Designing an introspective, multipurpose, controlled medical vocabulary

Abstract

The medical vocabulary used in clinical information systems must be more than a simple list of terms. We argue that such a vocabulary must have synonymy, domain completeness and multiple classifications, providing consistent views and explicit relationships, while remaining unambiguous and non-redundant. We examine the abilities of existing controlled vocabularies (ICD9-CM, SNOMED, MeSH, CMIT, CPT4, COSTAR, HELP, DXPLAIN, and UMLS) to meet these goals and propose an enhanced vocabulary structure based on a directed, acyclic semantic net. This structire provides a representation which permits introspection by the vocabulary maintenance system responsible for providing a terminology which meets our seven requirements. Ihe vocabulary, which we refer to as the Medical Entities Dictionary, will serve a variety of applications