JIRA Ticket - 

Amendment History

Review Timetable

© International Health Terminology Standards Development Organisation 2012. All rights reserved.
SNOMED CT® was originally created by the College of American Pathologists.
The International Release of SNOMED CT® is distributed by the International Health Terminology Standards Development Organisation (IHTSDO), and is subject to the IHTSDO's SNOMED CT® Affiliate Licence. Details of the SNOMED CT® Affiliate Licence may be found at http://www.ihtsdo.org/our-standards/licensing/.
No part of this document may be reproduced or transmitted in any form or by any means, or stored in any kind of retrieval system, except by an Affiliate of the IHTSDO in accordance with the SNOMED CT® Affiliate Licence. Any modification of this document (including without limitation the removal or modification of this notice) is prohibited without the express written permission of the IHTSDO.
Any copy of this document that is not obtained directly from the IHTSDO [or a Member of the IHTSDO] is not controlled by the IHTSDO, and may have been modified and may be out of date. Any recipient of this document who has received it by other means is encouraged to obtain a copy directly from the IHTSDO [or a Member of the IHTSDO. Details of the Members of the IHTSDO may be found at http://www.ihtsdo.org/members/].
Table of Contents
1 Glossary
1.1 Domain Terms
2 Introduction
2.1 Purpose
2.2 Audience and stakeholder domain:
2.2.1 Input from stakeholders:
2.2.2 Degree of consensus on the statement of problem:
3 Statement of the problem or need
3.1 Summary of problem or need, as reported:
3.2 Summary of requested solution:
3.3 Statement of problem as understood
3.4 Detailed analysis of reported problem, including background
3.4.1 Background
3.4.2 Detailed findings
3.5 Subsidiary and interrelated problems
3.5.1 Grading of Ligament Sprains
3.5.2 Traumatic verses non-traumatic ligament damage
3.5.3 Related content tracker projects:
4 Risks / Benefits
4.1 Risks of not addressing the problem
4.2 Controversy level
4.3 Risks of addressing the problem
5 Requirements: criteria for success and completion
5.1 Criteria for success/completion
5.2 Strategic and/or specific operational use cases
6 Solution Development
6.1 Initial Design
6.1.1 Outline of initial design
6.1.2 Significant design or implementation decisions / compromises
6.1.3 Evaluation of Design
6.2 Iteration One
7 Recommendation
7.1.1 Detailed design final specification
8 Quality program criteria
8.1 Quality metrics
8.1.1 Quality metric 1
8.1.2 Quality metric 2
8.1.3 Quality metric 3
8.2 Use case scenarios
8.2.1 Scenario One
9 Project Resource Estimates
9.1 Scope of construction phase
9.2 Projection of remaining overall project resource requirements
9.2.1 Expected project resource requirement category
9.2.2 Expected project impact and benefit
9.2.3 Indicative resource estimates for construction, transition and maintenance:
10 Appendices
10.1 Appendix One: Related user requests that have been accepted since the January 2015 release:

Glossary

Domain Terms

Introduction

Purpose

The purpose of this project is to review the current hierarchy for |263134008| Ligament rupture and apply quality criteria to this hierarchy, identify and resolve inconsistencies and omissions.

Audience and stakeholder domain:

The audience for this document includes all standards terminology leaders, implementers and users but is especially targeted at those stakeholders from the domain of orthopedics with a particular emphasis on physiotherapists
A further significant audience is the community of SNOMED authors that may be requested to implement the recommended specification.

Input from stakeholders:

The Chartered Society of Physiotherapy (CSP) in the UK commissioned the identification of a subset of SNOMED CT descriptions that could be used as search terms, linking common symptoms, signs and disorders with a directory of physiotherapy services (Clinic Types).
It was during this work that some anomalies were identified within the ligament rupture hierarchy and this was then brought to the attention of the IHTSDO. As the integrity of this hierarchy is important in ensuring that the requirements of the CSP Use Case are met they have remained key stakeholders.
In addition the Quality Assurance Committee have acted as stakeholders and have used this work as an example of how quality criteria might be applied to the content of SNOMED CT following a presentation at the October 2013 IHTSDO Quality Assurance Committee meeting.
A review of the inception/elaboration document was conducted by Cathy Richardson (on the 2013 CTP cohort) and Jeremy Rogers Consultant Clinical Terminologist. Their feedback has been incorporated into this (v0.5) draft.
Two external Consultant Orthopaedic Surgeons reviewed the documents and provided advice; Paul Paul from St Bartholomew's and Royal London Hospital and Andy Goldberg from the Royal National Orthopaedic Hospital Trust, London stakeholders

