitive disorder , Neurodevelopmental disorder→ examinations more narrowly in the context of the kinds of things neurologists, and pediatitricians assesses (aspects of mental functioning that provide insights into brain pathology or problems with normal brain development)
    • Mental disorder → examinations performed to cover the broad lanscape of mental disorders: neurocognitive, neurodeveloptal, and "psychological" examinations focused more on a person's social and emotional wellbeingf exams
    • "Psychological" disorder (need an appropriate concept)  → mental disorders other than neurodevelopmental and neurocognitive; so-called "psychological" disorders, i.e., the kinds of exams performed routinely by those in the mental health profession after a comprehsensive psychiatric and/or neurological exam has been performed and neurocognitve and neurodevelopmental dsorders have been ruled out or are being addressed separately.


     Piper

  10. Piper Allyn Ranallo

    Some additional thoughts below. I defer to the clinical SMEs in the CRG for input on accuracy of proposed defining attributes. 

    Concept

    Notes

    Defining Attributes

    Neurological mental status determination (procedure)


    Unsure whether mental status determinations in the context of neurology include physical examination (in mental health context MSE is a structured interview + observation of patient)


    Method = | Evaluation – action (qualifier value) |


    Has focus = 118940003 | Disorder of nervous system (disorder) |


    Has intent = | Diagnostic intent (qualifier value) |

    Mental Health Act examination (procedure)


    Source: “Examination authorities authorise a doctor or authorised mental health practitioner to enter premises to detain and involuntarily examine a person to decide if a recommendation for assessment should be made for the person. Examination authorities are a ‘last resort’ where there are serious concerns about a person’s mental health and wellbeing, and voluntary approaches are not achievable.”


    Method = | Evaluation – action (qualifier value) |


    Has focus = | Mental disorder (disorder) |

     

    Has intent = need a new concept to represent legal intent


    Need a concept to represent procedure performed without consent of patient; make new concept a parent of this concept

    Medico-legal mental status determination (procedure)


    Source: “A medico-legal report is a document that contains the results of Psychological Assessment and Harvey Abbott’s expert opinion, in a report that can be used in legal matters”


    Method = | Evaluation – action (qualifier value) |

    Has focus = need a new concept to represent the idea of legal status that would incorporate both whether patient is threat to self or others (commitment) and knowns right from wrong (legally responsible for behavior)

     

    Has intent = need a new concept to represent legal intent

    Examination for suspected mental disorder (procedure)

     

    Not clear on concept. Does this include both a physical examination to determine whether there is a biomedical etiology + a psychosocial evaluation to determine psychosocial etiology?

    Ambiguous

    Method = | Evaluation – action (qualifier value) |

    Method = | Examination – action (qualifier value) | (?)

     

    Has focus = | Mental disorder (disorder) |

    Has intent = | Diagnostic intent (qualifier value) |

    Assessment of mental status by psychiatrist (procedure)


    Has focus = | Mental state finding (finding) |

    Has intent = | Diagnostic intent (qualifier value) |

    Evaluation for signs and symptoms of mental/emotional health problems (procedure)


    Method = | Evaluation – action (qualifier value) |


    Has focus = | Mental state, behavior and/or psychosocial function finding (finding) |

     

    Has intent = | Diagnostic intent (qualifier value) |

    Initial psychiatric interview with mental status and evaluation (procedure)


    Note: Mental status exam = structured interview + observation of the person as an entire being (physical appearance and motor behavior)


    Method = | Evaluation – action (qualifier value) |

     

    Has intent = | Diagnostic intent (qualifier value) |

    History and physical examination, follow-up for emotional or mental disease (procedure)


    Not clear on concept. Is this a history and physical exam designed to rule out biomedical cause of a mental disorder that has been diagnosed, or is this a complete physical + mental health evaluation. i.e., clinical interview including MSE, either immediately following diagnosis of mental disorder or after some period of time (e.g., follow up after treatment)?

    Ambiguous

    Method = | History taking – action (qualifier value) |

    Method = | Examination – action (qualifier value) | (?)

     

    Has focus = | Mental disorder (disorder) |


    Has intent = no claim


    One of the following?

    Associated with = | Mental disorder (disorder) | (?)

    After = | Mental disorder (disorder) | (?)


  11. Stephen Beller

    Nice to see you're trying to define the concept of "mental." Following are my thoughts about what “mental” functions are, how they relate to physical functions, and how can they be examined?

    Mental functions:

    • Are subjective (first person) expressions (experiences) that, from a biological/physical perspective, emerge via neurological activities of the nervous system (including brain and sensory organ structures).
    • Cannot be fully understood from a biological/physical perspective since they produce subjective experiences that include (conscious and subconscious) awareness of reality perceived to exist in one’s internal and external environments, as well as in one’s imagination.
    • May or may not be observable depending on how they are expressed, e.g., they can be overtly expressed through one’s words and actions, and/or expressed privately through one’s thoughts as internal dialogues (“self-talk”) and images (in the “mind’s eye”).
    • Have physiological aspects involved in memory, attention, focus, and cognitions (reasoning, language, etc.).
    • Have aspects that can be assessed/evaluated directly via observation (as aforementioned) or indirectly with psychometric assessment tools; these mental aspects include:
      • Cognitions/Thoughts (beliefs, assumptions, psychological perceptions, appraisals, attributions, biases, intentions, knowledge, understandings, etc.)
      • Intuitions, imaginations, ideas, intentions
      • Delusions, illusions, and hallucinations
      • Concomitant affect, emotions, moods
      • Concomitant behaviors, reactions (reflexive actions).
    • Can be influenced (or caused) by one’s:
      • Social factors (such as childhood experiences and SDH)
      • Life experiences
      • Medication side-effects
      • Medical conditions’ symptoms.
    • May be maladaptive (disordered, dysfunctional, self-defeating, fostering poor outcomes) or adaptive (healthy, fostering beneficial outcomes).

    Hope this is helpful,

    Steve