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glossary-ref

Gloss
tSNOMED
CT
can be implemented in a wide range of clinical record applications. These include systems developed for use with other code systems that have been adapted to support glossary-ref
Gloss
tSNOMED
CT
as well as systems designed with the assumption that glossary-ref
Gloss
tSNOMED
CT
would serve as the primary terminology. The glossary-ref
Gloss
tSNOMED
CT
features that applications support and use may vary, partly due to differences in user requirements and partly due to development priorities. Against this background of variability, it is reasonable to ask what is a glossary-ref
Gloss
tSNOMED
CT
implementation
or what is a good glossary-ref
Gloss
tSNOMED
CT
implementation
. While there is not a single or simple answer to these questions, this section identifies some key dimensions which determine the capability of glossary-ref
Gloss
tSNOMED
CT
enabled clinical record systems.

Each of the following sections describes a dimension and outlines a spectrum of capabilities ranging from absence of support (Level 0) to full support (Level 2). A mixture of Level 0 and Level 1 capabilities are likely to be found in existing systems that have been adapted to work with

glossary-ref
Gloss
tSNOMED
CT
. A system specifically developed to work with glossary-ref
Gloss
tSNOMED
CT
should be expected to have capabilities that are at least at the high end of the Level 1 spectrum and should ideally have Level 2 capabilities.

The specification of different levels is not intended to suggest a step-by-step development path. Those needing to rapidly

glossary-ref
Gloss
tSNOMED
CT
enable an existing clinical record system are recommended to follow a two stage approach.

...

Developers who do not require a rapid deployment based on a revision of an existing systems are recommended to skip the first step and proceed to design and develop a flexible solution that utilizes the key strengths of

glossary-ref
Gloss
tSNOMED
CT
.

Each of the following sections describes one dimension that contributes to the overall implementation level. It is important to recognize that:

Anchor
_97dbd05b-45f1-4adf-9a23-3f6499311e45__0
_97dbd05b-45f1-4adf-9a23-3f6499311e45__0

...

A clinical record system may use

glossary-ref
Gloss
tSNOMED
CT
expressions
to represent some or all of the types of information outlined in the list below. The types of information for which glossary-ref
Gloss
tSNOMED
CT
can be used may be limited by the structure used to store the glossary-ref
Gloss
telectronic
health
record
. The significance of these limitations depends upon the intended use of the clinical record system.

  • Level 0: No support for glossary-ref
    Gloss
    tSNOMED
    CT
    expressions
    .
  • Level 1: Support for use of glossary-ref
    Gloss
    tSNOMED
    CT
    limited to particular types of clinical data:
    • Addressing the requirements for a particular type of use;
    • Addressing a set of requirements specified by a particular organization .
  • Level 2: Support for consistent use of glossary-ref
    Gloss
    tSNOMED
    CT
    across a broad scope of information types:
    • Providing a general purpose approach to the use of glossary-ref
      Gloss
      tSNOMED
      CT
      within an glossary-ref
      Gloss
      telectronic
      health
      record
    • Allowing configuration to vary the scope of coverage to meet specific requirements.

The following check-list identifies some of the

glossary-ref
Gloss
telectronic
health
record
elements in which glossary-ref
Gloss
tSNOMED
CT
expressions
might be used. The list is not complete but it covers many of the areas in which use of glossary-ref
Gloss
tSNOMED
CT
has been discussed in glossary-ref
Gloss
IHTSDO
tSNOMED International
working groups. It is intended to assist consideration of the areas in which glossary-ref
Gloss
tSNOMED
CT
should be used to meet the needs of users and organizations. The inclusion of an item in this list does not imply that the glossary-ref
Gloss
tSNOMED
CT
International
Release
provides comprehensive content to populate that part of the record.

...

The logical model underlying the structure of the record has a direct effect on the ability of a

glossary-ref
Gloss
tSNOMED
CT
enabled clinical record system to take advantage of the features of glossary-ref
Gloss
tSNOMED
CT
. An application may use an optimized proprietary internal representation of the glossary-ref
Gloss
telectronic
health
record
. However, consistent use of glossary-ref
Gloss
tSNOMED
CT
across a range of applications requires a common reference model to which proprietary structures are mapped. In addition to this, the ways in which glossary-ref
Gloss
tSNOMED
CT
expressions
are used within a common glossary-ref
Gloss
treference
information
model
need to be constrained to improve predictability and minimize ambiguity.

