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Health Informatics: the
Relevance of Open Source and Multilevel Modeling

Luciana T. Cavalini, MD, PhDTimothy W. Cook, MSc

Multilevel Healthcare Information Modeling (MLHIM) Laboratory (UFF/UERJ)

Associated to the National Institute of Science and Technology Medicine Assisted by Scientific Computing

Introduction

Healthcare is a dynamic and complex systemThe spatial changes are close

The time changes are fast

The number of basic concepts is 300,000+

Cavalini's conjecture: given a group of medical experts without any hierarchical relationship among them, the probability of them reaching 100% of agreement about any set of concepts from their domain tends to zero

Introduction

A single monolithic system for the complete health record of a person from cradle to grave is not feasible

Integration projects that were successful in other businesses have been attempted in healthcare over the last 46 years, spending trillions of dollars, with a 100% failure rate

The result: healthcare is the less computerized business in economy

Introduction

Electronic Health Records (EHR) have promised (and yet not delivered): waste of citizen's time in lines for appointments and referral

waste of staff time in search of critical information

duplication of tests, medications and procedures

early detection and prevention

adherence to therapeutic protocols

risk of adverse events and medical errors

avoidable hospitalization and mortality

Total loss: 12 billion in 10 years

Total loss: not published (6 years)

Total loss: US$200 million (13 years)

Not solving a problem is usually much more profitable than solving itAre you following me, Groo?

Introduction

Currently, medical records have a chaotic mixture of old (paper) and new (computer) support medias

The electronic records already implemented seldom follow any of the ISO TC 215 recommendations or any other standardization

The mixture of incompatible systems runs across the entire system: from inside the hospitals up to the local, regional, national and international levels

The reality of British NHS

=

The reality of American Medicare

=

The reality of Brazilian SUS

etc.

Hardware is not the problem anymore

What about software?

What software???

Interoperability

- Cough- For 3 months- Low feverChest X-Ray:- Nodule in right apexBAL:- TB

Interoperability!

- Cough- For 3 months- Low feverChest X-Ray:- Nodule in right apexBAL: TB

- Cough- For 3 months- Low feverChest X-Ray:- Nodule in right apex- Cough- For 3 months- Low feverChest X-Ray:- Nodule in right apexBAL: TB

ISO 13606 messages

HL7v2 messages

MS Access formInteroperability?

- Cough- For 3 months- Low feverChest X-Ray:- Nodule in right apexBAL:- TB

xxxxveryexpensivemapping

Where is the context?

Here is the context!

IHE

HL7

IHTSDO

ISO

WHO

SNOMED CT

ICDx

CEN

ASTM

CDA

EN13606-1

CCR

v2 messages

v3 messages

Data types

PDQ

CCOW

HSSP

PIX

HISA

RID

XDS

PMAC

EN13606-4

RBAC

EN13606-3

EN13606-2

Templates

Documents

Security

Services

Content models

Terminology

Thanks to: Thomas Beale (openEHR Foundation)

Traditional Modeling

Traditional Modeling

Information is modelled to serve the current needs of the healthcare system; but those needs change very fast and they are very different from one facility to another

Adding new concepts and customizing a legate system for another facility demands the total re-make of the system (re-modelling, re-implementation, re-test, re-deployment)

Unaffordable costs, frustrated users, abandonment of the systems (average time = 2 years)

Multilevel Modeling

This approach is compliant to the ISO 20514 standard

Multilevel Modeling

Fundamental Principle: separation between the Reference Model and Knowledge Modeling

The Reference Model is a necessary and sufficient set of generic classes for the persistence of all types of health information

The Knowledge Modeling is the combination of the Reference Model classes and the definition of constraints to those very classes, enough to define a given healthcare concept

Multilevel Modeling

Reference ModelKnowledge ModelingYour Application (GUI, BI etc)

Multilevel Modeling

SpecificationCompliance to StandardsOpenImplemented

openEHRInspired ISO 20514, 18308 and 13606YesYes(RM and KM tools = Yes)

MLHIMInspired by ISO 21090, 20514, 18308 and 13606 and W3C specsYESRM and KM tools

openEHR Reference Model
(High level structure)

Composition

openEHR Reference Model
(Low level structure)

Nanos gigantium humeris insidentesBernard of Chartres

Make things as simple as possible, but no simplerAlbert Einstein

MLHIM Reference Model

ELEMENTCCD

CareEntry or AdminEntry

Cluster

QuantitativeDatatypesNon-QuantitativeDatatypesDvQuantifiedDvStringDvEncapsulatedDvParagraphDvBooleanCluster

ELEMENTELEMENTDvDate TimeDvDurationDvIntervalRefRange...and its child classes

...and its child classes

Knowledge Modeling in MLM

Name(Spec)ArchitectureOpen# of KM artifacts / conceptSolution for Cavalini's conjectureCombination of KM artifactsOpen

Archetype(openEHR)Archetype Definition LanguageYesOneSpecialisationTemplatesYes

Concept Constraint Definition CCD(MLHIM)XSDYesUndefinedNo restriction for the # of CCDs / conceptMaster CCDYes

openEHR archetypes and
MLHIM CCDs

Analogy: Lego

openEHR archetypes and
MLHIM CCDs

Archetype / CCD

Concept

MLM Principles and OS

Principle 1: The Reference Model is language-agnostic and common to all implementations

Principle 2: The Knowledge Modeling artifacts should be valid against the Reference Model

Principles 1 an 2 require open specifications and strongly support open source implementations of the RM and open source KM tools

MLM Principles and OS

Principle 3: The Knowledge Modeling artifacts should contain all the semantic context of the information

Principle 4: The Knowledge Modeling artifacts are shareable among applications

Principles 3 and 4 strongly support open instances of KM repositories

Bioethical Principles and OS

Principle of Beneficence and Non-Maleficence (primum non nocere): bad health informatics can kill (http://iig.umit.at/efmi/badinformatics.htm)

Principle of Efficiency (or cost-effectiveness): IT adoption in healthcare is a healthcare intervention such as drugs, lab tests etc and it should be submitted to the same scrutiny

The principles of Beneficence / Non-Maleficenceand Efficiency strongly support the adoptionof OS MLM-based applications in healthcare

Thank you!

Join us:

Visit us:

http://macc.lncc.br

http://www.mlhim.org

My e-mail: lutricav@vm.uff.br

Special acknowledgements:Sergio FreireMike Bainbridge

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