version 3 - hl7’s “swiss army knife” what it is. what it does. g. w. beeler, jr....
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Version 3 - HL7’s“Swiss Army Knife”
What it is. What it does.
G. W. Beeler, Jr.beeler@mayo.edu
Topics
• Interoperability & HL7 standards– Version 3 - building on Version 2– Semantics first
• Infrastructure of standards for interoperability– Infomration Model (later in session)– Vocabulary– Clinical templates
• Applications of the infrastructure– Components (CCOW)– PRA Document architecture– Medical logic representation (Arden Syntax)
Semanticinteroperability
Functionalinteroperability
What IS interoperability?
• Intuitive answer is easy, but specific response is not
• Institute of Electrical and Electronics Engineers (IEEE) dictionary:
"The ability of two or more systems or components to exchange information and to use the information that has been exchanged.”
[IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries, IEEE, 1990]
Basis for Communication
Any meaningful exchange of utterances depends upon the prior existence of an agreed upon set of semantic and
syntactic rules
ISO TR9007:1987 Information Processing Systems – Concepts and Technology for the Conceptual Schema
and the Information Base
HL7 specificationsNouns
Things or entities that are
being communicated.
AdjectivesDescriptors and relationships
of the nouns.
VerbsActions being requested or
communicated.
What must be specified?
The semantics of the communicationThe semantics convey the actual "meaning" of the message. The semantics is conveyed via a set of symbols contained within the communication. An external "dictionary", thesaurus, or
terminology explains the meaning of the symbols as they occur.
A syntax for communicationThe syntax defines the structure and layout of the communication. Common syntax representations include ASN.1, XML, X.12, HL7, IDL, etc.
Services to accomplish the communicationExamples include the post office, a telephone switchboard, SMTP, FTP, Telnet, RPC, ORB services, etc.
A channel to carry the communicationExamples of channels include written documents, telephones, network connections, satellite links, etc.
HL7 Version 3 -
• HL7 “grew up” on the Version 2 series, culminating in 2.3.1
• But now, HL7 is into Version 3– What is it?– How is it different?– Why is it important?
Versions 2.x
• Widely used:– secondary and tertiary facilities– large practices
• Broad functional coverage:– clinical: laboratory, pharmacy, radiology, dietary, most
other diagnostic services, patient care, public health– “clinical administrative:” patient registration,
admission; patient accounts; medical document life cycle; master file maintenance, HIPAA attachments
• Designed in 1987– Based on older messaging formats such as X12
Versions 2.x
Strengths– broad functional coverage– highly adaptable
– IS environments differ– system capabilities variations
– vocabulary independent– least common denominator
technological base
Difficulties– broad functional coverage– highly adaptable
– “Seen one? Seen one.”– vendor capability mismatch
– vocabulary independent– least common denominator
technological base
Version 3 Differences
• Design based on consensus Reference Information Model
• Adaptable to current and future technology bases
• Vocabulary-level interoperability
• Explicit conformance model
• Built on strongly accepted industry base technologies
What is Version 3?
• A new form of standards– Messaging standards that are logically consistent with Versions
2.x, but with crucial semantic improvements – Document standards based on SGML/XML document
architecture– Component standards– Knowledge representation
AND
• A new process for developing those standards– A wholly new approach to the way HL7 develops its standards
Amounts to “re-engineering” the HL7 organization and process
Version 3 as a Standard
• A new communication framework that– Separates message content definition from transmission formats– Includes a Patient record architecture (PRA) - to define sharable
persistent documents– Facilitates use of external codes and terminologies
• Clinical templates– Ability to define specific clinical content that can be exchanged with
standard messages from Versions 2 and 3
• Components for– Clinical communications– Workstation integration
• Medical logic representation - Arden syntax
Version 3 as Process
• A wholly new approach to developing HL7 standards– Model and repository-based for increased control and standards
that are internally consistent
– Specific coupling of events, data elements, messages. documents, and more
– Increased detail, clarity and precision of specification
– Finer granularity in the ultimate messages
– Explicit inclusion of standard vocabularies, terminologies and code sets.
NounsThings or entities that are
being communicated.
AdjectivesDescriptors and relationships
of the nouns.
VerbsActions being requested or
communicated.
Semantics - the CORE issue
The semantics of the communicationThe semantics convey the actual "meaning" of the message. The semantics is conveyed via a set of symbols contained within the communication. An external "dictionary", thesaurus, or
terminology explains the meaning of the symbols as they occur.
