# procedure or finding?

**URL:** <https://discourse.openehr.org/t/procedure-or-finding/14739>\
**Category:** Clinical (archive)\
**Created:** [16 April 2008 02:46 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739 "2008-04-16T02:46:16Z")\
**Posts on this page:** 13\
**Page:** 1

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**Author:** ![Andrew\_Patterson](https://discourse.openehr.org/letter_avatar_proxy/v4/letter/a/76d3ee/32.png) [@Andrew\_Patterson](https://discourse.openehr.org/u/Andrew_Patterson)\
**Post date:** [16 April 2008 02:46 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/1 "2008-04-16T02:46:16Z")

</div>

I am making some Snomed bindings for some sample  
archetypes but am having some meta-level problems.

An example will probably help -

Say I want to snomed code the urinalysis archetype. It  
lists a large set of potential measurements from a  
urine dipstick test - blood, glucose, ketones etc.  
Snomed has comprehensive coverage of all of these  
categories as 'procedures'

252384001 Urine dipstick for bilirubin (procedure)  
270894005 Urine dipstick for blood (procedure)  
269879003 Urine dipstick for glucose (procedure)  
275714003 Urine dipstick for hemoglobin (procedure)  
271347000 Urine dipstick for ketones (procedure)

etc

However, part of my brain says that the nodes  
within the archetype should really be a finding, as the  
actual procedure would perhaps be recorded in a  
different archetype and this observation is recording  
what was 'found'. However, my initial searching has  
found less comprehensive coverage of urianalysis  
findings in Snomed - though this may be just that I  
haven't searched hard enough.

Would it be fundamentally wrong to have a procedure  
code in an observation archetype? Are there any  
hard and fast rules around this or is it case by case?

Thanks

Andrew

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**Author:** ![thomas.beale](https://discourse.openehr.org/user_avatar/discourse.openehr.org/thomas.beale/32/35_2.png) [@thomas.beale](https://discourse.openehr.org/u/thomas.beale)\
**Post date:** [16 April 2008 09:15 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/2 "2008-04-16T09:15:34Z")

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Andrew,

Finding codes in this case are what should be used - procedure codes are  
also used in openEHR archetypes - but in orders (i..e INSTRUCTIONs). We  
need to be extremely careful not to mix them up, in case  
users/application software does queries based only on Snomed codes and  
ignores instances of e.g. Urine dipstick for bilirubin (procedure)  
(which should be ignored in most cases), and fails to find any results.  
This is a classic case of 'status of a clinical statement' and needs to  
be handled properly to avoid potentially serious errors when querying  
solely using Snomed or similar terminologies.

- thomas beale

Andrew Patterson wrote:

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**Author:** ![Thilo\_Schuler1](https://discourse.openehr.org/letter_avatar_proxy/v4/letter/t/a4c791/32.png) [@Thilo\_Schuler1](https://discourse.openehr.org/u/Thilo_Schuler1)\
**Post date:** [16 April 2008 12:17 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/3 "2008-04-16T12:17:09Z")

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Hi Andrew,

just want to confirm what you instinctively felt and what Thomas explained. Single pre-coordinated SNOMED procedure codes should only be used with INSTRUCTION and/or ACTIONS.

Regarding your problem, this is what I suggest:

1. If there exists a fitting precoordinated finding concept/code like:

- Finding of ketone concentration, dipstick (finding) - 365658008
- Finding of blood concentration, dipstick (finding) - 365655006
- etc (use subconcepts of “Dipstick test finding (finding) - 250412004”)

Remark:  
As often in SNOMED the subconcepts of “Dipstick test finding (finding) - 250412004” are all PRIMITIVE, i.e. they don’t a unique relationship that distinguishes them from their parent. Their definition is relatively weak indicating only that it ‘interprets’ a ‘lab test’ and a ‘microbiology interpretation’.  
This is a bit problematic as there is one subconcept “Urine dipstick test finding (finding) - 417597005” mentions urine explicitly while the others don’t. Clinically, to my knowledge, in 99,99% urine will be tested with a dipstick. Thus when using the other concepts that don’t mention urine it can be assumed to it is a urine dipstick test, but it not precise.

