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1
Q

What is the primary focus of the chapter?

A

The use of terminologies, classifications, and code sets in electronic health record (EHR) and administrative systems

The chapter emphasizes the connection to semantic interoperability and implementation issues.

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2
Q

Define ‘terminology’ in the context of healthcare.

A

The domain of terms, codes, and their design and use

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3
Q

What are ‘terminologies’ also known as?

A

Code systems

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4
Q

What is the distinction between ‘terminology’ and ‘terminologies’?

A

Terminology refers to the domain of terms, while terminologies are specific knowledge assets in a domain

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5
Q

What is a ‘classification’?

A

A system that uses a monohierarchical arrangement to organize related entities

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6
Q

What does ‘controlled terminology’ mean?

A

A specific, managed knowledge asset distinguishing it from more general meanings

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7
Q

What is an example of a classification in healthcare?

A

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

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8
Q

What is an example of an ontology?

A

Logical Observation Identifiers Names and Codes (LOINC)

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9
Q

What is a concept-oriented terminology?

A

A specification of a set of words or phrases intended to represent the concepts required for a particular use

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10
Q

Fill in the blank: A good terminology should be _______.

A

concept-oriented

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11
Q

What does ‘concept permanence’ mean in terminologies?

A

The meanings of concepts do not change over time, even if the terminology evolves

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12
Q

True or False: A good terminology should use semantic identifiers.

A

False

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13
Q

What is a key feature of a good terminology regarding identifiers?

A

It should use nonsemantic identifiers

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14
Q

What does it mean for a terminology to support a polyhierarchy?

A

A concept can have more than one parent

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15
Q

What is the Unified Code for Units of Measure (UCUM) used for?

A

To define codes for units of measure

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16
Q

What is an example of a code system that supports compositional codes?

A

UCUM

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17
Q

What does LOINC stand for?

A

Logical Observation Identifiers Names and Codes

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18
Q

What type of identifiers do LOINC codes use?

A

Nonsemantic identifiers

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19
Q

What is the main purpose of RxNorm?

A

To provide normalized names for clinical drugs

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20
Q

What is the core unit in RxNorm?

A

Semantic clinical drug

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21
Q

How many unique active concepts does SNOMED CT define?

A

Almost 400,000

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22
Q

What does SNOMED CT include in addition to concepts?

A

Relationships between concepts

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23
Q

Fill in the blank: A terminology that uses a monohierarchical system is known as a _______.

A

classification

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24
Q

What is the significance of ‘not elsewhere classified’ in terminologies?