A syntax for communicationThe syntax defines the structure and layout of the communication. Common syntax representations include ASN.1, XML, X.12, HL7, IDL, etc.
Services to accomplish the communicationExamples include the post office, a telephone switchboard, SMTP, FTP, Telnet, RPC, ORB services, etc.
A channel to carry the communicationExamples of channels include written documents, telephones, network connections, satellite links, etc.
What does it mean when ...
• I identify the “patient’s attending physician?”– a single individual? Or– all of the physicians’ involved in the case?
• I send a “patient identifier?”– their Social Security Number? Or– the medical record number in my institution? Or– a shared MPI number?
• I key my action to the end of the current “episode?”– the period of time the patient undergoes care on a given day? Or– the period of time the patient spends being an inpatient? Or– the period of time during which the patient is diagnosed with the
same health condition (diabetes, hypertension, etc.)
HL7 sine qua non - Common semantic models
Observation_intent_or_orderpatient_hazard_codereason_for_study_cdrelevant_clinical_information_txtreporting_priority_cdspecimen_action_cd
Clinical_observation
abnormal_result_ind : IDlast_observed_normal_values_dttm : DTMnature_of_abnormal_testing_cd : CEclinically_relevant_begin_dttm : DTMclinically_relevant_end_dttm : DTMobservation_value_txt : NMprobability_number : NMreferences_range_text : STvalue_units_code : CE
Assessment
Healthcare_service_providerspecialty_cd : CNE
Stakeholder_identifierid : STidentif ier_type_cd : ID
Organizationorganization_name_type_cd : CNEorganization_nm : STstandard_industry_class_cd 0..*
0..1 is_a_subdivision_of
0..*
has_as_a_subdivision
0..1
Person
birth_dttm : DTMgender_cd : CNEmarital_status_cd : CNEprimary_name_representation_cd : CNEprimary_name_type_cd : CNEprimary_prsnm : PNrace_cd : CNE
Individual_healthcare_practitionerdesc : TXpractitioner_type_cd : CNE
1
0..1
takes_on_role_of1
is_a_role_of0..1
Stakeholderaddr : XADphon : XTN
0..*
1
is_assigned_to0..*
is_assigned1
Healthcare_provider_organization
0..1
1
is_a_role_of0..1
takes_on_role_of
1
Collected_specimen_samplebody_site_cd : CEcollection_end_dttm : DTMcollection_start_dttm : DTMcollection_volume_amt : CQhandling_cd : IDid : IIDmethod_of_collection_desc : TXspecimen_addit ive_txt : STspecimen_danger_cd : IDspecimen_source_cd : CE
0..*1
is_collected_by
0..*
collects
1
Patient
ambulatory_status_cdbirth_order_numberliving_arrangement_cdliving_dependency_cdmultiple_birth_indnewborn_baby_indorgan_donor_indpreferred_pharmacy_id
0..1
1
is_a_role_of
0..1takes_on_role_of
1
0..*
0..1
has_a_primary_provider
0..*is_the_primary_provider_for
0..1
0..*
0..1
is_sourced_from0..*
is_source_for0..1
Active_participation
participation_type_cd : ID
0..1
0..*
participates_in0..1
has_as_participant0..*
Master_patient_service_location
addr : XADemail_address : XTNid : IDnm : STphon : XTN
1..*
0..*provides_patient_services_at
1..*
provides_services_on_behalf_of0..*
0..*
0..1
is_included_in
0..*
includes 0..1
0..1
0..*
is_primary_facility_for0..1
has_as_primary_facility
0..*
Target_participationparticipation_type_cd : CE
0..1
0..*
is_target_of
0..1
has_as_target0..*
0..1
0..*
is_target_of
0..1
has_as_target
0..*
0..1
0..*
is_target_for0..1
has_as_target
0..*
Service_intent_or_orderfiller_order_id : IIDfiller_txt : TXorder_idorder_placed_dttm : DTMorder_quantitytiming_qt : TQplacer_order_id : IIDplacer_txt : TXreport_results_to_phone : XTNintent_or_order_cd : ID
0..* 0..1
participates_in
0..*
has_as_participant
0..1
1..*
0..1
is_target_of
1..*
has_as_target
0..1
1
0..*
is_entry_location_for
1
is_entered_at
0..*
Master_service
method_cd : CEmethod_desc : TXservice_desc : TXtarget_anatomic_site_cd : CEuniversal_service_id : CE
0..*
1
is_an_instance_of
0..*
is_instantiated_as
1
Service_event
service_desc : STservice_event_descspecimen_received_dttm : DTMname : CE