1. If you can find a precoordinated finding concept/code e.g. for the archetype node ‘pH’ you can often postcoordinate an appropriate concept, but for what I know this is not yet supported by the Ocean tools. In general it would work similar to this:

- To express a urine pH dipstick finding you can combine “Urine dipstick test finding (finding) - 417597005” and “Urine dipstick for pH (procedure) - 271348005” (here using SNOMED Compositional Grammar syntax).

Definition expression of precoordinated “Urine dipstick test finding (finding) - 417597005” concept (as in SNOMED)

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<div class="post-metadata">

**Author:** ![Andrew\_Patterson](https://discourse.openehr.org/letter_avatar_proxy/v4/letter/a/76d3ee/32.png) [@Andrew\_Patterson](https://discourse.openehr.org/u/Andrew_Patterson)\
**Post date:** [16 April 2008 13:27 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/4 "2008-04-16T13:27:23Z")

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> Remark:  
> As often in SNOMED the subconcepts of "Dipstick test finding (finding) -  
> 250412004" are all PRIMITIVE, i.e. they don't a unique relationship that  
> distinguishes them from their parent. Their definition is relatively weak  
> indicating only that it 'interprets' a 'lab test' and a 'microbiology  
> interpretation'.

I did notice that - it seemed peculiar to me that the best they could do  
is indicate that the 'Finding method' was a 'Procedure'. I would have thought  
this would be the point where they should link the 'Finding method' attribute  
back to the actual 'Urine dipstick for bilirubin (procedure)' etc.

> Definition expression of NEW (doesn't have its own code!) postcoordianted  
> urine pH dipstick finding concept  
> --------------------------------------------------------------------------------------------------------------------  
> 417597005|Urine dipstick test finding (finding)|  
> &nbsp;&nbsp;&nbsp;&nbsp;116680003|is a|=250412004|Dipstick test finding (finding)|  
> &nbsp;&nbsp;&nbsp;&nbsp;,363714003|Interprets (attribute)|=282288009|Microbiology  
> interpretation(observable entity)|  
> &nbsp;&nbsp;&nbsp;&nbsp;,418775008|Finding method (attribute)|=271348005|Urine dipstick for pH  
> (procedure)|  
> &nbsp;&nbsp;&nbsp;&nbsp;,363714003|Interprets (attribute)|=15220000|Laboratory test (procedure)|

Ok, this definitely makes sense to me. The only trick now is to work out a  
way of fitting it into the archetype (and agreeing on a suitable  
postcoordination  
format - I get the sense from the snomed documentation that even the  
snomed people aren't sure what the best way is).

> What do others think? Especially the SNOMED&openEHR experts from Sweden?

I'd love to hear what others have to say on this - I am in no way a  
terminology expert but am very keen to use whatever thoughts people have  
in practice (even if just to see how well the ideas work out)..

On a broader topic, is there any intention to add bindings for common  
terminologies  
into the 'release' archetypes that will go through the archetype governance  
process? If not, at what level are people expecting that terminology bindings  
will be added (local templates, or customised 'national' archetypes?).

Andrew

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**Author:** ![Karsten\_Hilbert](https://discourse.openehr.org/letter_avatar_proxy/v4/letter/k/e56c9b/32.png) [@Karsten\_Hilbert](https://discourse.openehr.org/u/Karsten_Hilbert)\
**Post date:** [16 April 2008 15:29 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/5 "2008-04-16T15:29:47Z")

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Or rather \*not\* as if it was then the \*urine\* dipstick code  
really ought to have been used.