Degree of consensus on the statement of problem:

There was agreement from all stakeholders on the statement of the problem and proposed solution.

Statement of the problem or need

Summary of problem or need, as reported:

A review of the hierarchy identified the following issues:

• Inconsistency of synonym use
• Inconsistency in availability of synonyms within sibling concepts
• Reduced availability of partial tear concepts with respect to complete tear concepts
• Inconsistency in use of navigational concepts (ligament v joint)
• A significant number of the concepts within the hierarchy remain primitive (71 concepts fully defined, 53 concepts primitive)

The impact of these inconsistencies results in an inability to consistently search and retrieve concepts relating to ligament rupture.

Summary of requested solution:

The stakeholders requested that the solution deliver the following:

• A literature review to ascertain the currently accepted terminology for ligament injuries (rupture or tear).
• Review the ligament rupture hierarchy and produce a set of concepts with their descriptions that adhere to the editorial principles for the fully specified names, preferred and synonymous terms.
• Ensure that there are available matching concepts for partial and complete ruptures.
• That each remaining concept labeled as primitive be modeled such that it becomes fully defined.

Statement of problem as understood

SNOMED CT is an amalgamation of 2 terminologies; SNOMED Reference Terminology and Clinical Terms Version 3. Each of these terminologies has an individual history that has shaped and supported the evolution of the respective terminology content to serve a number of different use cases in the US and UK.
Given that SNOMED CT is an amalgamation of 2 'local' terminologies it is likely that for a given clinical subject area there will be a mixture of descriptions that need to be harmonized and presented in a consistent manner. The subject area of ligament ruptures is one such area that needs to be reviewed with respect to content to ensure that there is consistency in use of descriptions and that those descriptions represent contemporary clinical usage.
The purpose of this content development project is to establish a set of concepts which support the recording of ligament ruptures consistently using contemporary clinical language and fully modeled within SNOMED CT.

Detailed analysis of reported problem, including background

Background

The use case for this implementation of SNOMED CT was the Choose and Book (CAB) application in General Practice within England. The CAB application is a national electronic referral service that allows general practitioners, their staff and patients to choose and book, in real time, an outpatient appointment from a selection available at a date, time, place and provider of their choice.
The CAB application links the general practice to the local outpatient service providers and can be accessed via the GP clinical system. When a GP wants to refer a patient with a particular disorder to a specialist he types an appropriate key word or phrase into the search box and this then returns a list of service providers who can assess and/or treat that problem. For example the GP may type in 'ruptured ligament' and the Choose and Book application will return a list of physiotherapy units within the area who would be able to provide an appropriate service for this condition.
The method used to identify the subset of SNOMED CT descriptions was to identify a particular symptom or disorder and then to use the human anatomical structure to order the list of terms and then use a SNOMED CT browser to identify the appropriate SNOMED CT Identifier and description.
This was a relatively simple process but in trying to achieve consistency and completeness across all of the detail of anatomical structures, symptoms and disorders it became apparent that at this moment in time the content of SNOMED CT within the musculoskeletal domain was not sufficiently consistent and complete to support a use case that required greater detail.
In addition the IHTSDO Quality Assurance Committee (QAC) were working to identify and apply Quality Metrics to the content of SNOMED CT. It was considered that looking more closely at the findings of the CAB subset project might provide useful input into this work. The following purposes were identified by the QAC:

• To identify a method for applying a limited number of quality metrics to the content of SNOMED CT.
• That the quality metrics used should identify inconsistencies and omissions that would be of significance to clinical users of SNOMED CT.
• To identify whether the incidence of the inconsistencies and omissions are of a sufficient level to bring disrepute to the product and IHTSDO, and if so, to raise this to the attention of the Content Committee for consideration

The quality metrics to be measured included:

• Number of primitive and fully defined terms
• Consistency of use of preferred and synonymous descriptions
• Presence/completeness of concepts within the hierarchy
• Consistency in use of 'grouper concept descriptions'
• Visual presentation of hierarchy
• Presence of editorial principles within the Editorial Guide to support consistent authoring in relation to the above.