0..*
0..1
participates_in0..*
has_as_active_participant
0..1
0..*
0..1
is_performed_at
0..*
is_location_for
0..1
0..*
0..1
is_target_of
0..*
has_as_target
0..1
0..1
0..*
is_fulfilled_by0..1
fulfills0..*
1
0..*
is_delivered_during1
delivers
0..*
Table 18: Classes
Abbr Laboratory Term Classes Abbr Clinical Term ClassesABXBACT Antibiotic susceptibility BDYCRC Body circumferenceALLERGY Response to antigens BDYHGT Body heightBC Cell counts (blood, CSF,
pleuritic fluid)BDYSURF Body surface area
BLDBK Blood bank BDYTMP Body temperatureCELLMARK
Cell surface models BDYWGT Body weight
CHAL Challenge tests BP Blood pressureCHALSKIN Skin challenge tests BP.CENT Blood pressure – centralCHEM Chemistry BP.PSTN Blood pressure – positionalCOAG Coagulation study BP.TIMED Blood pressure – timedCYTO Cytology BP.VENOU
SBlood pressure – venous
DRUG Drug levels CLIN Clinical NECDRUGDOSE
Drug dose (for transmittingdoses for pharmacokinetics)
ED Emergency department
FERT Fertility EKG ElectrocardiogramHEM Hematology (excluding
coagulation & differentialcount)
EKG.IMP Electrocardiogramimpression
HLA HLA tissue typing antigens EKG.MEAS Electrocardiogram measuresMICRO Microbiology EYE EyePATH Pathology FUNCTION Functional status (e.g.
Glasgow)SERO Serology (antibodies and most
antigens except blood bank andinfectious agents)
H&P History and physical
SURGPATH
Sugical pathology HEMODYN Hemodynamics
TOX Toxicology HRTRATE Heart rateUA Urinalysis IO Input/OutputVET Veterinary Medicine NEONAT Neonatal measures
OB.US Obstetric ultrasoundOBGYN Obstetrics/gynecologyRESP RespirationSKNFLD Skinfold measurementsUS.URO Urological ultrasoundVOLUME Volume (specimens)
Domain expertise
HL7 committees, affiliates, members & collaborators
Domain expertise
Vocabulary developers, professional societies, government agencies, HL7 committees
Messaging, Document structures, Clinical templates, Arden syntax, Component specification, …..
Applications
Model of Standards for Interoperability
Functional Infrastructure
Interactions Information Model Vocabulary
ORU: The usual result message
Observation Loop
Result/Element Loop
Status
A code that identifies the units of numerical data
in OBX-5
A code that identifies the
datatypeof OBX-5
A code
that identifies the data in
OBX-5(Temp
Reading)
OBX-5: Data
OBX: the flexible segment
OBX||NM|11289-6^^LN||38|C^^ISO+|||||F
Other data fields include: date of observation, identity of provider giving observation, normal ranges, abnormal flags
The code isfrom SNOMED
The code isfrom LOINC
OBX-5: DataA code for Female
A code that identifies the datatype as a
coded element
OBX: with a coded value
A code that identifies the data
in OBX-5(Fetal Gender)
OBX||CE|11882-8^Fetal Gender^LN||T-D0AA0^Female^SMI|
HL7 Reference Information Model
Class: Patient
Description: A person who may receive, is receiving, or has received healthcare services.
Associationsis_a_role_of (1,1) :: Personis_source_for (0,n) :: Specimen_sample
Attributesbirth_order_numberbirth_dttm (from Person)gender_cd <domain 35674> (from Person)marital_status_cd (from Person)
Codes in the HL7 RIM
Class: PersonAttribute: gender_cd <domain 35674>
HL7 Domain SpecificationId “35674”,Scheme “SMI”, version “3.4”,Name “Sex, NOS”,Include Set{{T-D0A90}}
SNOMED InternationalT-D0A90 Sex, NOS
T-D0A96 Indeterminate sexT-D0AA0 Female, NOST-D0AB0 Male, NOS
OBX|1|CE|11882-8^Fetal Gender^LN||T-D0AA0^Female^SMI|
SNOMED International T-D0A90 Sex, NOS
T-D0A96 Indeterminate sexT-D0AA0 Female, NOST-D0AB0 Male, NOS
Codes in an HL7 message
11882-8 GENDER:FIND:PT:^FETUS:NOM: ULTRASOUND:OB.US
LOINC 1.0K
• There is a tight connection between clinical data models and vocabulary
• Changes in structure cause changes to the vocabulary, and vice versa
• Vocabulary and structure must be coordinated to achieve an integrated whole
Vocabulary and Information Model
Purpose: To identify, organize and maintain coded vocabulary terms used in HL7 messages.