Karsten

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**Author:** ![thomas.beale](https://discourse.openehr.org/user_avatar/discourse.openehr.org/thomas.beale/32/35_2.png) [@thomas.beale](https://discourse.openehr.org/u/thomas.beale)\
**Post date:** [16 April 2008 16:38 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/6 "2008-04-16T16:38:30Z")

</div>

Andrew Patterson wrote:

> ```auto
> Ok, this definitely makes sense to me. The only trick now is to work out a
> way of fitting it into the archetype (and agreeing on a suitable
> postcoordination
> format - I get the sense from the snomed documentation that even the
> snomed people aren't sure what the best way is).
> 
> ```

they are working on the syntax, although it seems relatively solid at the moment. We are also working collectively within the NHS-sponsored Technical Advisory Group (TAG) on this. David Markwell is currently authoring an in-depth report on how to bind such exprssions to archetypes, and we are looking at what changes are needed to ADL etc to allow it to happen. There is a relatively simple change that would allow an expression rather than a single code on the right-hand side of any binding expresion that you currently find in an archetype - most likely that at least will happen, so you would get lines like the following in the ontology section:

term\_bindings = \<  
[Snomed\_ct] = \<  
[at0012] = \<[417597005 116680003=250412004,363714003=282288009,418775008=271348005,363714003=15220000]\> – Urine dipstick test finding (finding) is a = Dipstick test finding (finding), Interprets (attribute) Microbiology interpretation(observable entity), Finding method (attribute)=Urine dipstick for pH (procedure), Interprets (attribute)=Laboratory test (procedure)

> 

Now I don’t know whether this expression is one that you would actually use, but regardless of the details, there are some interesting issues:

- can we accommodate the expression syntax as an RHS value in a binding line in an archetype? As long as there can be no characters, it seems that we can
- how should we render it? I have used the purely coded form above, with the meaning taken out as a separate comment. This does raise some questions about how the natural language vresion shown in the comment should actually be rendered - currently it could not be reconstitutable back into the original structure due to the lack of delimiters on each term phrase (“Dipstick test finding (finding)” etc). Does this matter?

> ```auto
> On a broader topic, is there any intention to add bindings for common
> terminologies
> into the 'release' archetypes that will go through the archetype governance
> process? If not, at what level are people expecting that terminology bindings
> will be added (local templates, or customised 'national' archetypes?).
> 
> ```

this is a tricky question, not least because of the ambiguities and errors in Snomed. This very question you raised, and many others I have come across in discussions over the years make it clear that what you think is going to be a 1-minute decision on what Snomed code to use for some typical clinical data item…turns into a 3-hour debate. There seem to be two reasons for this:

- errors in Snomed. These are in theory fixable, they just have to be found and proper design logic applied when coming up with a fix. There are quite a lot of errors based on my own experience, one hopes they are fixable in a viable time.

- ‘ambiguities’ in meaning. This is where the meaning in Snomed doesn’t ‘quite’ match the meaning of something with a similar or same name in an archetype or other information model. I believe this is partly because Snomed was originally constructed as an ‘ontology of reaility’, otherwise known as a ‘model of meaning’ - i.e. a structural description of categories of things in the real world. However, it does not do well on describing informational items, and the problem is that some information items, e.g. “urine glucose” (meaning recorded measurement of urine glucose level") are not quite the same thing as the same thing in Snomed (meaning “actual level of glucose in urine of subject”). Snomed also includes numerous pathology test variants of the general phenomenon, hence the codes in your example above.

Personally I believe that we need a basic rule for saying that “archetypes record data points of the form ‘recording of measurement of X’” whereas Snomed contains a code point for X. As long as we are convinced that we are talking about exactly the same X, then at least this class of ambiguity goes away (same argument for thingst like “recording of ‘recommendation of X’”, “recording of ‘order for X’” etc)

Going further, I think Snomed needs to have a clearer theory of notions like: measurement of X, target value of X, recommended P, ordered P, (no) risk/(no) history/(no) family history/diagnosis of D. In my view, every code point in Snomed should correspond to either a phenomenon or a category in the real world. If X is “urine glucose”, it is clear what phenomenon it corresponds to. If D is diabetes, it is clear that the category which would classify some individuals is “diabetes sufferers”. Something like “no risk of breast cancer” is a fiat category, stated by physicians, although it probably does have an (unknowable) real boundary in the real world. All this leads to the need for Snomed to have a proper biomedical ontology underpinning it…but I don’t think there is one. Without such an ontology, there is no rigorous ability to decide what the real meaning of any concept in Snomed atually is.