Detailed findings

Examination of the | Ligament rupture | 263134008 hierarchy:

Simple counts (excluding parent concept):

Number of child concepts - 95

Number of fully defined concepts - 64

Number of primitive concepts – 31

Quality assurance of the concepts within the hierarchy

:

Potential inconsistency of synonym use:
The fully defined parent concept 263134008 itself has the following descriptions:
F ligament rupture (disorder)
Pligament rupture
Scomplete tear of ligament
Sligament tear
The parent Fully Specified and Preferred term refers to rupture without reference to whether it is partial or complete and therefore the addition of a synonym that specifies 'complete' tear would appear to be an error. This is supported by the presence of both complete and partial rupture/tear as children of this concept.
The Editorial Guide specifies that the use of a 'narrower' synonym must be avoided and therefore this is considered to be an error.

Inconsistency of use of preferred term within the child concepts:

The parent preferred term is 'ligament rupture' with a synonym of 'ligament tear'. There is mixed use of the terms 'rupture' and 'tear' as preferred terms within the children of the 263134008 parent that suggests inconsistency with the parent term:

• Number of preferred terms 'rupture' 19
• Number of preferred terms 'tear' 76

It should also be noted that a similar anomaly exists within the morphologic abnormality hierarchy for | rupture | 125671007 (syn. - Tear) in which the child concepts listed include:

• Number of preferred terms 'tear' 101
• Number of preferred terms 'tear' that have a synonym of 'rupture'0

Therefore while the parent term has a preferred term of ligament rupture if a user enters the search string of ligament rupture, only 18 concepts will be returned whereas using a search string of ligament tear will return 112 concepts.
The Editorial Guide makes no reference to the consistent use of preferred and synonymous terms within the child concepts.

Presence of complete and partial rupture/tear:

For each of the complete rupture terms there exists the possibility of a partial rupture.

• Number of partial rupture of ligament terms6 (discrete concepts)

Clearly there are a significant number of possible partial ruptures that cannot currently be recorded using a pre-coordinated term.
The Editorial Guide makes no reference to the requirement for completeness within any given hierarchy.

Naming of grouper concept descriptions navigational concepts:

There is inconsistency in the naming conventions of the navigational terms within the hierarchy:
595273018 complete tear, elbow joint (disorder)
595315016 complete tear, hip ligament (disorder)
As this section of the hierarchy refers to ligament injuries it would seem more appropriate for 'complete tear, elbow joint' to be replaced by 'complete tear, elbow ligament' and preferably adopt the pattern of. 'complete rupture of elbow ligament'.
The Editorial Guide identifies the requirement for navigational concepts but does not appear to address the specifics of what is considered to be good editorial naming policy for this class of concepts.

Visual presentation of the hierarchy (using UK Preferred descriptions):

If we examine the current groupings within the hierarchy the following pattern emerges:
263134008 ligament rupture
209621009 complete tear, hip ligament
398733004 partial rupture of ligament
263139003 rupture of ligament of knee joint
239725005 rupture of anterior cruciate ligament
209629006 complete tear, knee, anterior cruciate ligament
209520004 partial tear, knee, anterior cruciate ligament
While it is accepted that from description logic perspective the above presentation is not incorrect, except for the inconsistency in use of preferred and synonymous descriptions, from a clinical user's perspective the following might be more acceptable:
263134008 ligament rupture
123456789 rupture of ligament of hip joint
(Syn. tear of ligament of hip joint)
234567890 rupture of ligament of knee joint
(Syn. tear of ligament of knee joint)
345678901 complete rupture of ligament of knee joint
(Syn. complete tear of ligament of knee joint)
456789012 partial rupture of ligament of knee joint
(Syn. partial tear of ligament of knee joint)
In addition consideration could also be given to adding the following grouper concepts to aid retrieval:
xxxxxx rupture of ligament of axial skeleton
xxxxxx rupture of ligament of lower limb

