# Presentation: 020584

## STRUCTURED HEALTH MARKUP LANGUAGE

**SHML **®

**DAVID J. ROTHWELL M.D.**
**HEALTH LANGUAGE CENTER**

## Major Issues Affecting Patient Medical Record Information

- Continuing Barriers to Data Entry
- Increasing Role of Patient Choice
- Shift from Acute / Inpatient to Disease Prevention / Management
- Impact of Genomics
- Rapid Rise of Internet Standards

## Health Language Center Approach

- Convergence / Maturity of Two Major Technologies:
- Internet Standards - XML
- Natural Language Processing
- Potential to Keep Pace with Change

## PMRI

**PMRI**

**Provider Patient**
**Document**

**Utility**

**Care Process**
******Clinical Research**
******Aggregation of Data**
******Epidemiology**
******Adherence to guidelines**
******Eligibility for protocols**

**PMRI**

**Text**
**SDE**

**NLP XML**
**SHML**

**Clinically Important Information (minus)         verbiage**
******	****Clinically Relevant Content Units (CRCU)**

**Findings**

## Natural Language Processing

- A system which turns natural language clinical documents into structured data for a variety of applications.
- The NLP method makes explicit the informational structure of texts, using linguistic method and the most advanced information technology available today.

## NLP (cont’d)

- Language presents information linearly in strings--phrases, sentences, paragraphs, sections, documents, discourses, ...
- Information in these strings is carried by the semantic types of words, occurring in particular combinations.

## Slide 7

## NLP

- Formats include:

- Demographic Data
- Verbs
- Patient State Data
- Diagnosis
- S-S (H-INDIC)
- Patient Status Data
- Patient
- Anatomy (H-PTPART)

- Treatments
- Test and Result
- Time
- Uncertainty (H-MODAL)
- Negation
- Response
- Changes

## Slide 9

## Use of Medical Language Processing for HEDIS Measures

-           "BETA BLOCKER TREATMENT AFTER A HEART ATTACK"
- Hospital discharge -records in  text form (natural language) are prepared
- for processing, analyzed, formatted for retrieval of information, and the
- following queries submitted by Aurum Medical Language Processor:
-    Did the patient have an acute, myocardial infarction?
-    Was the patient given a beta blocker medication?
- 	   Did the patient have any contraindications?

**Use of Medical Language Processing for HEDIS Measures**

## * List of Beta Blockers: LOPRESSOR, METOPROLOL, NADOLOL, 

- CORGARD, ATENOLOL, TENORMIN, PlNDOLOL, VISKEN, PROPRANOLOL,
- INDERAL, INDURAL, BETA BLOCKER, ACEBUTOLOL, BETAXOLOL,
- BISOPROLOL, CARTEOLOL, CARVEDLOL, LABETALOL, PENBUT0LOL,
- SOTALOL, TIMOLOL.
** ***List***** *****of Contraindications**: HEART BLOCK, ATRIOVENTRICULAR BLOCK,
- BRADYCARDIA, BRADYCARDIC, LV DYSFUNCTION, VENTRICULAR
- DYSFUNCTION, DIASTOLIC DYSFUNCTION, VENTRICULAR DIASTOLIC
- DYSFUNCTION, COPD, CHRONIC OBSTRUCTIVE PULMONARY DISEASE,
- DIABETES MELLITUS, ASTHMA, CONGESTIVE HEART FAILURE,
- 	* **Results from database queries**:
- 				**Beta Blocker ****	****Beta Blocker**
**	****	****	****	****	****Given****	****	****Not Given****	****Total**	**With contraindications****	****	****42****	****	****19****	****	****61****	****Without contraindications*****	*****28****	****	**** 2****	****	****30****	****Total****	****	****	****	****70****	****	****2l****	****	****91**

## eXtensible Markup Language (XML)

- Streamlined subset of SGML
- XML is a language
- Document Type Definition
- DTD defines it's use (it's grammar)
- Designed for data exchange
- Data processing oriented rather than publishing (SGML)
- Create own 'tags' -what you need to know
- i.e. Annotate document with meaning