HL7 Vocabulary TC
• The HL7 Vocabulary TC is committed to using existing vocabularies (coding systems) as values for coded fields in HL7 messages, rather than creating a new terminology.
• We need a solution that allows HL7 to reference and use proprietary vocabularies (SNOMED, Read, etc.) in a manner that is equitable to all vocabulary creation/maintenance organizations.
The Approach
Model of Standards for Interoperability
Functional Infrastructure
Constraints(Templates)
Interactions Information Model Vocabulary
ORU: The usual result message
Element Loop
Answer Part Loop
MSH, EVN, PID, PV1, ORC,
OBR||8974-9^BP Battery^LN|
OBX|1|CE|8357-6^METHOD^LN|M^Manual|
OBX|2|CE|8358-4^DEVICE^LN|1|AC^Adult Cuff|
OBX|3|CE|8359-2^SITE^LN|1|RBA^Rt Brachial Artery|
OBX|4|CE|8361-7^POSITION^LN|1|SIT^Sitting|
OBX|5|NM|8479-8^SBP^LN|1|138|mmHg|
OBX|6|NM|8462-4^DBP^LN|1|85|mmHg|
An instance of an ORU message
A BP Battery Template
Battery Level ConstraintBPBattery ::= SET {
obr {
universalServiceID (8974-9^BP Battery) }
obxs {
MethodObs,
DeviceObs,
SiteObs,
PositionObs,
SystolicBPObs,
DiastolicBPObs }
Observation Template
Observation level constraint
PositionObs ::= SET{
observationId (8361^POSITION^LN),
value (PositionDomain) }
SystolicBPObs ::= SET{
observationId (8479-8^SBP^LN),
value (Numeric, “DDD”) },
units (mmHg) }
The RIM and Clinical Templates
Patient_slot
Referral
authorized_visits_qtydescreason_txt
Dietary_intent_or_order
diet_type_cddietary_instruction_descdietary_tray_type_cdservice_period_cdservice_type_cd
Individual_healthcare_practitioner_slot
Observation_intent_or_order
patient_hazard_cdreason_for_study_cdrelevant_clinical_information_txtreporting_priority_cdspecimen_action_cd
Treatment_service_event
prescription_idrefills_remaining_qtynotes_txtPTroutPTcompindication_cdexpiration_dttmsubstance_lot_number_txtsubstance_manufacturer_cd
Treatment_service_administration
administered_rate_txtcompletion_status_cdsubstance_refusal_reason_cdsubstitution_cdsystem_entry_dttm
Treatment_service_dispense
dispense_package_method_cddispense_package_size_amtneeds_human_review_indrejection_reason_txtsubstitution_cdsuppliers_special_dispensing_instruction_cdtotal_daily_dose_amt
Treatment_service_give
administration_descgive_per_time_unit_cdgive_quantitytiming_qtgive_rate_amtmax_give_amtmin_give_amtneeds_human_review_indsubstitution_status_cdsupplier_special_administration_instruction_cd
Goal
action_cdaction_dttmclassification_cdcurrent_review_status_cdcurrent_review_status_dttmepisode_of_care_idestablished_dttmevaluation_cdevaluation_comment_txtexpected_achievement_dttmgoal_list_priority_amtlife_cycle_dttmlife_cycle_status_cdmanagement_discipline_cdnext_review_dttmprevious_review_dttmreview_interval_cdtarget_txttarget_type_cdgoal_cd
Clinical_observation
abnormal_result_indlast_observed_normal_values_dttmnature_of_abnormal_testing_cdclinically_relevant_begin_dttmclinically_relevant_end_dttmobservation_method_cdobservation_status_cdobservation_status_dttmobservation_sub_idobservation_value_txtprobability_amtreferences_range_txtuniversal_service_identifier_suffix_txtuser_defined_access_check_txtvalue_type_cdvalue_units_cd
Patient_appointment_
Consent
Care_event
Assessment
Resource_request
allowable_substitutions_cdduration_qtystart_dttmstart_offset_qtystatus_cd
Appointment_request
appointment_rqst_reason_cdappointment_rqst_type_cdequip_selection_criteria_pvidlocation_selection_criteria_pvoccurence_idpriority_cdrepeating_interval_duration_qtyrequested_rirqst_event_reason_cdrqsted_duration_qtystart_dttime_selection_criteria_pv
0
1
is_requested_by0
requests 1
Service_scheduling_request
allowable_substitutions_cdduration_qtystart_dttmstart_offset_qtystatus_cd