  • Level 0: A proprietary structure that is neither aligned with nor mapped to a standard glossary-ref
    Gloss
    treference
    information
    model
    :
    • Low: Text only record with no use of clinical codes;
    • High: Structured record supporting use of clinical codes.
  • Level 1: A structure that is aligned with or mapped to a standard glossary-ref
    Gloss
    treference
    information
    model
    :
    Anchor
    _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__4
    _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__4
    • Low: Proprietary structure mapped to a standard model to support limited messaging requirements. Supports the use of glossary-ref
      Gloss
      tSNOMED
      CT
      coding within that structure.
    • High: Structure aligned with a standard glossary-ref
      Gloss
      treference
      information
      model
      that supports that supports use of glossary-ref
      Gloss
      tSNOMED
      CT
      coding.
    • Examples of standard glossary-ref
      Gloss
      treference
      information
      models
      include:
      Anchor
      _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__9
      _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__9
      • The glossary-ref
        Gloss
        tHL7
        Version 3 glossary-ref
        Gloss
        tReference
        Information
        Model
        (RIM);
      • The glossary-ref
        Gloss
        tCEN
        TC251
        Health informatics - glossary-ref
        Gloss
        tElectronic
        health
        record
        communication - Part 1: Reference model ( glossary-ref
        Gloss
        tEN13606
        ).
  • Level 2: An aligned or mapped structure in which glossary-ref
    Gloss
    tSNOMED
    CT
    expressions
    are used in accordance with agreed guidelines for use of a standard glossary-ref
    Gloss
    treference
    information
    model
    :
    Anchor
    _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__b
    _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__b
    • In Level 2 glossary-ref
      Gloss
      tSNOMED
      CT
      is used in accordance with glossary-ref
      Gloss
      tterminology
      binding
      guidance to minimize the semantic gaps and overlaps between the terminology and the information model. Without constraints, these gaps and overlaps lead to inconsistent representation of similar data and thus limit the effective reuse of information.
    • Example of agreed guidelines for using use of glossary-ref
      Gloss
      tSNOMED
      CT
      expression
      in particular reference models include:
      Anchor
      _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__2
      _8b6d88a7-b1c3-479b-9c8f-456f80206b7d__2
      • The glossary-ref
        Gloss
        tHL7TermInfo
        DSTU - Guide to the Use of glossary-ref
        Gloss
        tSNOMED
        CT
        in glossary-ref
        Gloss
        tHL7
        Version 3;
      • Guidance on glossary-ref
        Gloss
        tterminology
        binding
        developed by the glossary-ref
        Gloss
        tUK
        NHS
        Logical Record Architecture for use in an glossary-ref
        Gloss
        tEN13606
        based logical model.

Anchor
_83b41d37-9666-4a92-a163-a03f39ab41d1
_83b41d37-9666-4a92-a163-a03f39ab41d1
Implementation Level - Expression storage

Support for storing

glossary-ref
Gloss
tprecoordinated
and SNOMED CT
Glossary ref
postcoordinated
Glossary ref
Gloss
Spacetrue
tpostcoordinated
Gloss
tSNOMED CT expressions
determines the extent to which glossary-ref
Gloss
tSNOMED
CT
can be used to represent detailed information within an glossary-ref
Gloss
telectronic
health
record
.

  • Level 0: No support for storage of glossary-ref
    Gloss
    tSNOMED
    CT
    expressions
  • Level 1: Support for storage of SNOMED CT
    Glossary ref
    precoordinated
    Glossary ref
    Gloss
    Spacetrue
    tprecoordinated
    Gloss
    tSNOMED CT expressions
    :
    Anchor
    _83b41d37-9666-4a92-a163-a03f39ab41d1__3
    _83b41d37-9666-4a92-a163-a03f39ab41d1__3
    • Support for storage of a glossary-ref
      Gloss
      tprecoordinated
      expression
      implies the ability to store a representation of a glossary-ref
      Gloss
      tconcept
      identifier
      as part of each item for which glossary-ref
      Gloss
      tSNOMED
      CT
      is used:
      Anchor
      _83b41d37-9666-4a92-a163-a03f39ab41d1__1
      _83b41d37-9666-4a92-a163-a03f39ab41d1__1
      • The glossary-ref
        Gloss
        tconcept
        identifier
        may be represented as a 64-bit integer
        Specref
        RefTypedata type
        tInteger
        or as an 18-digit string ;
      • Other internal representations may be used provided they can be resolved to the appropriate glossary-ref
        Gloss
        tIdentifier
        for display, communication or processing.
  • Level 2: Support for storage of SNOMED CT
    Glossary ref
    postcoordinated
    Glossary ref
    Gloss
    Spacetrue
    tpostcoordinated
    Gloss
    tSNOMED CT expressions
    :
    Anchor
    _83b41d37-9666-4a92-a163-a03f39ab41d1__2
    _83b41d37-9666-4a92-a163-a03f39ab41d1__2
    • Support for storage of glossary-ref
      Gloss
      tpostcoordinated
      expression
      implies the ability to store a representation that captures the logical model of a glossary-ref
      Gloss
      tpostcoordinated
      expression
      :
      • The simplest representation of a glossary-ref
        Gloss
        tpostcoordinated
        expression
        is the glossary-ref
        Gloss
        tSNOMED
        CT
        compositional
        grammar
        . Due to the open-ended nature of glossary-ref
        Gloss
        tpostcoordinated
        expressions
        , this representation results in a string of variable length with no clear-cut maximum length.
      • The guide discusses alternative representations including the use of glossary-ref
        Gloss
        texpression
        reference table which enables use of a fixed length reference within the records. This approach uses a UUID which can be represented as a 128-bit integer
        Specref
        RefTypedata type
        tInteger
        or as a hexadecimal string (see Storing expressions ) .
    • This level has variants depending on the extent of support for glossary-ref
      Gloss
      tpostcoordinated
      expression
      storage:
      Anchor
      _83b41d37-9666-4a92-a163-a03f39ab41d1__e
      _83b41d37-9666-4a92-a163-a03f39ab41d1__e
      • Low: Storage of glossary-ref
        Gloss
        tpostcoordinated
        expressions
        limited to specific fields in the record structure;
      • High: Full support for storage of glossary-ref
        Gloss
        tpostcoordinated
        expression
        allowing any valid glossary-ref
        Gloss
        texpression
        to be stored and retrieved.