Subsidiary and interrelated problems

Grading of Ligament Sprains

Since this project began there has been an update to the musculoskeletal section, in particular the addition of:

|1791000119105| Sprain of ankle grade I (disorder)

|1781000119107| Sprain of ankle grade II (disorder)

|609495006| Sprain of ankle grade III (disorder)

The following definitions[1] have been assigned to these concepts:

Grade 1 sprain:        Microtears and stretching but ligament integrity intact

Grade 2 sprain:        Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.

Grade 3 sprain:        Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.

A review of the American Academy of Orthopaedic Surgeons and the medical literature suggest that this grading is fairly uniformly applied to sprains of all of the major ligaments. Further work may be necessary to establish whether this would be acceptable to other jurisdictions.

In addition sprain is defined[2] as ‘A joint injury in which some of the fibres of a supporting ligament are ruptured but the continuity of the ligament remains intact’. This definition seems to be at odds with the grading suggested above given that grade 3 is complete rupture.

There is a concept | Sprain or partial tear, knee, lateral collateral ligament (disorder) | 209515004 which has an IS_A relationship with | Partial tear, knee, lateral collateral ligament (disorder) | 209517007 and | Sprain of lateral collateral ligament of knee | 35726004 which would suggest that at some point there has been a view that there may be a relationship between sprain and partial rupture.

A further complication arises as SNOMED CT morphology suggests the following:

|384709000| Sprain (morphologic abnormality is a form of |3399917004| Traumatic abnormality by mechanism (morphologic abnormality) whereas |263722006| Complete rupture (morphologic abnormality) and |263834005| Partial tear (morphologic abnormality) are both forms of |107658001| Mechanical abnormality (morphologic abnormality).

So we have a situation in which a sprain is considered to be secondary to some traumatic injury and yet the definitions of the grades of sprain are defined by structural characteristics which are agnostic to the mechanism of injury, whether traumatic or non-traumatic.

1.1.1 Traumatic verses non-traumatic ligament damage

A further question arises as to whether it is possible to suffer any form of ligament structural damage without a traumatic insult and, if you can, whether such disease entities should properly be labelled a ‘sprain’ or, if sprain and rupture are synonymous, a ‘rupture’.. A review of the literature suggests that there are certain genetic conditions which can give rise to abnormalities of collagen structure (regulation of size and configuration of type I collagen fibrils).

The literature cites Achilles tendon and anterior cruciate ligament rupture associated with collagen, type V, alpha 1 (COL5A1) polymorphism[3], these are reported as spontaneous sprains/ruptures in athletes undergoing normal athletic activity rather than as a result of ‘traumatic injury’. This begs the question of whether the label ‘trauma’ does, or should, distinguish between excessive force applied to normal strength tissue, and normal forceapplied to unusually weak tissue. A pathological fracture is not normally considered a subclass of traumatic injury, so we may assume neither should a pathological sprain.Anatomy for structure of ligament of joint

An attempt to identify all possible ligaments was made by examination of the body structure section and in particular:

| Structure of ligament of joint (body structure) | 123859001

There are 714 concepts within this section, all primitive. Some concepts are, however, known to be either missing or are misplaced and it is quite difficult to ascertain the full number of body ligaments. This is being addressed as part of the anatomy project.

At the time that this project was first begun there are many non-human anatomical structures present within this hierarchy, including:

370627006 annular ligament of equine distal limb

370712001 suspensory ligaments of equine limb

These have now been addressed as part of the veterinary extension and are no longer present in the core release.

