1. What do SNOMED CT Concepts Represent? Stefan Schulz University Medical Center, Freiburg, Germany 31 July & 1 August 2009 Internationales Begegnungszentrum Bergstraße 7a, 18057 Rostock

2. Why ontology matters for medicine Introduction Examples Discussion Conclusions

3. World Health Organization; ICD-113

4. 4

5. Thanks: Christopher Chute, Mayo Clinic5

6. International Classification of Diseases Introduction Examples Discussion Conclusions

7. Why ontologies matter for medicine Introduction Examples Discussion Conclusions Create taxonomies of natural kinds –classify instances in the world –basic for health statistics –exemplified in disease & procedure classification systems

8. Thanks: Christopher Chute, Mayo Clinic8

9. Medical Subject Headings Introduction Examples Discussion Conclusions

12. Why ontologies matter for medicine Create taxonomies of natural kinds –classify instances in the world –basic for health statistics –exemplified in disease & procedure classification systems Creating common vocabularies / terminologies –normalization of word meanings –annotation of research data –facilitate document and fact retrieval Introduction Examples Discussion Conclusions

13. Why ontologies matter for medicine Create taxonomies of natural kinds –classify instances in the world –basic for health statistics –exemplified in disease & procedure classification systems Creating common terminologies –normalization of word meanings –annotation of research data –facilitate document and fact retrieval Introduction Examples Discussion Conclusions set theory extensionality real things linguistics intensionality concepts

14. SNOMED: Development SNOP SNOMED SNOMED II SNOMED 3.0 SNOMED 3.5 SNOMED RT SNOMED CT 1965 1970 1975 1980 1985 1990 1995 2000 2005 pathology nomenclature multiaxial nomenclature of whole medicine logic-based descriptions Fusion with CTV3 ontological principles Context Model IHTSDO SNOMED im UMLS Introduction Examples Discussion Conclusions

15. SNOMED CT Stefan Schulz: SNOMED CT Introduction Examples Discussion Conclusions “Standardized Nomenclature of Medicine – Clinical Terms” Comprehensive clinical terminology ( > 300,000 representational units) Devised to represent the meaning of clinical terms for whole range of health and clinical care Increasingly guided by ontological design principles Using a formal language: (Basic) Description Logics EL: –equivalence (  ), subsumption ( ⊑ ) –existential role restriction (  ), conjunction ( ⊓ )

16. SNOMED CT as a controlled vocabulary links medical terms including synonyms and translations to language- independent concepts z.Zt. 311 000 concepts 732 000 engl. terms Stefan Schulz: SNOMED CT Introduction Examples Discussion Conclusions

17. SNOMED CT as a formal system hierarchies: strict specialization (is-a) Stefan Schulz: SNOMED CT Introduction Examples Discussion Conclusions

18. SNOMED CT as a formal system restrictions based on simple description logics: C1 – Rel – C2 interpreted as:  x: instanceOf(x, C1)   y: instanceOf(C2)  Rel(x,y) Relations (Attributes): z.B. Associated morphology Finding site (50 relation types) Stefan Schulz: SNOMED CT Introduction Examples Discussion Conclusions

19. SNOMED CT als formales System definierte vs. primitive Konzepte defined vs. primitive concepts Stefan Schulz: SNOMED CT Introduction Examples Discussion Conclusions

20. Deficit of previous non-formal SNOMED versions D5-46210Acute appendicitis, NOS D5-46100Appendicitis, NOS G-A231Acute M-41000Acute inflammation, NOS G-C006In T-59200Appendix, NOS G-A231Acute M-40000Inflammation G-C006In T-59200Appendix, NOS SNOMED INTERNATIONAL Unterschiedliche Beschreibungen desselben Sachverhalts sind nicht aufeinander abbildbar Aneinanderreihung von Konzepten und Relationen nicht eindeutig interpretierbar Introduction Examples Discussion Conclusions