## eXtensible Markup Language (cont’d)(XML)

- Data and document are combined
- Tagged text transforms it into data
- Tags are granular descriptive views of text
- Tags are metadata--information not explicit in text
- Puts meaning and interpretation on top of text
- Ability to catalogue all information in document
- Preserves fundamental structure of document (PMRI)
- Tagged data can fit into any data format or data model

## XML Tags

**<elementType> Content </elementType>**
**Pneumonia**
- <Diagnosis> **Pneumonia** </Diagnosis>
**Pneumonia, right lower lobe**
- <Diagnosis> **Pneumonia** <location> **right lower lobe** </location> </Diagnosis>
**Pneumonia, right lower lobe, superior, due to Klebsiella**.
- <Diagnosis> **Pneumonia** <location> **right lower lobe** </location> <position>
**superior**</position><link>**due to**</link> <org>**Klebsiella** </org> </Diagnosis>
**PRESENTATION FORMAT** (one of many)
**	****	****Diagnosis:****	****Pneumonia****	****	****Location:****	****RLL, superior****	****	****Organism:****	****Klebsiella**

## XSL

**Demographic Data**
**Node positive carcinoma of the left breast, treated by mastectomy, chemotherapy and radiotherapy**
- Radiotherapy treatment summary: the left breast and draining nodal areas received a dose of 42.9 Gy in 13 fractions treating three times a week with 6 Mv photons. Treatment started on the 15th of September and was completed on the 14th October, 1995.

**Radiotherapy Treatment Summary**
- Status before radiotherapy:
-    Diagnosis			**Carcinoma left breast**
-    Spread			 	**Left axillary nodes**
-    Previous treatment		**Mastectomy, chemotherapy**
- Radiotherapy given
-    Treatment type		 	**6 Mv photons**
-    Site				**Left chest wall and draining** **nodes**
**   **Total dose given**	****	****43 Gy**
-    Schedule**	****	****	****3 fractions/week 15 September 1995 to ... **Follow up plan			**One visit . . .**

## Structured Health Markup Language

- Utilizes Linguistic Model not Coding
- Utilizes XML
- Designed to Integrate both Structured Data Entry and Text

## SHML® and MLP

**Medical documents**

- standardization

**Documents with SIDs**

**MLP**

- MLP in HLC/SHML **Dictionaries**

**Documents in CRCU’s with SHML and MLP tags**

**Documents in rows of standard dBMS**

**GENERATORS**
- SHML/DTD
- SHML/XSL
- SHML/XQL

- Other Applications

## Mapping --NLP Dictionary / SHML ®

**Term****	****	****	****NLP Class****	****	****SHML **®

- Altered awareness	     H-INDIC--N		fs neuro
- Alternate		     H-TMREP--TV		tmr
- Alternating between	     H-CONN--P		lprep
- Altogether		     H-AMT--D			mamt
- Aluminosis		     H-INDIC--N		fd tox
- Augmentations	     H-CHANGE:MORE--N	mcha
- August			     NTIME1--N		tme
- Aunt			     H-FAMILY--N		per kin
- Auricle			     H-PTPART--N		as ear
- Auriculectomy		     H-TTCHIR--N		pr
- Auriculo-osteodysplasia  H-INDIC--N		fd cong
- Auriculotemporal	     H-PTPART--ADJ		areg
- Auscultate		     H-TXCLIN--TV		pr

## SHML ® TAGS  Traditional Set

- Demographic data		<dem>  	(subclasses)
- Anatomic Structure 	<A.S.>  	(Digital Anatomist)
- Medication			<dr>	  	(Multum, First Data)
- Organisms			<or>
- Chemical			<ch>	   	(nonphysiologic)
- Devices			<dev>   	(ECRI)
- Occupation			<occ>	    	(National, international)
- Procedures			<pr>	    	(CPT, other)
- Diagnosis			<fd>       	(ICD-9, ICD-O, Medcin)

## SHML ® TAGS (cont’d)

- Verbs			<lv>		Subsets defined by MLP
- Preposition		<prep>		All except time prep
- Dietary/Food		<diet>		Nutrition
- Time			<tm>		Exact, begin, end, frequency
- Amount			<mamt>
- Change			<mcha>		Less, more
- Certainty		<mcer>		Uncertainty, modal, certainty
- Negation		<mneg>
- Stage grade		<ms-g>
- Dimension		<mdim>
- Adjective		<mad>
- Appearance		<mapp>		Color, shape, clarity
- Odor			<msmell>
- Position			<ppo>		Top to bottom, laterality
- Person			<per>		Masc, Fem, pronouns
- Environment		<env>		Physical locations
- Transparent		<transp>		Derived from entity, modified