1
0requests
1
is_requested_by
0
Durable_medical_equipment_slot
Durable_medical_equipment
idslot_size_increment_qtytype_cd
0
1
is_a_scheduleable_unit_for0
is_scheduled_by1
Durable_medical_equipment_request
quantity_amttype_cd
0
1
requests
0
is_requested_by
1Durable_medical_equipment_group
id
1
0
belongs_to
1 contains
0
0..*
0..1may_request
0..*
is_requested_by
0..1
Diagnostic_related_group
base_rate_amtcapital_reimbursement_amtcost_weight_amtidmajor_diagnostic_category_cdoperating_reimbursement_amtreimbursement_amtstandard_day_qtystandard_total_charge_amttrim_high_day_qtytrim_low_day_qty
Patient_departure
actual_discharge_disposition_cddischarge_dttmdischarge_location_idexpected_discharge_disp_cd
Patient_admission
admission_dttmadmission_reason_cdadmission_referral_cdadmission_source_cdadmission_type_cdpatient_valuables_descpre_admit_test_indreadmission_indvaluables_location_desc
Encounter_drg
approval_indassigned_dttmconfidential_indcost_outlier_amtdescgrouper_review_cdgrouper_version_idoutlier_days_qtyoutlier_reimbursement_amtoutlier_type_cd
1
0
is_assigned_as1
is_an_assignment_of0
Inpatient_encounter
actual_days_qtyestimated_days_qty
1
0
is_terminated_by1
terminates
0
1
1
is_preceded_by
1preceded
1
0..*
1
is_assigned_to0..*
is_assigned
1
Individual_healthcare_practitioner_group
idIndividual_healthcare_practitioner_request
practitioner_type_cd0 0
is_requested_by
0
may_request
0 Treatment_intent_or_order
dosage_txtearliest_dispense_dtIndication_cdnon_form_authorized_indproviders_treatment_instruction_txtrejection_reason_cdrequested_give_rate_amtrequested_give_strength_amtsubstitution_allowed_indsupplier_special_dispensing_instruction_cdverification_required_ind
Treatment_intent_or_order_revision
dispense_package_method_cddispense_package_size_amtgive_indication_cdgive_per_time_unit_cdgive_rate_amtlast_refilled_dttmmax_give_amtmin_give_amtneeds_human_review_indorder_revision_PTcomporder_revision_PTroutorder_revision_quantitytiming_qtordered_administration_method_cdprescription_idproviders_administration_instruction_cdrefills_allowed_qtyrefills_doses_dispensed_qtyrefills_remaining_qtysubstitution_status_cdsuppliers_dispensing_instruction_cdtotal_daily_dose_amttotal_daily_dose_cd
1
1
has_parts1
is_part_of1
Resource_slot
offset_qtyquantity_amtresource_type_cdslot_state_cdstart_dttm
Schedule
id1
0
contains
1
is_managed_by
0
Appointment_contact_person
role_cd
Condition_node
actual_resolution_dttmestimated_resolution_dttmlife_cycle_status_dttmlifecycle_status_cdmanagement_discipline_cdonset_time_txtonset_dttmranking_amtemployment_related_ind
Procedure
anesthesia_cdanesthesia_minutes_qtydelay_reason_txtincision_closed_dttmincision_open_dttmpriority_amtprocedure_cdprocedure_dttmprocedure_functional_type_cdprocedure_minute_qtymodifier_cd
Patient_service_location_slot
Patient_service_location_request
type_cd
Patient_service_location_group
id
0
0
is_requested_by0
may_request
0
Service_intent_or_order_
relationship_type_cdreflex_testing_trigger_rules_descconstraint_txtquantitytiming_qt
Preauthorization
authorized_encounters_amtauthorized_period_begin_dtauthorized_period_end_dtidissued_dttmrequested_dttmrestriction_descstatus_cdstatus_change_dttm
Administrative_birth_event
baby_detained_indbirth_certificate_idbirth_method_cdbirth_recorded_county_cdbirth_recorded_dtnewborn_days_qtystillborn_ind
Patient_arrival
acuity_level_cdarrival_dttmarrival_type_cdmedical_service_idsource_of_arrival_cdmode_cd
Risk_management_incident
incident_cdincident_dttmincident_severity_cdincident_type_cd
Appointment