21. Ontological commitment “Agreement about the ontological nature of the entities being referred to by the representational units in an ontology” (modified definition following Gruber 93) Formal ontologies: subsumption and equivalence statements are either true or false Problem: change of truth-value of axioms and sentences according to resulting competing interpretations Introduction Examples Discussion Conclusions

23. Tonsillectomy Introduction Examples Discussion Conclusions http://z.about.com/d/create/1/0/z/n/-/-/0119.jpg

24. 1.Tonsillectomy planned   rg.(  associatedProcedure.Tonsillectomy ⊓  procedureContext.Planned ⊓  subjectRelationshipContext.SubjectOfRecord ⊓  temporalContext.CurrentOrSpecifiedTime) 2.Denied tonsillectomy  Tonsillectomy ⊓  Priority.Denied 3.Tetralogy of Fallot  PulmonicValveStenosis ⊓ VentricularSeptalDefect ⊓ OverridingAorta ⊓ RightVentricular hypertrophy SNOMED CT Examples Introduction Examples Discussion Conclusions

25. 1.Tonsillectomy planned   rg.(  associatedProcedure.Tonsillectomy ⊓  procedureContext.Planned ⊓  subjectRelationshipContext.SubjectOfRecord ⊓  temporalContext.CurrentOrSpecifiedTime) 2.Denied tonsillectomy  Tonsillectomy ⊓  Priority.Denied 3.Tetralogy of Fallot  PulmonicValveStenosis ⊓ VentricularSeptalDefect ⊓ OverridingAorta ⊓ RightVentricular hypertrophy SNOMED CT Examples Introduction Examples Discussion Conclusions

26. 1.Tonsillectomy planned   rg.(  associatedProcedure.Tonsillectomy ⊓  procedureContext.Planned ⊓  subjectRelationshipContext.SubjectOfRecord ⊓  temporalContext.CurrentOrSpecifiedTime) 2.Denied tonsillectomy  Tonsillectomy ⊓  Priority.Denied 3.Tetralogy of Fallot  PulmonicValveStenosis ⊓ VentricularSeptalDefect ⊓ OverridingAorta ⊓ RightVentricular hypertrophy SNOMED CT Examples Introduction Examples Discussion Conclusions

27. http://iwannabeadr.com/ Pulmonic valve stenosis Introduction Examples Discussion Conclusions

28. http://iwannabeadr.com/ Pulmonic valve stenosis Introduction Examples Discussion Conclusions Tetralogy of Fallot

29. http://iwannabeadr.com/ Pulmonic valve stenosis Tetralogy of Fallot Introduction Examples Discussion Conclusions

30. 1.Tonsillectomy planned   rg.(  associatedProcedure.Tonsillectomy ⊓  procedureContext.Planned ⊓  subjectRelationshipContext. SubjectOfRecord ⊓  temporalContext.CurrentOrSpecifiedTime) 2.Denied tonsillectomy  Tonsillectomy ⊓  Priority.Denied 3.Tetralogy of Fallot  PulmonicValveStenosis ⊓ VentricularSeptalDefect ⊓ OverridingAorta ⊓ RightVentricular hypertrophy SNOMED CT Examples Introduction Examples Discussion Conclusions

31. 1.Tonsillectomy planned   rg.(  associatedProcedure.Tonsillectomy ⊓  procedureContext.Planned ⊓  subjectRelationshipContext. SubjectOfRecord ⊓  temporalContext.CurrentOrSpecifiedTime) 2.Denied tonsillectomy  Tonsillectomy ⊓  Priority.Denied 3.Tetralogy of Fallot  PulmonicValveStenosis ⊓ VentricularSeptalDefect ⊓ OverridingAorta ⊓ RightVentricular hypertrophy SNOMED CT Examples Introduction Examples Discussion Conclusions “every denied tonsillectomy is a tonsillectomy” “every instance of “Tonsillectomy planned” implies some tonsillectomy” “every Fallot is also a Pulmonic Valve Stenosis”