Some thoughts relating to ontology and openEHR are here - [http://www.openehr.org/wiki/display/ontol/Ontologies+Home](http://www.openehr.org/wiki/display/ontol/Ontologies+Home) See Barry Smith’s page at [http://ontology.buffalo.edu/smith/](http://ontology.buffalo.edu/smith/) for many papers on biomedical ontologies.

- thomas beale

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**Author:** ![Daniel\_Karlsson](https://discourse.openehr.org/user_avatar/discourse.openehr.org/daniel_karlsson/32/3383_2.png) [@Daniel\_Karlsson](https://discourse.openehr.org/u/Daniel_Karlsson)\
**Post date:** [16 April 2008 17:24 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/7 "2008-04-16T17:24:23Z")

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Dear Everyone,

as said before Snomed (mostly) models "lab properties" as procedures and  
most other properties as observables. There might however be a change  
and a "lab observable" hierarchy (whatever a lab observable is?) is  
under discussion.

Again however, the issue is a bit more tricky as some, although few,  
properties in lab medicine for comparability reasons needs to be defined  
up to the exact procedure used when measuring (or observing).

Regards,  
Daniel

Daniel Karlsson, IHTSDO QA Committee & IFCC/IUPAC C-NPU

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**Author:** ![system](https://discourse.openehr.org/uploads/default/original/2X/f/f0a1dedb20c42747bddcafd6c7df9db5f34f003c.svg) [@system](https://discourse.openehr.org/u/system)\
**Post date:** [16 April 2008 19:29 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/8 "2008-04-16T19:29:41Z")

</div>

Hi Daniel

I would suggest that SNOMED should try and keep the abstract concept of something that can be measured at the heart of its ontology. The fact that this can be used to define a finding, a target or goal, a procedure to measure it, the act of measuring it etc is probably better dealt with in the information model ie through post coordination.

Within an archetype for urinalysis the idea of urine bilirubin is a non-ambiguous statement from the point of view of context - but capturing it in SNOMED is highly problematic as there are lots of sorts of dipsticks with different ranges or ordinals etc.

I know Stan Huff (LOINC), who do use the same code for an order and the result (except when they are different - TFTs → TSH, FT4 etc) feels that the general alignment of the concept in the order and the result is very important from a safety point of view. Aligning general concepts such as Hb is relatively easy, but aligning a code for ordering a Hb measurement, the taking of the measurement and the result adds enormous overheads.

We know that IHTSDO are beginning to see alignment with a logical EHR as important to simplify this space.

Cheers, Sam

Daniel Karlsson wrote:

> **(attachments)**
>
> ![OceanCsmall.png](https://discourse.openehr.org/images/transparent.png)

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**Author:** ![thomas.beale](https://discourse.openehr.org/user_avatar/discourse.openehr.org/thomas.beale/32/35_2.png) [@thomas.beale](https://discourse.openehr.org/u/thomas.beale)\
**Post date:** [16 April 2008 23:10 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/9 "2008-04-16T23:10:20Z")

</div>

AThomas Beale wrote:

> they are working on the syntax, although it seems relatively solid at  
> the moment. We are also working collectively within the NHS-sponsored  
> Technical Advisory Group (TAG) on this. David Markwell is currently  
> authoring an in-depth report on how to bind such exprssions to  
> archetypes, and we are looking at what changes are needed to ADL etc  
> to allow it to happen. There is a relatively simple change that would  
> allow an expression rather than a single code on the right-hand side  
> of any binding expresion that you currently find in an archetype -  
> most likely that at least will happen, so you would get lines like the  
> following in the ontology section:
> 
> term\_bindings = \<  
> &nbsp;&nbsp;&nbsp;&nbsp;[Snomed\_ct] = \<  
> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[at0012] = \<[417597005  
> 116680003=250412004,363714003=282288009,418775008=271348005,363714003=15220000]\>  
> -- Urine dipstick test finding (finding) is a = Dipstick test finding  
> (finding), Interprets (attribute) Microbiology  
> interpretation(observable entity), Finding method (attribute)=Urine  
> dipstick for pH (procedure), Interprets (attribute)=Laboratory test  
> (procedure)  
> &nbsp;&nbsp;&nbsp;&nbsp;\>  
> \>

\*Andrew,

I intended to finish by saying that if you need to implement something  
now, the above is a good guide to what is likely to happen in ADL, and  
the logical equivalent in XML (code\_string= the whole thing). When the  
work on bindings is more complete, of course we will ensure it is made  
available as soon as possible.

