version 3 - hl7’s “swiss army knife” what it is. what it does. g. w. beeler, jr....

Version 3 - HL7’s“Swiss Army Knife”

What it is. What it does.

G. W. Beeler, [email protected]

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



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


Applications (of the 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





Vocabulary

DocumentSharing




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





Vocabulary

DocumentSharing

PortableRules




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'}





Vocabulary




Communication Model

Interrogative (query)

Indicative (unsolicited update)

Imperative (order)

Operationally Dependent

Operationally Dependent or Independent


Communication Model




Vocabulary

Interoperable SystemsDocumentSharingOperationally

Dependent

PortableRulesOperationally

Independent



Imperative (order)

Services, Service Approach

NoneCORBA DCOM

Component: technology neutral

Future?

Light-weight

HTTP SNMP MIME XML

Communication Model



DocumentSharingOperationally

DependentOperationallyIndependent



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


SubstanceSubstance

FormForm

version 3 - hl7’s “swiss army knife” what it is. what it does. g. w. beeler, jr....

Documents

hl7 version

hl7 specificationsnounsthings

information basewhat

communicationthe semantics

communicationthe syntax

common syntax representations

patient registration

patient care