Jim Case

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Jim Case

• Updated model for cerebrovascular accident based on new model for injuries

Discussion: 

Comments from Monique van Berkum with BGO response:

JTC: To clarify the traumatic injury model:  It was recognized at the time that the model was developed that there was both phyiscal trauma and psychological trauma.  The absence of a required ASSOCIATED MORPHOLOGY relationship in traumatic injury concepts thus allows for both types of trauma to be included in the model.  Currently, concept such as  47505003 |Posttraumatic stress disorder (disorder)| classify both as a traumatic injury and as an Axiety disorder.  If one looks at the broad definition of trauma as being either physical or psychological or both, this classification is not incorrect.  One question to answer is whether there is benefit in separating out physical and psychological trauma?

Decision:

• Revised proposal for modeling cerebrovascular accidents.pptx

Monica Harry

Jim Case

Briefing note for review:

Duplicate concepts in the Computed Tomography imaging hierarchy

Discussion:

Comments from Monique van Berkum: Duplicate concepts CT comments - MVB

James R. Campbell attached

Decision:

Group determined that the combined terms (that did not specify guidance) should be inactivated as ambiguous.

• Monica Harry  to inactivate combined concepts as ambiguous

Resolving Ambiguity – Options for Consideration

Following the last EAG meeting members were asked to consider the 3 options for resolving ambiguity for concepts where not all of the elements that make up full semantic equivalence could or should be offered as clinically suitable replacements.

We would be grateful if you could review the above and provide your views and comments In the comments boxes below.

The following simple example is used to demonstrate each option:

3094009 |Vomiting in infants AND/OR children (disorder)|

..has 3 potential meanings:

Vomiting in infants

Vomiting in children

Vomiting in infants and children

The sum of these 3 meanings gives complete semantic equivalence with the concept 3094009 |Vomiting in infants AND/OR children (disorder)|, however, from the perspective of clinical use “Vomiting in infants and children” is not likely to be helpful as a statement in the individual patient’s record as they cannot be both an infant and a child at the time when the record entry was made.

In order to resolve the inactivation of the ambiguous concept 3094009 |Vomiting in infants AND/OR children (disorder)|there are 3 potential solutions:

Option 1: Representing complete semantic equivalence with “POSSIBLY_EQUIVALENT_TO”:

3094009 |Vomiting in infants AND/OR children (disorder)|

Inactivated as “Ambiguous”:

POSSIBLY_EQUIVALENT_TO new concept |Vomiting in infants (disorder)|

POSSIBLY_EQUIVALENT_TO new concept |Vomiting in children (disorder)|

POSSIBLY_EQUIVALENT_TO new concept |Vomiting in infants and children (disorder)|

As a second stage:

new concept |Vomiting in infants and children (disorder)|

…would be inactivated as “Erroneous” with an annotation; “Vomiting in infants and children is an erroneous concept because an individual cannot be both a child and an infant at the same time”.

There is then a judgment to be made, whether to provide a potential replacement or not. Given that the concept is deemed “Erroneous” it would be acceptable not to provide a suitable replacement that is of equal or less specificity than the original, however, it may be more helpful to use a  historical association of “REPLACEED_BY” and point to the concept 422400008 |Vomiting (disorder)|.

This approach clearly indicates to the user and system implementer that 3094009 |Vomiting in infants AND/OR children (disorder)| is an ambiguous concept and that it is possible to provide full semantic equivalence using individual concepts to exactly represent each element of the ambiguity and from which the user must choose one as a target replacement.

If the user does not know whether this was intended to be vomiting in an infant or child, they would choose |Vomiting in infants and children (disorder)|, at which point the system would then indicate that this concept had been inactivated and replaced by 422400008 |Vomiting (disorder) as the replacement.

This approach intends to make explicit the thinking behind the inactivation and its resolution in a way that is both machine-processable and transparent to the end-user.

There is an impact on the author/editor in having to create and then inactivate the concept that is never to be released as an active concept but much of this process could be supported by enhanced tooling.

Option 2: Using a combination of both “POSSIBLY_EQUIVALENT_TO” and “POSSIBLY_REPLACED_BY”:

3094009 |Vomiting in infants AND/OR children (disorder)|

Inactivate as “Ambiguous”:

POSSIBLY_EQUIVALENT_TO new concept |Vomiting in infants (disorder)|

POSSIBLY_EQUIVALENT_TO new concept |Vomiting in children (disorder)|

POSSIBLY_REPLACED_BY 422400008 |Vomiting (disorder)

An annotation would need to be added; “This concept cannot be made fully semantically equivalent using only clinically useful “POSSIBLY_EQUIVALENT_TO” concepts and therefore a clinically relevant “POSSIBLY_REPLACED_BY” alternative has been provided for that element that is thought to be clinically in error”.

This approach appears to give the same end result as option 1 above, however, the end-user is shielded from the detailed judgment that the author/editor made to identify full semantic equivalence of the inactivated concept. How they then identified and replaced that element that was deemed not to be clinically useful. It also makes it more difficult for implementers if the resolution of ambiguity is sometimes achieved with “POSSIBLY_EQUIVALENT_TO” alone and sometimes in combination with “POSSIBLY_REPLACED_BY”.