A

It creates ambiguity as the meaning of such terms may change over time

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25
What is the purpose of the International Classification of Diseases, Tenth Revision (ICD-10-CM)?
To support statistical aggregation and public health statistics
26
What type of terminology is RxNorm classified as?
Terminology/Ontology
27
What is RxNorm?
A standardized nomenclature for medications that provides maps to the FDA's Unique Ingredient Identifier and National Drug Codes ## Footnote RxNorm codes are used in Medication Reference Terminology (MED-RT) classifications.
28
What is SNOMED CT?
The largest and most comprehensive terminology in widespread use, defining almost 400,000 unique active concepts and 1.3 million relationships ## Footnote SNOMED CT is published by SNOMED International and supports various use cases.
29
How many unique active concepts does SNOMED CT define?
Almost 400,000 unique active concepts
30
What is the purpose of SNOMED CT's semantic richness?
To support a variety of use cases, including those that may not yet be known
31
What is terminology binding?
The process of tying together a data element in an information model with a set of concepts that may appropriately complete the thought
32
What is a value set?
A subset of a terminology that designates the values (codes and terms) appropriate to a data element
33
What are the two ways to construct a value set definition?
1. Extensional definition (explicitly listing required values) 2. Intensional definition (stating a rule for inclusion)
34
What is a value set expansion?
The resulting list of values when a value set definition is applied to the terminologies from which it draws its terms
35
What does binding strength refer to?
The level of rigor with which the constraint of a value set should be enforced
36
True or False: A value set can change over time.
True
37
What is model impedance?
The phenomenon where the semantics of the model and the terminology don’t quite fit
38
What is the role of maps in clinical systems?
To produce interoperable messages using standard terminologies by asserting equivalences between local codes and standard codes
39
What is native standardization?
The approach of implementing standard codes directly in the operational system
40
What is an ontology in knowledge management?
A formal, explicit specification of a shared conceptualization
41
What is the significance of description logics (DL)?
They support automated logical inference using a class of tools that can infer new facts from previously asserted facts
42
What is an example of a clinical decision support rule?
Proposing the administration of aspirin to patients presenting with chest pain
43
What is the advantage of using classifications like SNOMED CT for drug checks?
They allow for rules that can adapt to various drug interactions without needing constant updates
44
What is the impact of the concept identifier in SNOMED CT?
It supports both clinical decision-making and billing processes
45
What does a value set definition distinguish between?
The value set definition and the value set expansion
46
Fill in the blank: The process of ensuring that data elements are tied to appropriate concepts is called _______.
terminology binding
47
What is the purpose of using a foundational terminology?
To include relationship values that support model binding and semantic interoperability
48
What is the purpose of recording a diagnosis such as 'bacterial pneumonia'?
To support treatment orders and billing ## Footnote The diagnosis concept identifier in SNOMED CT may also facilitate automated inference.
49
What is a key value proposition for ontologies in healthcare?
Recognition of clinically significant relationships ## Footnote This is especially important in situations where human perspective is limited.
50
What is the role of SNOMED International in relation to terminology quality?
Assuring the quality of the terminology ## Footnote However, achieving quality for actionable clinical recommendations remains a future goal.
51
What does the Interoperability Standards Advisory (ISA) process coordinate?
Identification, assessment, and determination of recognized interoperability standards ## Footnote This is managed by the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology.
52
What does the United States Core Data for Interoperability (USCDI) represent?
A standardized set of health data classes and constituent data elements ## Footnote It is intended for nationwide interoperable health information exchange.
53
What types of information does the USCDI cover?
* Clinical information * Administrative information * Patient plans and goals * Potentially unstructured information ## Footnote Examples include problems, allergies, medications, demographics, and clinical notes.
54
What is the goal of the Advanced Cancer Center's dashboard component?
To summarize key information about leukemia patients ## Footnote The aim is to streamline visits with oncologists by presenting relevant data.
55
What standards does the Advanced Cancer Center adopt for its medical records?
* USCDI standards * SNOMED CT for diagnoses and procedures * RxNorm for medications * LOINC for lab results ## Footnote This ensures consistency in data representation.
56
What is a terminologist tasked with when developing value sets?
Blending clinical understanding with terminology understanding ## Footnote This involves identifying relevant SNOMED CT codes and other terminology codes.
57
What is the significance of understanding RxNorm in healthcare terminology?
It is the key terminology for medications ## Footnote RxNorm links to other drug class hierarchies but does not include a hierarchy of drug classes itself.
58
What is a polyhierarchical terminology?
A terminology in which a value can have more than one parent ## Footnote This allows for multiple paths to the root of the tree.
59
What does a value set definition distinguish from?
Value set expansion ## Footnote Understanding this distinction is crucial for effective terminology management.
60
Which terminology is commonly used for vital signs and laboratory test results?
LOINC ## Footnote LOINC is essential for representing laboratory tests and vital signs in electronic health records.
61
What is an example of model impedance?
A system needs to record a value not yet provided by the specified terminology ## Footnote This can hinder interoperability and data exchange.
62
What is a nonsemantic identifier?
Refers to a syntactic rather than a semantic code ## Footnote It does not embed meaning in the code itself.
63
Which terminology meets all of Cimino’s desiderata?
SNOMED CT ## Footnote It is recognized for its comprehensive and structured approach to medical vocabularies.
64
What does the need for a data element to support new values imply?
A need for a more rigorous binding strength ## Footnote This ensures that the system can accommodate unforeseen data requirements.

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