32. Problems The negation of a process is a specialization of this process A plan is defined such as its realization is implied A (definitional) proper part of a compound entity is its taxonomic parent Introduction Examples Discussion Conclusions

33. Proper parts of taxonomic parents ? is-a Tetralogy of Fallot Traffic Light Red Light Yellow Light Green LightASD PVS RVH OA Introduction Examples Discussion Conclusions Example from Harold Solbrig

34. Relevance The three examples are not accidental errors – they represent systematic architectural patterns of SNOMED CT –for 50,000 procedure concepts, “denied” subconcepts can be created –hundreds of concepts have properties like “planned”, “suspected” or “known absent” in their definition –77,000 “procedure” or “finding” concepts have their constituent parts as parent concepts (side effect of role group constructor) Hypothesis: they represent different and competing ontological commitments strongly influenced by the practice of clinical coding and documentation Introduction Examples Discussion Conclusions

35. Alternative interpretations ? Introduction Examples Discussion Conclusions

36. Alternative interpretation (I) 4 7:30 #388827 1024 Bil. Tonsillectomy AB OB AR Int CN 4 8:15 #445321 1022 Adenoidectomy AB OB AR Int CN 4 9:00 #200334 1023 Bil. Tonsillectomy OB AB AR Int CN 4 9:45 #889881 1001 Mastoidectomy AB OB AR Int CN suspended Introduction Examples Discussion Conclusions Information Artifact

37. Alternative interpretation (I) SNOMED CT concepts are instantiated by representational artifacts as contained in an electronic patient record –A documentation artifact of a certain kind is created for each patient scheduled for an operation –The class of these information artifacts includes subclasses of information artifacts that include values such as “planned”, “executed”, “denied” etc. –An expression such as  associatedProcedure.Tonsillectomy can be seen representing a plan (but  is false anyway) – Priority.Denied refines the class of information artifacts but not the class of tonsillectomies Introduction Examples Discussion Conclusions

38. Alternative interpretation (I) Extension of “Tonsillectomy” includes extension of “Denied Tonsillectomy”: FALSE x x x Introduction Examples Discussion Conclusions

39. Alternative interpretation (I) Extension of “Record of Tonsillectomy” includes extension of “Record of Denied Tonsillectomy”: TRUE T T T T T T T T T T T T T T T T T T T T T T T T T T T T x x x Introduction Examples Discussion Conclusions

40. Alternative interpretation (II) SNOMED CT concepts are instantiated by patients or clinical situations. –Pulmonic Valve Stenosis stands for “Patient with a pulmonic valve stenosis” –Tetralogy of Fallot stands for “Fallot Patient” –All Fallot patients are also patients with pulmonic valve stenosis because every instance of Tetralogy of Fallot has one instance of pulmonic valve stenosis as part Consequence: –Finding and procedure concepts extend to classes of patients but not to classes of findings or procedures Introduction Examples Discussion Conclusions

41. Extension of “Pulmonic Valve Stenosis” includes extension of “Tetralogy of Fallot”: FALSE Introduction Examples Discussion Conclusions Alternative interpretation (II)

42. F PPPP FF P F PP Extension of “Patient with Pulmonic Valve Stenosis” includes extension of “Patient with Tetralogy of Fallot”: TRUE Introduction Examples Discussion Conclusions Alternative interpretation (II)

43. F PPPP FF P F PP Extension of “Situation with Pulmonic Valve Stenosis” includes extension of “Situation with Tetralogy of Fallot”: TRUE Alternative interpretation (II) Introduction Examples Discussion Conclusions

44. Conclusions SNOMED CT’s ontological commitment is heterogeneous SNOMED CT’s alternative interpretations are implicit, thus leaving burden of interpretation to the user. The alternative interpretations reflect clinicians’ reasoning patterns SNOMED mixes elements of an ontology with elements of information models (information artifacts) Use of SNOMED CT as an ontology depends on agreement about its ontological commitment Introduction Examples Discussion Conclusions