appointment_disposition_cdappointment_duration_qtyappointment_reason_cdappointment_request_reason_cdappointment_timing_tqappointment_type_cdcancellation_dttmcancellation_reason_cdestimated_duration_amtevent_reason_cdexpected_end_dttmexpected_service_descexpected_start_dttmidoccurence_idoverbook_indscheduling_begin_dttmscheduling_completed_dttmscheduling_status_cdstatus_cdurgency_cdvisit_type_cdwait_list_priority_amt
00
is_reserved_by
0
reserves
0
1..*
0..*
contains
1..* are_booked_in
0..*
0..*
1
participates_in0..*
involves1
Episode
descepisode_type_cdidlist_closed_indoutcome_txtrecurring_service_ind
0
0
specified_in
0
specfies
0
Location_encounter_role
accommodation_cdeffective_dttmlocation_role_cdstatus_cdtermination_dttmtransfer_reason_cdtransfer_reason_descusage_approved_ind
Collected_specimen_sample
body_site_cdcollection_body_site_modifier_cdcollection_end_dttmcollection_method_modifier_cdcollection_scheduled_dttmcollection_start_dttmcollection_volume_amtcondition_cdhandling_cdidmethod_of_collection_descnumber_of_sample_containers_qtyspecimen_additive_txtspecimen_danger_cdspecimen_source_cdtransport_logistics_cd
0
0
is_collected_during
0
collects
0
Master_patient_service_location
addrclosing_dtdescemail_addressidlicensed_bed_qtynmopening_dtphonservice_specialty_cdslot_size_increment_qtystatus_cdtype_cdequipment_type_cd
0
1
is_a_scheduleable_unit_for
0
is_scheduled_by
1
1
0..*
is_requested_by
1
requests0..*
1..*
0..*
belongs_to
1..*
contains
0..*
1
0..*
has
1
pertains_to0..*
0..*0..1is_included_in0..*includes0..1
Clinical_document_header
authentication_dtavailability_status_cdchange_reason_cdcompletion_status_cdconfidentiality_status_cdcontent_presentation_cddocument_header_creation_dtfile_nmidlast_edit_dtorigination_dtreporting_priority_cdresults_report_dttmstorage_status_cdtranscription_dttype_cd
0
0
is_parent_document_for0
has_as_a_parent_document0
Service_intent_or_order
charge_type_cdclarification_phonend_condition_cdentering_device_cdescort_required_indexpected_performance_time_qtyfiller_order_idfiller_txtorder_control_cdorder_control_reason_cdorder_effective_dttmorder_group_idorder_idorder_placed_dttmorder_quantitytiming_qtplacer_order_idplacer_txtplanned_patient_transport_cdreport_results_to_phonresponse_requested_cdservice_body_site_cdservice_body_site_modifier_cdservice_body_source_cdtarget_of_service_cdtransport_arranged_indtransport_arrangement_responsibility_cdtransport_mode_cdwhen_to_charge_dttmwhen_to_charge_txtresults_status_cdintent_or_order_cdjoin_cd
1
0
is_source_for
1
has_as_source0
1
0..*
is_target_for
1
has_as_target0..*
1
0..*
is_entry_location_for
1
is_entered_at
0..*
0..1
0..*
may_be_referred_to_in
0..1
is_related_to
0..*
Patient_encounter
administrative_outcome_txtcancellation_reason_cddescencounter_classification_cdend_dttmexpected_insurance_plan_qtyfirst_similar_illness_dtfollow_up_type_cdidpatient_classification_cdpurpose_cdrecord_signing_dttmspecial_courtesies_cdstart_dttmstatus_cdtransport_requirement_cdurgency_cdtriage_classification_cdmedical_service_cdconfidentiality_constraint_cd
1
0
is_authorized_by1
authorizes
0
1
0..*
has_parts1
is_part_of0..*
0..1
1
precedes
0..1 is_preceded_by
1
0..*
1
pertains_to
0..*
has
1
1..*
0..*
is_scheduled_by1..*
schedules
0..*
1
1..*
has_parts
1
is_part_of
1..*
1..*
1
pertains_to
1..*
has
1
0..*
0..1
precedes0..*
follows0..1
Service_event_
relationship_type_cd
Active_participation
begin_dttmend_dttmduration_tmparticipation_type_cd
0
0
participates_in
0
has_as_participant
0
Target_participation
begin_dttmend_dttmduration_tmparticipation_type_cd
0
0
is_target_of
0
has_as_target0
0..1 0..*
is_target_for
0..1
has_as_target
0..*
1..*
0..1
is_target_of
1..*
has_as_target
0..1
Service_reason
determination_dttmdocumentation_dttmreason_txt
0
0
is_reason_for
0
has_as_reason