## Additional SHML ® TAGS

-   Findings   <Finding>    Vital Signs
- 			    Signs/symptoms by organ system
- 		       	    Lab; Image;
- 			    Behaviors
- 			    Living		Functional status
- 			    Injury		Disability
- 			    Exposures		Compliance
- 			    Travel		Dental
- 			    ADL		Alternative care
- 			    Exercise		etc.
- 			    Leisure, sports
- 			    Immunization
- 			    Allergy, tolerances
- 			    Education, counseling

## SHML ® / XML TAGGING<elementType>Content</elementType>

- Clinical Table

- Vocabulary Table

- Terms
- Taxonomic knowledge
- Hierarchical knowledge (classificatory)
- Synonyms/Equivalent terms
- Linguistic knowledge
- Definitional knowledge
- Non-unique term knowledge
_**Tag knowledge**_

- Chest Pain
-  	Location
- 	     Substernal
- 	Onset
- 	     --hrs ago
- 	     --days ago
- 	Brought on by
- 	     jogging
- 	     walking
- 	Relieved by
- 	     rest
- 	     nitroglycerin

## SHML Vocabulary Table (Outline)

- Digestive Tract (*syn* G.I. Tract, Alimentary Tract)
- 		Upper G.I. Tract
- 			Mouth
- 				Tongue
- 				Teeth
- 				Gums
- 			Pharynx
- 				Oropharynx
- 				Hypoharynx
- 			Esophagus
- 			Stomach
- 			Lower G.I. Tract
- 				Small Intestine
- 					Duodenum
- 					Jegunum
- 				Large Intestine
- 					Cecum
- 					Appendix
- 					Colon
- 					Rectum
- 					Anus

## Term/phrase      Relation/Attribute    Term/Phrase         	Relation	 Relation TAG                                      (has member)

- _Term/phrase_      _Relation/Attribute _  _ Term/Phrase_         	_Relation_	 _Relation TAG_                                      (has member)
- Anatomic Structure	as	Integumentary System	is a	Anatomic StructureAnatomic Structure          as 	Breast		is a	Anatomic StructureAnatomic Structure          as 	Musculoskeletal System	is a	Anatomic StructureAnatomic Structure	as	Digestive System	is a	Anatomic StructureDigestive System	as	Digestive Tract	is a	Anatomic StructureDigestive System	as	Digestive Organs	is a	Anatomic StructureDigestive Tract	as	Upper GI Tract	is a	Anatomic StructureDigestive Tract	as	Lower GI Tract	is a	Anatomic Structure
- Upper G. I. Tract	as	Mouth		is a	Anatomic StructureOral		syn	Mouth		BLANK	BLANKUpper G. I. Tract	as	Pharynx		is a	Anatomic StructureUpper G. I. Tract	as	Esophagus		is a	Anatomic Structure Upper G. I. Tract	as	Stomach		is a	Anatomic Structure
- Mouth		as	Lips		is a	Anatomic StructureMouth		as	Tongue		is a	Anatomic Structure
- Mouth		as	Palate		is a	Anatomic StructureRoof of mouth	syn	Palate		BLANK	BLANK
- Tongue	   	as	Posterior third	 is a	Anatomic StructureTongue	  	as	Anterior 2/3 	 is a	Anatomic Structure

## Vocabulary Attribute Table Design---Findings

- Term/phrase       Relation      Term/phrase   	       	Relation    Tag
- 		  (has member)
- 				Finding			      is a        Source
- Finding		      Finding	Finding constitutional (fc)
- Finding		      Finding	Finding tissue(ft)
- Finding		      Finding	Finding integumentary (fs integ)
- Finding		      Finding	Finding musculoskeletal (fsmss)
- Finding		      Finding	Finding respiratory (fs resp)
- Finding		      Finding	Finding neurologic (fs neuro)
- Finding neurological     Finding	Dyslexia			       is a	     Finding
- Finding neurological     Finding	Aphasia			       is a	     Finding
- Finding neurological     Finding	Phobia 			       is a	     Finding
- Phobia		      Finding	Acrophobia		       is a	     Finding
- Phobia		      Finding	Claustrophobia		       is a	     Finding