1.1.2 Related content tracker projects:

The following content tracker projects have a relationship with or may be impacted by this project:

• artf6206 : Anatomy
• artf222770 : Review concepts: Non-human
• artf222524 : Rework Hierarchy: Arthropathy of knee joint

Risks / Benefits

Some of the problems identified may not be soluble given the current state of 'knowledge' of the subject area; in particular the extent to which it is possible to clearly identify whether any grade of sprain can be easily attributed to a traumatic or non-traumatic (genetic or otherwise) cause.
For this reason a decision has been taken to consider the risks of addressing all the issues raised except those associated with the cause, traumatic v non-traumatic, of the ligament rupture, however, this risk cannot be excluded from the risk of actually addressing the problem.

Risks of not addressing the problem

The following risks may arise if the problems identified are not addressed:

• Difficulty in searching concepts relating to ligament rupture/tear consistently and accurately
• Difficulty in computing equivalence and therefore retrieving concepts consistently for decision support and aggregate analysis
• Translation into other languages will be more difficult if there is inconsistency in use of descriptions
• Possible reputational risk if potential users perceive the content in this area to be inconsistent or incomplete
• Potential confusion due to apparent duplication of concepts between the hierarchies of ligament rupture and sprains.

The project risk profile is determined using the project risk profile assessment instrument as described in the "Guide to Stakeholder Engagement in Content Development" document.

Controversy level

Controversy level is considered to be low with a score of 1 which arises from the need to have clear agreement upon the definitions for traumatic and non-traumatic instances of ligament damage and establish whether ligament ruptures might at some stage in the future be considered to be a form of sprain.

Risks of addressing the problem

The risks associated with addressing the problem, in part relate to the current state of uncertainty around the following:

• The final position regarding the post coordination roadmap has yet to be made and therefore any solution implemented may give rise to either over or under pre-coordination until the concept of expression libraries is implemented. The interim measure is to model and pre-coordinate the most common ligament sprains/ruptures and then add more by request based upon user demand
• If in clinical practice it is difficult to be certain as to whether ligament rupture, of what ever grade, has resulted from a non-traumatic cause therefore if both traumatic and non-traumatic variants were available this might lead to difficulty in choosing the correct SCT concept

Requirements: criteria for success and completion

Criteria for success/completion

The criteria for completion and success of the ligament hierarchy development project include the quality program criteria:

• Consistent application of a terming pattern for ligament rupture FSNs and there synonyms
• Consistent application of logic-based modeling pattern to all relevant concepts
  • Lexical identification of candidate concepts
  • Logical identification of candidate concepts
• No missed inferences, based on lexical identification of possible subtypes and inspection of logic-based inferred hierarchies.
• No duplicates – as verified by inspection, and by no equivalence errors on classification
• All concepts in the ligament and sprain hierarchies sufficiently defined, or, specified reasons if left as primitive

In addition:

• Pay due regard to the draft of ICD-11
• Produce updated editorial guidance

Strategic and/or specific operational use cases

This project aligns itself with the following IHTSDO Strategic aims:

1. making it easier to use SNOMED CT for priority use cases:

• By facilitating the accurate collection and sharing of clinical, public health, and related health information through improving the semantic representation and interoperability of health records (including personal health records and those created by health professionals)
• By contributing to improved delivery of care by the clinical and social care professions through supporting efficient, effective, and safe decision support; and
• By enabling "health system" or "secondary" uses of data held in individuals' health records.

1. Produce robust terminology standards that are "fit for purpose" for priority use cases

• Agree a program for quality enhancement of existing and expanded content, including documentation regarding the terminology and its maintenance process:

From IHTSDO Content Product Development Plan:
Facilitate the accurate collection and sharing of clinical, public health and related health information as well as the semantic interoperability of health records:
1A. Patient summary/Discharge summary
1B. Problem list - Diagnosis

Solution Development

Initial Design

Outline of initial design

The goal of the solution is to create a hierarchy for ligament ruptures/sprains that faithfully represents current clinical understanding and which adheres to the editorial guidelines and is modelled to support consistent recording and retrieval of information in this domain.
Because this project has identified a significant number of interrelated issues the description of the proposed solution takes a step approach that amalgamates the solution design with the significant design and implementation decisions as they occur.