0
Service_event
attestation_dttmattestation_due_dtbegin_dttmcharge_to_practice_amtcharge_to_practice_cdpatient_sensitivity_cdconsent_cddeclined_indservice_descend_dttmfiller_idfiller_order_status_cdfiller_order_status_dttmrecurring_service_cdscheduled_start_dttmservice_event_descspecimen_received_dttmspecimen_action_cdnmfamily_awareness_txtindividual_awareness_cdconfidential_ind
0
0
is_performed_at0
is_location_for
0
0..*
0..*
is_documented_by
0..*
documents
0..*
0..1
0..*
is_fulfilled_by
0..1
fulfills
0..*
0..*
0..1
is_assigned_to
0..*
has_assigned_to_it
0..1
1
0..*
is_target_for
1
has_as_target0..*
1
0..*
is_source_for
1
has_as_source
0..*
0..*
0..1
participates_in
0..*
has_as_active_participant
0..1
0..*
0..1
is_target_of
0..*
has_as_target 0..1
0..*
0..1
has_as_evidence
0..*
is_evidence_for0..1
0..*
0..1
is_reason_for
0..*
has_as_reason0..1
Root
Stakeholder Service Event
AssessmentOrderOrganization Person
Rx Order
Service Order
Observation
Goal
UARetics
O2 Sat
120+
1,000+Eye
What are clinical templates?
• “Constraint of an existing information model”– Reference Information Model (RIM) – Message Information Model (MIM)– Message Element Type (MET)– Hierarchical Message Definition (HMD)
• Constraint of specific RIM classes:– clinical assessment– clinical observation– service event– service order– others
• Can be applied to Version 2.X or version 3.0
Clinical Template Work Items
• Define the formal notation for templates– Literary representation– Database representation– Graphical representation
• Define a process for creating, approving, and maintaining templates
• Define a mechanism for participating with professional societies or other clinical experts in the creation of template content
• Create a repository for storing and allowing access to templates
Model of Standards for Interoperability
Applications (of the infrastructure)
Functional Infrastructure
Interactions Information Model Constraints(Templates)
Vocabulary
Interoperable Systems
OperationallyDependent
OperationallyIndependent
Operational Coupling
• Tightly Coupled– navigation system and
gyroscope– model: function call– operational dependence– the default mode for
software component services
– frequently associated with one-source data
• Loosely Coupled– navigation system and map
data– model: message– operational independence,
or semi-dependence– can be implemented with
software component services
– data replication
– Couple– Coordinate– Synchronize
Disparate applications on the workstation at the point of care.
(similar to HL7 but on the “front-end”)
– Couple– Coordinate– Synchronize
Disparate applications on the workstation at the point of care.
(similar to HL7 but on the “front-end”)
What is CCOW?
A Standard to: A Standard to:
StandardStandard
Manatee: a sea cow
The Provider's Workstation
“Visual” Integration
“Data” Integration
The Provider
The Clinical Applications
Server
Server
ServerVisual
Integration
Context Manager Component
C
The Clinical Applications
The Provider
The Provider's Workstation
COMAutomation
It’s real and it worksIt’s real and it works
Current Patient = Nancy Furlow as shown within:Current Patient = Nancy Furlow as shown within:• Multum MediSourceMultum MediSource• Oacis EMPI Oacis EMPI • Medicalogic Logician Medicalogic Logician • Hewlett Packard CareVue Hewlett Packard CareVue
Within Oacis EMPI, search for a new patient and Within Oacis EMPI, search for a new patient and select Michael O’Donnell.select Michael O’Donnell.
The patient context is automatically switched toThe patient context is automatically switched toMichael O’Donnell within all systems at the pointMichael O’Donnell within all systems at the pointuse.use.
Component Implementation
Context Manager
Implementation
CM
CDCommonContext
Data
CP
CP
Application #n Implementation
Application #1 Implementation
Patient Mapper Implementation
MA
II
Current Work
• Single sign-on: – users do not have to memorize many user names and
passwords– authentication via password, badge swipe, biometrics
• Web-based applications– share context with client/server apps– “pure” web-based: awaits an interested participant
Model of Standards for Interoperability
Applications (of the infrastructure)
Functional Infrastructure
Interactions Information Model Constraints(Templates)
Vocabulary
DocumentSharing
Interoperable Systems
OperationallyDependent
OperationallyIndependent
Document Patient Record Architecture
• Proposal
• Architecture that allows for varying levels of complexity in clinical documents
• Interface that is a mediator between two applications or systems
• Exchange mechanism from a document centered perspective with varying levels of requirements
A Transformation
<PRESCRIPTION>
<MEDNAME MED="Amoxil">
Prescribed medication: Amoxil
</MEDNAME>
APPLICATION PRA
Architectural Forms specify how tags are changed:
<PLAN CC.CLIENT.ETN="PRESCRIPTION">
<MENTION DOMAIN="Kona Example" NORMALIZED.CONTENT="Amoxil" CC.CLIENT.ETN="MEDNAME"> Prescribed medication: Amoxil
</MENTION>
Transform <PRESCRIPTION> to <PLAN>
The Patient Record Architecture
• Multi-layered schema consisting of three layers A basic, abstract layer to exchange narrative documents
(ProseDoc) A layer that provides simple classification (ClinicalContent) A layer that requires greater clinical semantics
The Patient Record Architecture
Example: Document Repository
Organization 1 Organization 2Op-Note DTD 1
Op-Note (1)
Op-Note DTD 2
Op-Note (2)
Op-Note (PRA)
Transform
Op-Note (PRA)
Transform
Diabetes DTD 1
Diabetes Note (1)
Transform
Diabetes Note (PRA Level one)
A person can readall the contents of
all the notes
A computer can searchall the notes based on
Level One admin. Data, anddo smart processing on
Op-notes based on the PRA subset
Model of Standards for Interoperability
Applications (of the infrastructure)
Functional Infrastructure
Interactions Information Model Constraints(Templates)
Vocabulary
DocumentSharing
PortableRules
Interoperable Systems
OperationallyDependent
OperationallyIndependent
data: storage_of_potassium := EVENT {storage of potassium}; potassium := READ LAST {potassium level}; digoxin_order := read last {digoxin order}; if potassium >= 3.3 then conclude false; endif; if (digoxin_order is null) then conclude false; endif;
conclude true; ;; action: write "The patient's potassium level (" ||potassium|| " mEq/l on " ||time of potassium|| ") is low. If the patient is currently taking digoxin, then the hypokalemia may potentiate the development of digoxin-related arrhythmias."; ;; urgency: 50;;end:
Arden Syntax--Portable Medical Logic
data: storage_of_potassium := EVENT {storage of potassium}; potassium := READ LAST {potassium level}; digoxin_order := read last {digoxin order}; if potassium >= 3.3 then conclude false; endif; if (digoxin_order is null) then conclude false; endif;
conclude true; ;; action: write "The patient's potassium level (" ||potassium|| " mEq/l on " ||time of potassium|| ") is low. If the patient is currently taking digoxin, then the hypokalemia may potentiate the development of digoxin-related arrhythmias."; ;; urgency: 50;;end:
“Curly braces” nonstandard data access specification
{'dam'="PDQRES1"; ;
'any 32310~intravascular potassium'}
Model of Standards for Interoperability
Applications (of the infrastructure)
Functional Infrastructure
Interactions Information Model Constraints(Templates)
Vocabulary
Interoperable Systems
OperationallyDependent
OperationallyIndependent
Communication Model
Interrogative (query)
Indicative (unsolicited update)
Imperative (order)
Operationally Dependent
Operationally Dependent or Independent
Model of Standards for Interoperability
Communication Model
Applications (of the infrastructure)
Functional Infrastructure
Interactions Information Model Constraints(Templates)
Vocabulary
Interoperable SystemsDocumentSharingOperationally
Dependent
PortableRulesOperationally
Independent
Interrogative (query)
Indicative (unsolicited update)
Imperative (order)
Services, Service Approach
NoneCORBA DCOM
Component: technology neutral
Future?
Light-weight
HTTP SNMP MIME XML
Communication Model
Applications (of the infrastructure)
Interactions Information Model Constraints(Templates)
DocumentSharingOperationally
DependentOperationallyIndependent
Interrogative (query)
Indicative (unsolicited update)
CORBA DCOM Future? HTTP SNMP MIME
Emphasis on SemanticsEmphasis on Semantics
Range of ApplicationsRange of Applications
Explicit, fine-Explicit, fine-grained grained
conformance conformance modelmodel
Wrapping it Up
Robust, interoperable implementations Robust, interoperable implementations in multiple technologiesin multiple technologies
Some Words To Live By
• Substance is enduring
• Form is ephemeral
• Confusing the two – hides the problems– invites obsolescence
Model of Standards for Interoperability
SubstanceSubstance
FormForm
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