...

The categorization in this section in based on the extent to which the system enables entry of

glossary-ref
Gloss
tSNOMED
CT
expressions
. In addition, this section indicates the importance of a well-designed user-interface.

  • Level 0: No support for entry of glossary-ref
    Gloss
    tSNOMED
    CT
    expressions
    .

.

  • Level 1: Support for Glossary refSNOMED CT
    Glossary ref
    precoordinated
    Gloss
    Spacetrue
    tprecoordinated
    Gloss
    tSNOMED CT expression
    entry:
    Anchor
    _51c1d64a-8ab6-43ad-93f0-fde5daf99bab__3
    _51c1d64a-8ab6-43ad-93f0-fde5daf99bab__3
    • Low: Access limited to fixed set of glossary-ref
      Gloss
      tSNOMED
      CT
      concepts
      ;
    • Medium: Access to full content of glossary-ref
      Gloss
      tSNOMED
      CT
      ;
    • High: Access to full content of glossary-ref
      Gloss
      tSNOMED
      CT
      with configurable glossary-ref
      Gloss
      tvalue
      sets
      matched to user requirements.
  • Level 2: Support for glossary-ref
    Gloss
    tpostcoordinated
    expression
    entry:
    Anchor
    _51c1d64a-8ab6-43ad-93f0-fde5daf99bab__1
    _51c1d64a-8ab6-43ad-93f0-fde5daf99bab__1
    • Low: Access to limited glossary-ref
      Gloss
      tpostcoordination
      (matching data storage restrictions);
    • Medium: Access to full range of glossary-ref
      Gloss
      tpostcoordination
      supported by the glossary-ref
      Gloss
      tConcept
      Model
      ;
    • High: Access to glossary-ref
      Gloss
      tpostcoordination
      with configurable glossary-ref
      Gloss
      tconstraint
      matched to user requirements.

Another important data entry issue is the ease of use which depends on the usability, relevance and performance of searches. Where

glossary-ref
Gloss
tpostcoordinated
data entry is supported the approach to selecting or constructing glossary-ref
Gloss
tpostcoordinated
expressions
is also significant.

An attempt to categorize specific approaches to the user-interface is subjective as alternative

glossary-ref
Gloss
tuser
interfaces
may be appropriate to different uses. However, for most environments a flexible range of configurable glossary-ref
Gloss
tSNOMED
CT
aware user-interface tools is likely to offer a better user experience than reliance on a one-size fits all glossary-ref
Gloss
tbrowser
or search engine.

Anchor
_f60106b9-a1c8-44c6-82d9-75965e0d0bce
_f60106b9-a1c8-44c6-82d9-75965e0d0bce
Implementation Level - Data retrieval

A major strength of

glossary-ref
Gloss
tSNOMED
CT
is its ability to support meaning based selective retrieval. The extent to which this feature is used by a clinical record system determines the value of entering and storing the data.

