Medical-concept models and medical records: an approach based on GALEN and PEN&PAD.

OBJECTIVES

To investigate the issues raised in applying a preliminary version of the GALEN compositional concept reference (CORE) model to a series of radiographic reports, and to demonstrate that the same underlying concept model could be used in conjunction with both a detailed, fine-grained model of medical records based on that used in the PEN&PAD project and with other more conventional medical-record models.

DESIGN

Following analysis and representation of concepts from a set of reports, a single report was taken as a "case study." This report was analyzed in detail in its entirety and represented using each of the medical-record models.

RESULTS

The reports were successfully represented within the limits of the study, but a number of significant issues were raised.

CONCLUSION

The compositional approach plus the PEN&PAD medical-record model allowed detailed information in the radiographic report to be represented, including information about the inferences and the clinical process. The resulting representation was large, and more compact representations may be necessary for some systems. Alternative encapsulations of the information as might be used in such systems were successfully prepared. The compositional approach avoided many issues that often cause controversy in the design of traditional coding and classification systems, but it raised other issues, including the handling of ambiguity and underspecification, linkage to information not explicitly present in the report, and questions concerning the focus of individual concepts. All work is preliminary and definitive conclusions await further studies and systematic evaluation.