## SHML® and NLP: Example #2

***SID=NE1519  017A.11.01**
**ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100 , WITH PREMATURE VENTRICULAR CONTRACTIONS AND POSSIBLE OLD INFERIOR AND ANTEROSEPTAL MYOCARDIAL INFARCTS**** .**

- WITH

**ON THE 16TH HOSPITAL DAY , AN ELECTRO-CARDIOGRAM SHOWED PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100**

- AND

**PREMATURE VENTRICULAR CONTRACTIONS**

- AND

**POSSIBLE OLD INFERIOR MYOCARDIAL INFARCTS**

**POSSIBLE OLD ANTEROSEPTAL MYOCARDIAL INFARCTS**

## SHML® and NLP: Example #2.1

***SID=NE1519  017A.11.01**
**ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100**** , ****WITH PREMATURE VENTRICULAR CONTRACTIONS AND POSSIBLE OLD INFERIOR AND ANTEROSEPTAL MYOCARDIAL INFARCTS .**
- <CONNECTIVE><CONJOINED><CONN><P>**WITH**</P></CONN></CONJOINED>
- <PATIENT-STATE>
-        <METHOD><PROCEDURE><T>**AN**</T><N><**pr**>**ELECTROCARDIOGRAM**</**pr**></N>
-                              </PROCEDURE></METHOD>
-        <VERB><TV tense=“[PAST]”><**show**>**SHOWED**</**show**></TV>
-                       <EVENT-TIME><P>**ON**</P><T>**THE** </T><ADJ>**16TH**</ADJ>
-                                       <N><**env**>**HOSPITAL**</**env**></N><N><**tmloc**>**DAY**</**tmloc**></N> **,**
**                      **</EVENT-TIME></VERB>
-        <PSTATE-DATA>
-           <S-S><N><**fns**>**FIBRILLATION**</**fns**></N><P>**AT**</P>
-                    <MODS><MODAL><ADJ><**mcer**>**PROBABLE**</**mcer**></ADJ></MODAL>
-                                    <PTPART><ADJ><**ans**>**ATRIAL**</**ans**></ADJ></PTPART></MODS></S-S>
-          <PTFUNC><T>**A**</T><N><**fun**>**RATE**</**fun**></N><P>**OF**</P>
**             **      <MODS><PTPART><ADJ><**ans**>**VENTRICULAR**</**ans**></ADJ></PTPART></MODS>
-                </PTFUNC>
-          <QUANT><Q-N><NUM><Q><**numb**>**100**</**numb**><Q>**,**</NUM></QN></QUANT></PSTATE-DATA>
- </PATIENT-STATE>
- 										**next...**

## SHML® and NLP: Example #2.2

***SID=NE1519  017A.11.01**
**ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100 ,**** ****WITH ****PREMATURE**** ****VENTRICULAR CONTRACTIONS**** AND POSSIBLE OLD INFERIOR AND ANTEROSEPTAL MYOCARDIAL INFARCTS .**
- WITH
- 	**ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED**
**	****	****PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100**
- <CONNECTIVE><CONJOINED><CONN>**AND**</CONN></CONJOINED>
- <PATIENT-STATE>
- 	<PSTATE-DATA>
- 		<S-S><ADJ><H-INDIC><**tmloc**>**PREMATURE**</**tmloc**></H-INDIC></ADJ></S-S>
- 		<PTPART><ADJ><H-PTPART><**ans**>**VENTRICULAR**</**ans**></H-PTPART></ADJ></PTPART>
- 		<PTFUNC><N><H-PTFUNC><**fun**>**CONTRACTIONS**</**fun**></H-PTFUNC></N></PTFUNC>
- 	</PSTATE-DATA>
- </PATIENT-STATE>
**	****	****	****	****	****	****	****	****	****next ...**