- thomas

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**Author:** ![Daniel\_Karlsson](https://discourse.openehr.org/user_avatar/discourse.openehr.org/daniel_karlsson/32/3383_2.png) [@Daniel\_Karlsson](https://discourse.openehr.org/u/Daniel_Karlsson)\
**Post date:** [17 April 2008 05:26 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/10 "2008-04-17T05:26:10Z")

</div>

Hi,

I think I thoroughly agree with Sam on most things, but would like to  
add another example:

&nbsp;&nbsp;Urine—  
Acebutolol;  
&nbsp;&nbsp;arbitrary concentration(IOC Screen; 0 1)  
&nbsp;&nbsp;M = 336,43 g/mol  
&nbsp;&nbsp;Authority: IOC; IFCC/C-LDA; INN  
&nbsp;&nbsp;NPU01001  
&nbsp;&nbsp;U—Acebutolol;arb.c.(IOC Screen; 0 1) = ?

Here is a ordinal scale concentration (either it's there or it's not) of  
a substance on the IOC doping list. IOC has a specific procedure (or  
rather method) for performing the measurement to guarantee legal  
security. This is the level of detail presumably needed by laboratories,  
and in this case, athletes.

Regards,  
Daniel

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**Author:** ![system](https://discourse.openehr.org/uploads/default/original/2X/f/f0a1dedb20c42747bddcafd6c7df9db5f34f003c.svg) [@system](https://discourse.openehr.org/u/system)\
**Post date:** [21 April 2008 11:17 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/11 "2008-04-21T11:17:18Z")

</div>

Eric Browne wrote (but it did not get to the list for some reason)

I consider this issue of term/terminology binding and SNOMED particularly  
important and so worth clarifying the concepts and also articulating some  
principles. I've drafted some preliminary notes - now on the openEHR wiki  
(thanks Sam) at:

[http://www.openehr.org/wiki/display/healthmod/Terminology+binding](http://www.openehr.org/wiki/display/healthmod/Terminology+binding)

eric

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**Author:** ![Thilo\_Schuler1](https://discourse.openehr.org/letter_avatar_proxy/v4/letter/t/a4c791/32.png) [@Thilo\_Schuler1](https://discourse.openehr.org/u/Thilo_Schuler1)\
**Post date:** [21 April 2008 17:17 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/12 "2008-04-21T17:17:56Z")

</div>

Hi Eric & Sam, and servus to everyone else!

This is a reply to Eric's great Wiki post. I added a further section  
"use cases for terminology referencing in archetypes" and a comment  
to the page [http://www.openehr.org/wiki/display/healthmod/Terminology+binding](http://www.openehr.org/wiki/display/healthmod/Terminology+binding)

Thilo

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**Author:** ![ian.mcnicoll](https://discourse.openehr.org/user_avatar/discourse.openehr.org/ian.mcnicoll/32/4430_2.png) [@ian.mcnicoll](https://discourse.openehr.org/u/ian.mcnicoll)\
**Post date:** [23 April 2008 01:39 UTC](https://discourse.openehr.org/t/procedure-or-finding/14739/13 "2008-04-23T01:39:37Z")

</div>

Thanks for the wiki comments - good stuff. I will try and respond later this week. Can I suggest that anyone with an interest in Snomed binding to OpenEHR have a look at the documents by David Markwell at the NHS clinical models site?

[http://www.ehr.chime.ucl.ac.uk/display/nhsmodels/NHS+CFH+EHR+Content+TAG](http://www.ehr.chime.ucl.ac.uk/display/nhsmodels/NHS+CFH+EHR+Content+TAG)

David has done a great deal of work in defining the possible different approaches as part of the NHS work. This is still in development and your thoughts would be very welcome.

Ian