Morphological considerations

There appears to be consensus on the pathophysiology of ligament injury and the division into the following categories:

1. Microscopic tearing of collagen fibres in the ligament
2. Complete tears of some but not all collagen fibres in the ligament (partial tear of ligament)
3. Complete tear of the ligament

The literature frequently uses 'rupture' and 'tear' synonymously therefore the following morphologic concepts and naming conventions are proposed:

Sprain = clinical finding
hasMorpholgicalAbnormality=<Microscopic rupture | Partial rupture | Complete rupture >
hasFindingSite = < some structure of ligament >
after = < | Traumatic injury | 417746004 >

1. Ligament rupture due to disorder

Ligament rupture = clinical finding
hasMorpholgicalAbnormality=<Microscopic rupture | Partial rupture | Complete rupture >
hasFindingSite = < some structure of ligament >
due to = < some disorder >

Concept description principles

The editorial guidelines should be adhered to for all descriptions which gives rise to the following patterns:

1. Sprains:

FSN Grade 1 sprain of lateral collateral ligament of knee (disorder)
Synonym Grade 1 sprain of lateral collateral ligament of knee
SynonymFirst degree sprain of lateral collateral ligament of knee
Synonym1^st degree sprain of lateral collateral ligament of knee
This pattern would be repeated for each of: Grade 2 (partial rupture) and Grade 3 (complete rupture)

1. Ligament rupture:

FSNMicroscopic rupture of lateral collateral ligament of knee (disorder)
SynonymMicroscopic rupture of lateral collateral ligament of knee
SynonymMicroscopic tear of lateral collateral ligament of knee
This pattern would be repeated for each of: partial and complete ruptures.
The advantage of this approach is that the completeness of the descriptions and associated synonyms will support comprehensive search and retrieval within this domain.

Concept modelling principles

Full modelling of the above concepts is achieved by applying the following relationships:

1. Sprains

FSN Grade 1 sprain of lateral collateral ligament of knee (disorder)
IS_A Grade 1 sprain of ligament of knee joint
IA_A Injury of lateral collateral ligament of knee
Group 1
Assoc. morphologyMicroscopic rupture (morphologic abnormality)
Finding site Structure of lateral collateral ligament of knee joint

1. Ligament rupture

FSN Microscopic rupture of lateral collateral ligament of knee
IS_A Microscopic rupture of ligament of knee joint
Group 1
Assoc. morphologyMicroscopic rupture (morphologic abnormality)
Finding site Structure of lateral collateral ligament of knee joint

Extent of pre-coordination and hierarchical structure

The extent to which SNOMED CT should support a specified level of pre-coordination within the International Release has long been a subject of interest and discussion and resulted in the creation of the Pre-coordination Roadmap Project in March 2010. This is also the subject of one of the content tracker projects at inception and elaboration phases developed by Geraldine Wade.
The purpose of the Pre-coordination roadmap Project was to:

• Develop editorial principles for adding content to the International Release
• Provide guidance for implementation (expression library, examples)
• Harmonize with the implementation group on requirements and constraints, use and test cases

For the purposes of this project there are 3 possible options:

• Fully enumerate all ligament ruptures, microscopic, partial and complete
• Replicate current more limited anatomical coverage for joint ligaments, adding any missing common joint ligament ruptures
• Seek to model all sprains and ligament ruptures using post coordination and either retire the existing concepts and/or remodel to ensure that equivalence detection can be supported