## SHML® and NLP: Example #2.3

***SID=NE1519  017A.11.01**
**ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100 ,**** ****WITH PREMATURE VENTRICULAR CONTRACTIONS AND ****POSSIBLE OLD INFERIOR AND ANTEROSEPTAL MYOCARDIAL INFARCTS**** .**
- <CONNECTIVE><CONJOINED><CONN>**AND**</CONN></CONJOINED>
- <PATIENT-STATE><PSTATE-DATA>
-               <DIAG><N><H-DIAG><**ft**>**INFARCTS**</**ft**></H-DIAG></N>
-                      <EVENT-TIME><ADJ><H-TMLOC><**tmls**>**OLD**</**tmls**></H-TMLOC></ADJ></EVENT-TIME>
-                      <MODS><MODAL><ADJ><H-MODAL><**mcer**>**POSSIBLE**</**mcer**></H-MODAL></ADJ>
-                                      </MODAL><MODS></DIAG>
-              <PTPART><ADJ><H-PTAREA><**ppo**>**INFERIOR**</**ppo**></H-PTAREA></ADJ>
-                                 <ADJ><H-PTPART><**as_cv**>**MYOCARDIAL**</**as_cv**></H-PTPART></ADJ>
-              </PTPART></PSTATE-DATA></PATIENT-STATE>
- <PATIENT-STATE><PSTATE-DATA>
-               <DIAG><N><H-DIAG><**ft**>**INFARCTS**</**ft**></H-DIAG></N>
-                      <EVENT-TIME><ADJ><H-TMLOC><**tmls**>**OLD**</**tmls**></H-TMLOC></ADJ></EVENT-TIME>
-                      <MODS><MODAL><ADJ><H-MODAL><**mcer**>**POSSIBLE**</**mcer**></H-MODAL></ADJ>
-                                      </MODAL><MODS></DIAG>
-              <PTPART><ADJ><H-PTPART><**ppo**>**ANTEROSEPTAL**</**ppo**></H-PTPART></ADJ>
-                                 <ADJ><H-PTPART><**as_cv**>**MYOCARDIAL**</**as_cv**></H-PTPART></ADJ>
-              </PTPART></PSTATE-DATA></PATIENT-STATE>
- </CONNECTIVE></CONNECTIVE></CONNECTIVE>

## Slide 30

## SHML® TAGGING

## Demographic

Symptoms

History

Allergies

- Symptoms
- History
- Allergies

- 28 y/o female
- Stabbing, aching, burning pain, back of neck
- Pain radiating to right side into scapula
- Pain occurs occasional, usually end of day
- Numbness of left triceps occasional
- No urine problems
- No bowel problems
- No gait problems
- No drug allergies

**SHML**®** Tagging of Encounter**

## SHML ® Tagging (cont’d)

- Medications
- Physical Exam
- Impression
- Plan

- Advil, 400 mg.hs,prn
- Neck, normal position
- Neck supple
- Neck full range of motion
- Neck  freedom of movement
- Right Trapezoid mildly tense
- Spine no point tenderness
- Arms, full strength
- Fingers, full strength
- Arms  1+ reflexes
- Legs 1+ reflexes
- Musculoskeletal pain
- Herniated disc, C-5 level, small symptoms mild
- Surgery not an option at this time
- MRI deferred until/should
- 	 bowel findings
- 	 bladder findings
- 	 focal weakness (which persists)
- 	 focal numbness (which persists)
- 	 point tenderness(neck)
- Anvil 800 mg.tid, watch for G.I. side effects
- Physical therapy

## Potential of SHML® Approach

- Ability to Resolve Ambiguity
- Ability to Deal with Multiple Hierarchies

## NLP / SHML ®

- Depression
- 	<fs psy>		psychological
- 	<ft>			depression of surface, shape
- 	<mcha>		depression of WBC, platelet
-   “ST segment depression”  - idiom (phrasal term)

## NLP / SHML ®

-   EKG          revealed        sinus       bradycardia

**  ****<**pr cv ekg**>**

-  <show>

-    <fs cv>

**<as cv>**	Heart
**<as resp>**	Repiratory
**<as mss>**	Within bone
**<ft>****	**	Rectal sinus, (fistula)

## Use with Structured Data Entry

- Onset
- 	# hrs ago
- 	# days ago
- Duration
- 	20 min
- 	1 day
- Location
- Laterality
- Character
- Brought on by
- Associated with
- Aggravated
- Relieved by
- Severity
- Radiating to
- Trend