  • Level 0: No native support for glossary-ref
    Gloss
    tSNOMED
    CT
    enabled data retrieval:
    Anchor
    _f60106b9-a1c8-44c6-82d9-75965e0d0bce__f
    _f60106b9-a1c8-44c6-82d9-75965e0d0bce__f
    • This level has variants depending on whether it can map code in exported data to glossary-ref
      Gloss
      tSNOMED
      CT
      expressions
      :
      Anchor
      _f60106b9-a1c8-44c6-82d9-75965e0d0bce__0
      _f60106b9-a1c8-44c6-82d9-75965e0d0bce__0
      • Low: No support for glossary-ref
        Gloss
        tSNOMED
        CT
        based analysis;
      • High: Support for extracting a specified set of locally coded data and mapping the local codes to appropriate glossary-ref
        Gloss
        tSNOMED
        CT
        expression
        for central aggregation and analysis.
  • Level 1: Support for retrieval of Glossary refSNOMED CT
    Glossary ref
    precoordinated
    Gloss
    Spacetrue
    tprecoordinated
    Gloss
    tSNOMED CT expressions
    :
    Anchor
    _f60106b9-a1c8-44c6-82d9-75965e0d0bce__1
    _f60106b9-a1c8-44c6-82d9-75965e0d0bce__1
    • This level has a spectrum of variants depending on the level of support for the following features:
      Anchor
      _f60106b9-a1c8-44c6-82d9-75965e0d0bce__5
      _f60106b9-a1c8-44c6-82d9-75965e0d0bce__5
      • Query expressivity: The ability to express
        Specref
        RefTypefield
        tquery
        predicates that explicitly include or exclude glossary-ref
        Gloss
        tsubtypes
        of specifically identified glossary-ref
        Gloss
        tconcepts
        ;
      • Subsumption testing: Use of subtype
        Glossary ref
        SNOMED CT
        Glossary ref
        Gloss
        Spacetrue
        tSNOMED CT
        Gloss
        tsubtype hierarchy
        to interpret and evaluate queries; glossary-ref
      • Gloss
        tConcept
        Equivalence
        : The ability to retrieve equivalent information even if it is represented in different structures within the record;
      • Context awareness: The ability to take account of contextual information, derived from the record structure and/or the
        Glossary ref
        SNOMED
        Glossary ref
        Gloss
        Spacetrue
        tSNOMED
        Gloss
        texpression
        , when interpreting and evaluating queries;
      • Performance: The ability to interpret and evaluate queries within an appropriate period of time and without causing deterioration in other system functions.
  • Level 2: Support for retrieval of SNOMED CT
    Glossary ref
    postcoordinated
    Glossary ref
    Gloss
    Spacetrue
    tpostcoordinated
    Gloss
    tSNOMED CT expressions
    :
    Anchor
    _f60106b9-a1c8-44c6-82d9-75965e0d0bce__6
    _f60106b9-a1c8-44c6-82d9-75965e0d0bce__6
    • This level has a spectrum of variants depending on the level of support for the following additional aspects of the features specified for Level 1:
      Anchor
      _f60106b9-a1c8-44c6-82d9-75965e0d0bce__e
      _f60106b9-a1c8-44c6-82d9-75965e0d0bce__e
      • Query expressivity: The ability to represent glossary-ref
        Gloss
        tpostcoordinated
        predicates in a
        Specref
        RefTypefield
        tquery
        ;
      • Subsumption testing: Use of glossary-ref
        Gloss
        tdefining
        characteristics
        and glossary-ref
        Gloss
        tnormal
        form
        transformations
        (or a glossary-ref
        Gloss
        tdescription
        logic
        classifier
        ) to determine whether glossary-ref
        Gloss
        texpressions
        are subsumed by
        Specref
        RefTypefield
        tquery
        predicates; glossary-ref
      • Gloss
        tEquivalence
        : Use of glossary-ref
        Gloss
        tdefining
        characteristics
        and glossary-ref
        Gloss
        tnormal
        form
        transformations
        (or a glossary-ref
        Gloss
        tdescription
        logic
        classifier
        ) to determine glossary-ref
        Gloss
        tequivalence
        between different glossary-ref
        Gloss
        tpostcoordinated
        expressions
        and in different structures within the record;
      • Context awareness: The ability to take account of contextual information derived from the record structure and/or
        Glossary ref
        postcoordinated
        Glossary ref
        SNOMED
        Glossary ref
        Gloss
        Spacetrue
        tpostcoordinated
        Gloss
        Spacetrue
        tSNOMED
        Gloss
        texpressions
        , when interpreting and evaluating queries;
      • Performance: The ability to interpret and evaluate queries that support glossary-ref
        Gloss
        tpostcoordinated
        representations within an appropriate period of time and without causing deterioration in other system functions.

...