Full enumeration for both ligament ruptures and Sprains for all 3 degrees of rupture would result in a significant requirement for new content over the current set of 95, and would be a good example of (technically tractable but probably mostly pointless) combinatorial explosion:
704 listed ligaments of joints
4 types of ligament rupture for each ligament
4 types of sprain for each ligament
5700 Total concepts required (excluding laterality)*
*(April 2013 IHTSDO UAT International Release, included some animal ligaments which have subsequently been moved to the non-human subset)
This would represent a significant requirement for new content, some of which would be used little or not at all. It also does not conform to the recommendations from the Pre-coordination Roadmap project and therefore will not be considered as an option for further consideration.
In an ideal world the most efficient solution would be to model the content using full post coordination with an accompanying expression library. However, there already exists some enumerated content for the most common ligament ruptures and in addition the Use Case for this project is set in an environment where there are few SNOMED CT based systems which are capable of implementing full post coordination or expression libraries and therefore this option is currently discounted.
It is proposed that all currently existing joint ligament rupture and sprain concepts are used as the basis for the subset of all joint ligaments and these should each be represented within the ligament rupture and sprain hierarchies to include all 3 grades of sprain and morphological ruptures.
This approach would result a requirement for approximately 90 separate joint ligaments each with a representation of microscopic, partial and complete ruptures. A total of 270 concepts plus hierarchical grouper concepts, say 300 concepts in total. If repeated for each of the 3 grades of sprain this would result in a further 300 concepts, a total of 600 concepts for the complete project.
Where concepts and descriptions already exist they will be used to re-populate the new hierarchies and the gaps filled by the new content.
There will be a need to retire some existing FSNs and descriptions to be replaced by those that are conformant to the editorial guidelines.
An example of the proposed new hierarchy (Descriptions + FSN without semantic tag) for ligament rupture is given below (this pattern would be repeated for Sprain and its 3 grades):

The following possible compromise has been taken

• Although the Pre-coordination Roadmap project recommends a move towards post coordination and the use of expression libraries a decision to pre-coordinate the ligament ruptures for the major joints and common ruptures has been taken to reduce the impact on current users and implementers

Evaluation of Design

Exceptions and Problems

If at a future date it is decided that ligament ruptures can only occur secondary to trauma there will be a need to retire either the section on ligament ruptures or sprains. However, by ensuring consistency of approach between these two hierarchies it will be relatively simple to retire one section and map to the other section.

Design Strengths

The following design strengths are identified:

• New content and hierarchy structure represent current clinical understanding of the subject area
• Consistency in use of descriptions and synonyms supports consistent and reproducible search and retrieval
• Extent of pre-coordination supports existing content and supports the primary use case in which there are few systems currently available that implement post coordination.
• Completion of this project will result in achieving fully defined status for all of the content reviewed and updated

Design Weakness

There may be a requirement to retire a number of existing descriptions, both FSNs and synonyms to ensure a consistent approach to restructuring these hierarchies.

Design Risks

Iteration One

No further iterations have been considered necessary at this stage.

Recommendation

Detailed design final specification

Sufficient agreement from current stakeholder engagement indicated that further revision of the initial design was not required.
However, consideration may be given to including stakeholders from other member jurisdictions in order to confirm this position

Quality program criteria

Quality metrics

Quality metric 1

Quality metric 2

Quality metric 3

Use case scenarios

Scenario One

Expected Setting

Review of hierarchies by orthopaedic surgeons and physiotherapists

Data capture requirement

The following questions should be asked:

• Have all of the common ligament ruptures and sprains been included, if not which ones are missing
• Are there any commonly used synonyms missing
• Using standard browser is it possible for you to easily find the sprains and ligament ruptures which you encounter easily

Project Resource Estimates

Scope of construction phase

The construction phase could be divided into two stages, one for ligament rupture and the other for Sprain of ligament of joint. However there is merit in the construction of the 2 stages together as this will promote consistency of approach.
Either a terminology editor or consultant terminologist could complete the construction phase of this development project.
The construction phase is anticipated to take approximately 20 man days based on modelling 4 concepts per hour, including the 400 new descriptions and associated synonyms. This to be conducted over an elapse time of 2 months.
It might be prudent if the editorial work were reviewed by an orthopaedic surgeon and physiotherapist prior to final release.

Projection of remaining overall project resource requirements

Expected project resource requirement category

The size of the project is considered to be small without the need for project management

Expected project impact and benefit

Updated view of impact and benefit, organized by stage if the project is to be staged

Indicative resource estimates for construction, transition and maintenance:

Construction and transition phase: 200 new concepts to be authored and 400 new descriptions with completion of modelling to convert all primitive concepts to fully defined.
Anticipate work could be done by a single terminologist and sign off/review by chief terminologist.
Maintenance phase: 50 -100 new 'frequent usage' concept requests in the first 3 years following inclusion of the current new requests detailed in the appendices

Appendices

Appendix One: Related user requests that have been accepted since the January 2015 release: