Meaningful records and meaningless boxes

David MarkwellPrincipal Consultant

The Clinical Information Consultancy Ltd

www.clininfo.co.uk

HL7 UK Conference 2007

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Meaningless boxes?

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Meaningless boxes?

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Terminologies& classifications

Communicationspecifications

Applications & data storage

Data capture andUser interfaces

Information models archetypes and templates

Meaningful records

For health record information to be reusable it must be processable in a meaningful way by a variety of different applications

How should the ‘meaningless boxes’ be used to meet this objective?

Requirements for meaningful health records

Requirements for meaningful processing of health record information come from a variety of different sources including:– Clinicians involved in direct patient care– Epidemiologists and researchers– Service managers at local and national levels

To meet these varied requirements the health record content must be represented in ways that encompass multiple perspectives

Different perspectives on health information

Clinical discipline and specialty viewsDifferent ways of working and priorities affect

• Degree of detail that can be readily captured• Balance between data capture styles• Record content that needs to be displayed for review• Opportunities for effective use of decisions support• Reporting requirements

Specific process views

For example• Requesting and reporting investigations• Prescribing, dispensing and administration of medication• Managing immunisation programs• Referrals and appointment bookings

Integrating different perspectives

Specific perspectives are important– Specialty specific views support clinical users – Process specific views enable efficient and effective

delivery of services

Integration of multiple perspectives is important– The same information is often collected by, and

relevant to, many specialties and processes– Consistent representation of information is essential

to enable reuse of relevant information– Requirements for consistency are often ignored

when focusing attention on one process or specialty

Process and meaningful health record views

(slides 8-13 were hidden and not used in HL7UK Conference presentation)

Reusable, meaningful health records in the context of

The delivery of health care to a person or a population consists of various processes – Each process has specific requirements for data

collection and communication • For example, the process of providing routine immunisations

Health records contain information collected during various processes– The information collected is often relevant to and

related with multiple care delivery processes• For example, information about an immunisation may be

relevant determining the differential diagnosis for a subsequent febrile illness

Processes based requirements

Data requirements– Provide each party with sufficient information to fulfil their role– Track progress to confirm consistent completion– Identify exceptions

Data capture and communication requirements– Simplify capture of data essential to the process– Specify the requirements for communications that are essential

to the process Typical end result

– Forms, information structures and messages directly matching specific requirements with minimal requirements for data transformation

– Not ideal if the information needs to be reused by other related processes

An example of a process: Routine immunisation

Call person to immunisation clinic– Record call and booked appointment

Take and review history for contra-indications Decide on immunisation required Explain recommendation and obtain consent

– Record history, immunisation decision and consent Administer the appropriate quantity of the vaccine by

the appropriate route– Record details of the substance, quantity, batch number and

route of administration Arrange follow up for next step in course

– Submit required information to support claims and/or update central/shared immunisation registers

Health record requirements

Information requirements – Provide appropriate accurate information when and where it is

needed• To enable delivery of evidence-based personal care to individuals

• To enable more effective delivery of care to the wider population

– Allow incremental growth of ‘meaningful information’

Capture and communication requirements– Facilitate capture of information from which the meaning can be

determined without detailed knowledge of the specific data collection process

– Represent communications in ways that conserve ‘meaningful information’ derived from different processes and applications

An example of a meaningful health record view:Immunisation information

Questions a meaningful health record should be able to answer: What immunisations has this person had – and when? Has this person had an adverse reaction to a past immunisation? What immunisations are due or incomplete? Is this person up to date for immunisation against disease X? What percentage of a population completed their immunisations? Who received immunisations from a suspected faulty batch? Which members of the population are at risk from a current

outbreak of a disease due to out of date immunisation? Has this GP/PCT hit a target for coverage of the population? Have particular immunisations, routes or regimes been associated

with greater risks of side effects? … and many more …

Meaningful electronic health records

A meaningful health record makes it possible to answer relevant questions accurately and efficiently

Relevant questions that a health record may need to answer

It is impossible to enumerate every potentially relevant question (the number is huge and growing)

It is possible to identify general types of questionsFor example …– What information is known about this person?– Does this person have a particular item or collection of items of

information in their record?– How many incidents of a specified type have occurred to

members of a population (or selected subpopulation)?– Which members of a population have a particular item of

collection of items of information in their record? Each type of question can be refined

– different selection criteria – different ways in which to represent the answers

Illustration of a differences between ‘process view’ & ‘meaningful record view’ Are the following questions the same?

– Did this person complete the routine immunisation process against disease X?

– Is this person’s appropriately immunised against disease X?

Not really – One is ‘process’ question the other is a ‘meaning’ question

The answers are related but may differ– Evidence of the effectiveness of the vaccine given may change

so the cover is no longer effective– Immunisation may be done and recorded in other situations

• For example, an A&E department or travel clinic

An immunisation in any situation is still an

immunisation

Requirements for accuracy and efficiency

Accuracy – includes– Precision

• Reducing the risk of false positives

– Completeness• Reducing the risk of false negatives

Efficiency – includes– Ease

• Time and expertise needed to pose questions

– Frequency• How often does a question need to be answered

– Rapidity • How quickly is an answer needed

Retrieval

Display

Capture

Reportingand analysis

StoredEHR Content

CommunicationsStored Content

Other EHR systems

A simplified overview of health record information

flows

DecisionSupport

What functions determine the requirements for processable health record content?

Retrieval as a determiner of data content and representation

A meaningful health record makes it possible to answer relevant questions accurately and efficiently

In order to answer relevant questions information must be selectively retrieved so it can be displayed or analysed

Therefore retrieval requirements are clearly an important determiner of requirements for data content and representation

Display as a determiner of data content and representation

Display requirements can be phrased as questionsFor example– General: What information is held about this person?– Specific: What allergies does this patient have?– Population: Which patients require follow up?

Display is one of the underlying requirements for selective retrievalDisplay retrieval requires– High performance - rapid responses– Clear rendering and layout of responses– Integration with data capture in the user interface

Data capture as a determiner of data content and representation

Effective data capture is vitally important– It needs to be easy in terms both of

• the time and effort require; and• the way it fits in with working practices

Data capture is only worthwhile if the data captured can be usefully reusedTherefore – Data capture does not define the requirements for

data content and representation – Data capture needs to be designed to meet

requirements for subsequent retrieval

Alternative modes of data entry are good servants but poor masters

• Approaches to data entry need to be tailored to

the way different groups of clinicians work and

think• A common approach to the user interface• But not one size fits all

• As the following examples illustrate the same

information may be captured in different ways• How does this affect content and representation?

Different ways to capture the same meaning (1)Simple check-boxes

Suggests a Model of Use consisting of codes assigned values of “true”, “false” or “unknown”.

Different ways to capture the same meaning (2)

Selection of terms

Suggests a Model of Use consisting of individual coded statements with associated text

Different ways to capture the same meaning (3)Free text with natural language processing

Suggests a Model of Use consisting of text tagged with relevant codes.

Answering questions based on data capture representations

• If information is represented according to the way it is

captured it may be difficult to answer simple questions• Does the patient have a family history of diabetes

mellitus? … expands to …• Do they have a family history form in which ‘diabetes mellitus’ is

checked as present?• Do they have a family history record in which the code for ‘FH

diabetes mellitus’ is present?• Do they have text that is tagged with the code for ‘diabetes

mellitus’ in the context of a section of text tagged as ‘family

history’?• ... there are also other data capture representations to consider

Data capture and meaningful records

Reuse of information captured in different ways should be supported by enabling transformation from specific data capture forms to a common ‘model of meaning’

For example– The results of the preceding data capture illustrations should be

transformed to a common model of meaning that allows questions about family history of asthma, diabetes mellitus and heart disease to be answered consistently

The model of meaning should – Encapsulate essential contextual information

• i.e. family history, absence/presence

– Represent appropriate and available detail– Allow general questions to be reliably answered by records that

may contain more detailed representations• e.g. “family history or type 2 diabetes mellitus”

Communication as a determiner of data content and representation

Communication requires the sending system to selectively retrieve the information to be sent

There is no point in communicating information that is not retrievable on the recipient system– Reuse of communicated information requires selective retrieval

Therefore, communication requirements are secondary to requirements for reuse and retrieval

Possible exception: A communication specification may be the only source of requirements for data that is captured specifically to populate a message, has a specific role in the receiving system and is not reused for any other purposes.