- tmbeg
- tmd
- A.S.
- ppo-lat
- fi-SS-
- fac
- fi-SS
- li
- li
- mamt
- li
- fres

- Chest Pain

## Structured Health Markup LanguageSHML ® /XML

- Adopt rules, notation that are in place for SGML/XML for the medical record (PMRI)
- Create an architecture for data types
- Structure the EMR
- Utilize XML rules, notation for content (semantics)
- e**X**tensible **M**arkup **L**anguage (**XML)**
- SHML/XML works with language; it does not reinvent it!!!
- XML provides structure and contextual meaning to a document
- XML is a self describing data structure

##   STRUCTURED HEALTH MARKUP LANGUAGE       SHML®

- Subcomponent of XML
- Health DTD for validation tags and their rendering
- Tags assigned to terms/phrases and CRCUs
- Tags specific for health
- Tags specific for NLP
- Structured
- Defines a syntax of tags
- Rules of well-formedness
- XSL eXtensible Style Language for rendering

## SHML® vs MLP elementType’s

- MLP (syntactic) part-of-speech elementType’s are based on major word classes, e.g. nouns (N), adjectives (ADJ), tensed verbs (TV), adverbs (D),... E.g. shortness of breath, **<N>;**
- MLP co-occurrence semantic elementType’s are based on word usage (context), e.g. shortness of breath, **<H-INDIC>;**
- SHML semantic elementType’s are based on medical knowledge (classification), e.g. shortness of breath, **<fs_resp>.**

## SHML® DTD for CRCU’s

- <? XML VERSION=“1.0 ?>
- <!DOCTYPE STRUCTURED HEALTH MARKUP LANGUAGE “shml.dtd”>
- <!ELEMENT PATIENT-STATE
- 		(PARAGR, PT-DEMOG, METHOD, SUBJECT, VERB, TENSE,
- 		 PSTATE-DATA, PRECISIONS, TIME, TEXTPLUS)>
- <!ELEMENT PATIENT-TREATMENTS
- 		(PARAGR, PT-DEMOG, TREATMENT, STATE-SUBJ, PRECISIONS,
- 		 TIME, TEXTPLUS)>
- <!ELEMENT LABTEST
- 		(PARAGR,PT-DEMOG, INST, PT, TEST-INFO, VERB, TIME,
- 		 TEXTPLUS)>
- <!ELEMENT PARAG (#PCDATA)*>
- <!ELEMENT PT-DEMOG (AGE, RACE, SEX, FAMILY)>
- <!ELEMENT AGE (#PCDATA)*>
- <!ELEMENT RACE (#PCDATA)*>
- <!ELEMENT SEX (MALE, FEMALE)>
- <!ELEMENT MALE (#PCDATA)*>
- <!ELEMENT FEMALE (#PCDATA)*>
- <!ELEMENT METHOD (PROCEDURE, EXAMTEST, DEVICE)>
- <!ELEMENT TREATMENT (GEN, CHIR, MED, COMP)>
- <!ELEMENT PROCEDURE (#PCDATA)*>
- <!ELEMENT EXAMTEST (#PCDATA)*>					...etc.

## Presentation of Data (Reformatting)

-      An echocardiogram performed in the Coronary Care Unit
-      shows dilated left atrium, moderate global LV dysfunction,
-      ejection fraction of 30%, moderate global RV dysfunction,
-      severe mitral regurgitation.
- 	pr cv:			Echocardiogram
- 	Env (place): 		CCU
- 	Finding cv:		Dilated left atrium
- 				Moderate global LV dysfunction
- 		Ejection fraction 30%
-  		Moderate global RV dysfunction
-  		Severe mitral regurgitation

## Mission of HLC / SHML®

- Define a granular representation of terms and phrases that within a given language (domain) unambiguously define clinical concepts
- Provide for an adequate representation of these terms and concepts in a simple and easily understood architecture
- Provide for discrete mapping to any other “nomenclature” and/or “code set”
- Utilize easily available, inexpensive and widely supported tools for authoring, maintenance and use
- Provide this as a non-proprietary standard under the auspices of a private not-for-profit entity

## Slide 44