3. Using “POSSIBLY_REPLACED_BY” alone:

3094009 |Vomiting in infants AND/OR children (disorder)|

Inactivate as ambiguous

POSSIBLY_REPLACED_BY new concept |Vomiting in infants (disorder)|

POSSIBLY_REPLACED_BY new concept |Vomiting in children (disorder)|

POSSIBLY_REPLACED_BY 422400008 |Vomiting (disorder)

The issue with this approach is that it implies that it was not possible to provide semantically equivalent concepts for ANY part of the concept 3094009 |Vomiting in infants AND/OR children (disorder)|. This is of course not true as we have already established that 2 of the 3 elements can be provided with semantically equivalent alternatives.

Discussion:

James R. Campbell We should be considering the also the advisability of creating new concepts just to maintain the expressivity implied in some of these ambiguous concepts.  See the attached frequency of use of SNOMED 'Vomiting' concepts at Nebraska.  I would favor a revised option 2 above with only REPLACE BY 422400008|Vomiting.

Decision:

Paul Amos to bring back additional examples that better demonstrate the challenges related to potentially ambiguous concepts

• Paul Amos to bring back additional examples with proposed historical relationships for further discussion

Paul Amos

Jim Case

Positive/Negative X (finding)

The hierarchy 118245000 |Measurement finding (finding)| includes:

74 concepts of the form xxx positive (finding)

e.g. 165816005 |Human immunodeficiency virus positive (finding)|

54 concepts of the form xxx negative (finding)

e.g. 165815009 |Human immunodeficiency virus negative (finding)|

In a comment on artf 222738 - Review hierarchy: Positive laboratory findings JCA stated:

"One consideration in assessing the proper use of HasInterpretation for these types of concepts is to disallow the use of the finding values "positive" and "negative" in the concept model. These have long been problematic and do not reflect the actual capability of the laboratory test. I have been advocating for a while that we only use "detected", "not detected" and "equivocal" as results for non-numeric laboratory results due to the limits under which a laboratory test operates. We can never be certain that a test is negative as the lower limit of detection prevents us from determining true absence. The term positive implies to some people much more than is warranted by a particular laboratory test."

Given that The hierarchy 118245000 |Measurement finding (finding)| is part of the QI project a decision needs to be made on whether now is the time to review these concepts or leave them for a later date.

The observables project has sanctioned the use of 260373001 |Detected (qualifier value)| and 260415000 |Not detected (qualifier value)| for detecting the presence of organisms and I would like to propose that we adopt this approach for the positive/negative findings in this hierarchy for the purposes of modeling. The question is then whether we should seek the agreement of the community of practice to update the FSN/PT. it would be good if we could avoid wholesale inactivation and replacement.

Therefore, the options are:

1. Inactivate existing content as “Erroneous” (because we are saying that the existing FSN does not represent the limitations of the laboratory test) and replace it with the proposed concepts as indicated in the proposal above.
2. Inactivate the existing FSN/PT and replace it with the wording as indicated above.
3. Include a synonym of “xxx positive” or “xxx negative” as appropriate and inactivate the existing FSN/PT and replace it with the wording as indicated above.

Whichever option is chosen will require consultation with the community of practice given the importance of laboratory findings in clinical records.

Briefing note: https://drive.google.com/file/d/1MovcTNvY8-UuKw4R9_6K8M8u59r1iFox/view?usp=sharing

Discussion:

The example provided ( and probably most of the concepts of this type) were determined to be ambiguous as stated in the FSN s these measurements may related to multiple aspects of the analytes in question.  For example, an "X organism positive" finding may refer to the whole organism, a part of the organism or antibodies to that organism.  In many cases these terms are modeled as antibody tests, while not specifying that in the FSN.  

Decision:

Consensus of the group is that these concepts shouldbe inactivated as ambiguous and replaced by more specific concepts representing the different types of measurements.

The use of "Positive" and "Negative" was agreed to be inappropriate for this type of measurement findings.  Use of "detected", "not detected" and "indeterminate" (as needed) should be applied to the new concepts created to replace the ambiguous terms.

• Paul Amos to implement the decisions reached by the EAG

Andrew Norton James R. Campbell

Based on a discussion at the Anesthesia CRG and Observables Project there is a requirement to add more content for Glasgow Coma Scale

Please see full discussion here: https://confluence.ihtsdotools.org/display/ACRGT/Glasgow+Coma+Score

Presentation included with this agenda item suggesting common observables definitions.

References to Standarization of the GCS:

https://zibs.nl/wiki/GlasgowComaScale-v3.2(2020EN)

https://ckm.openehr.org/ckm/archetypes/1013.1.137/printable

https://www.glasgowcomascale.org/

Draft document from Anesthesia CRG: https://drive.google.com/file/d/1lZJlarREeIIRPk5E1zVtZUktLQlPH3G5/view?usp=sharing

Discussions within Observables Project Group and and review of assessment scores deployed at Nebraska have proceeded with extended proposal for inclusion of assessment scales in use in Sweden as well as US.   

Modelling proposal added to Attachment s summarizing Assessment Scale Score Observables development: Clinical Scale Scores_20210224.pptx.  Proposal promotes expanding content model for full definition of scales such as co-morbidity, Glasgow Coma Scale and SOFA scores.

Anesthesia CRG wishes to explore further the best model for including definitions/explanations of Ordinal Scale score Value sets used in calculated scores.

Discussion:

An overview of the goals for the modeling of Assessment instruments and clinical findings related to patient assessment was provided.  Participants in the call were encouraged to join OIMP calls.  Details about the Observables project canbe found at: https://confluence.ihtsdotools.org/display/OBSERVABLE

• clinicians would like to see

Daniel Karlsson@James Campbell

Toni Morrison

Jim Case