Communication of meaningful records

Information with the same meaning may be represented differently in different systems and in different messages– To meet different use cases in term of levels of detail– To benefit from proprietary optimisations– To utilise different communication standards appropriate to

specific requirements

Communications of health record information should be based on (or transformable to) a common model of meaning– A common model of meaning offers a shared view allowing

consistent retrieval of data irrespective of its point of origin

Meaningful electronic health records

A meaningful health record makes it possible to answer relevant questions accurately and efficiently

The primary drivers for the data content and representation of health records are– The questions that are deemed to be relevant – The accuracy and efficiency necessary to adequately

address those questions

RetrievalRequirements

DisplayRequirements

CaptureRequirements

Reportingand analysis

Requirements

EHR ContentRequirements

CommunicationsRequirements

Content Requirements

Other EHR systems

Requirements arise from the questions that

need to be answered

DecisionSupport

Requirements

RetrievalRequirements

‘Posing question

s’

Requirements for a commonmodel of meaning

A model of meaning into which data captured in different ways can be transformed is required to support – Consistent processing within an application that

collects similar data in different ways• ‘Semantic operability’

A common model of meaning in which data from different application can be shared is required to support – Communications between applications which employ

different internal models of meaning• ‘Semantic interoperability’

What should a common model of meaning look like

A virtual view of information that can be used as a point of reference for questions

Ensure that similar information can be retrieved in similar ways– Avoid special cases in which particular information is

only accessible using particular queries• This does not preclude specialised views but it does require

that the information is also accessible using the general view

– Avoid multiple representations of similar information based on process or level of detail• The model of meaning should tolerate different levels of

details within the common structure

Templates and other constraints

Templates and archetypes act as useful constraints to information models that can assist many aspects of health record system specificationIncluding– Design of data capture screens and protocols,– Design and implementation of health record repositories,– Message design and message instance validation.

Like other information models these structures should be bound to terminologies to make them meaningful– Structural constraints should not be assumed to encapsulate

meaning– Instances of information that conform to structural constrants

should be reliably transformed to a common model of meaning to enable comparability with other representations of similar information

Starting point for a common model of meaning

The HL7 DSTU ‘Guide to the use of SNOMED CT with HL7v3’ (TermInfo) is a starting point from which to develop a common model or meaning– It discusses many general issues encountered at the boundary

between information models and terminology models– It identifies specific issues at the boundary between ‘HL7

Clinical Statements’ and ‘SNOMED CT Terms’ and specifies rules and guidance for dealing with many of these issues.

– It provides a point of reference – rather than a finished work – since it remains subject to evolutionary improvement

Similar work is needed in respect of– Other information models (e.g. EN13606 and OpenEHR)– Any additional terminologies used in health records

Reusable meaningful records depend on rules for assembling meaningless boxes into a consistent inclusive ‘model of meaning’

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Progress In the last year …

– Two relevant standards were passed in DSTU ballots• HL7 Clinical Statements

• HL7 Guide to Use of SNOMED CT in HL7v3

– Ownership of SNOMED CT passed to the IHTSDO• International Health Terminology Standards Development Organisation

Recently …– An IHTSDO project to specify SNOMED CT Machine Readable

Concept Model constraints was launched– Work started on approaches to binding SNOMED CT to

EN13606 archetypes and openEHR templates

There are stronger signs of practical convergence between EHR related standards today than in the past– … but much remains to be done

Conclusions Reusable heath records need to support

selective retrieval to answer relevant questions, accurately and efficiently

Selective retrieval requirements are the primary driver for specification of the content of the EHR

A common model of meaning is essential to enable effective retrieval

Specifications concerned with capture and communication of health record information need to enable transformation to an agreed common model of meaning

Meaningful records from meaningless boxes

Thank you for your attention– Any questions?

– Contact details• www.clininfo.co.uk• www.cliniclue.com