The ability to send and received

glossary-ref
Gloss
tSNOMED
CT
expressions
in messages or other communication is partially dependent on data entry, storage and retrieval capabilities. However, some types of communication may be supported by mapping or human-readable renderings even in the absence of internal support for glossary-ref
Gloss
tSNOMED
CT
.

  • Anchor
    _c0528298-1f3b-4abc-b965-97db5ade147d__d
    _c0528298-1f3b-4abc-b965-97db5ade147d__d
    Level 0: Mapping based support for communication of glossary-ref
    Gloss
    tSNOMED
    CT
    expressions
    :
    • Inbound communications containing glossary-ref
      Gloss
      tSNOMED
      CT
      expressions
      :
      Anchor
      _c0528298-1f3b-4abc-b965-97db5ade147d__7
      _c0528298-1f3b-4abc-b965-97db5ade147d__7
      • Low: Not supported.
      • Medium: Rendered as human-readable text. Unless the inbound message also contains the
        Specref
        RefTypefield
        tterm
        text, this requires access to some glossary-ref
        Gloss
        tSNOMED
        CT
        enable glossary-ref
        Gloss
        tTerminology
        services
        to lookup and display the relevant terms
        Specref
        RefTypefield
        tterm
        .
      • High: Mapped to an internal coding scheme or classification. This may be feasible to support specific use cases but not for the full scope of clinical information.
    • Outbound communication containing glossary-ref
      Gloss
      tSNOMED
      CT
      expressions
      :
      • Low: Not supported;
      • Medium: Supported for a few specific types of clinical data in the existing system by mapping to from an existing code system to glossary-ref
        Gloss
        tSNOMED
        CT
        ;
      • High: Supported for most clinical data in the existing system by mapping to from an existing code system to glossary-ref
        Gloss
        tSNOMED
        CT
        .
  • Level 1: Native support for communication of Glossary refSNOMED CT
    Glossary ref
    precoordinated
    Gloss
    Spacetrue
    tprecoordinated
    Gloss
    tSNOMED CT expressions
    :
    • Inbound communications containing Glossary refSNOMED CT
      Glossary ref
      precoordinated
      Gloss
      Spacetrue
      tprecoordinated
      Gloss
      tSNOMED CT expressions
      :
      • Low: Supported for some types of information but constrained by data entry and glossary-ref
        Gloss
        texpression
        storage capabilities;
      • High: Supported for most types of information.
    • Outbound communications containing Glossary refSNOMED CT
      Glossary ref
      precoordinated
      Gloss
      Spacetrue
      tprecoordinated
      Gloss
      tSNOMED CT expressions
      :
      Anchor
      _c0528298-1f3b-4abc-b965-97db5ade147d__6
      _c0528298-1f3b-4abc-b965-97db5ade147d__6
      • Low: Supported but limited by data entry and storage and retrieval capabilities;
      • High: Supported for most types of information.
  • Level 2: Native support for communication of SNOMED CT
    Glossary ref
    postcoordinated
    Glossary ref
    Gloss
    Spacetrue
    tpostcoordinated
    Gloss
    tSNOMED CT expressions
    :
    Anchor
    _c0528298-1f3b-4abc-b965-97db5ade147d__e
    _c0528298-1f3b-4abc-b965-97db5ade147d__e
    • Inbound communications containing Glossary refSNOMED CT
      Glossary ref
      postcoordinated
      Gloss
      Spacetrue
      tpostcoordinated
      Gloss
      tSNOMED CT expressions
      :
      • Low: Support limited to particular attributes (e.g. |laterality|, |causative agent|) in glossary-ref
        Gloss
        tpostcoordinated
        expression
        ;
      • Medium: Support for general glossary-ref
        Gloss
        tpostcoordination
        applied to some types of information;
      • High: Able to receive, process and store any valid glossary-ref
        Gloss
        tpostcoordinated
        expression
        .
    • Outbound communications containing SNOMED CT
      Glossary ref
      postcoordinated
      Glossary ref
      Gloss
      Spacetrue
      tpostcoordinated
      Gloss
      tSNOMED CT expressions
      :
      Anchor
      _c0528298-1f3b-4abc-b965-97db5ade147d__3
      _c0528298-1f3b-4abc-b965-97db5ade147d__3
      • Low: Support limited to particular attributes (e.g. |laterality|, |causative agent|) in glossary-ref
        Gloss
        tpostcoordinated
        expression
        ;
      • Medium: Support for outbound communication of any glossary-ref
        Gloss
        tpostcoordinated
        expression
        that can be entered or stored in the system;
      • High: Support for outbound communication of any valid glossary-ref
        Gloss
        tpostcoordinated
        expression
        .