Dr Michael Mair

Timaru Eye Clinic New ZealandSydney 24-25 April Health IT Standards

Free TextMany practitioners regard free text as a symbol for medicine as an art versus structured text and interactive recording as symbols for scientific, evidence-based, and guided documentation. Sydney 24-25 AprilTimaru Eye Clinic

The Health Standards Committee of the International Standards Organization:ISOTC/215 Mission statement:Standardization in the field of information for health, and Health Information and Communications Technology (ICT) to achieve compatibility and interoperability between independent systems. Also, to ensure compatibility of data for comparative statistical purposes (e.g. classifications), and to reduce duplication of effort and redundancies. Sydney 24-25 AprilTimaru Eye Clinic

Extensible Markup LanguageA meta-language recommendation from the World Wide Web Consortium (W3C)Extensible Markup Language, abbreviated XML, describes a class of data objects called XML documents and partially describes the behavior of computer programs which process them. [1. Introduction]Sydney 24-25 AprilTimaru Eye Clinic

Extensible Markup LanguageXML: a method of modeling documents and data for computerized applications. Documents and data? Whats the difference?Bosak: "A document is data that you can read."

Is data, then, (parts of) a document that a computer can process?Sydney 24-25 AprilTimaru Eye Clinic

Structure, content, markupXML can model the structure and the content of a document:structure: a list, paragraph, section, tablecontent: chief complaint, author, price, unitXML uses markup to encode structure and contentCats love mice! Sydney 24-25 AprilTimaru Eye Clinic

XML featuresSeparates content/structure from presentation/formatnon-proprietaryvendor, platform, application neutral

. but wait, theres more...Sydney 24-25 AprilTimaru Eye Clinic

XML(eXtensible Markup Language)Emerging standard for content-aware Web pages that will replace HTMLSeparates data display from semanticsProvides atomic metadata about object in a documentSydney 24-25 AprilTimaru Eye Clinic

XML LimitationsXML describes grammars--is a syntactic standard--no way to recognize semantic unitsPure XML does NOT create a data modelSydney 24-25 AprilTimaru Eye Clinic

Why Standards?Healthcare Information is increasingly transmitted electronically.For Healthcare IT systems to exchange information, they can either:communicate via custom interfacesshare a common data formatCustom interfaces are costly to design and difficult to maintain (~ $100k each).A common data format is cost-effective, but needs up-front agreement and commitment = a Standard.Sydney 24-25 AprilTimaru Eye Clinic

Other Examples of StandardsMobile Phones (GSM)CDsATMsSydney 24-25 AprilTimaru Eye Clinic

Why Have Health Information Technology Standards?Many applications, little interoperability Healthcare Economics will benefitThe need to analyse more healthcare data The need to share more healthcare dataThere are growing numbers of conceptsPresent Health record practices are inefficientSydney 24-25 AprilTimaru Eye Clinic

Interoperability is the property of different systems to work together 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]Sydney 24-25 AprilTimaru Eye Clinic

Interoperability has two componentsInteroperability: 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]Sydney 24-25 AprilTimaru Eye Clinic

Healthcare Economicsare adversely affected by poor documentation quality. In the United States alone, the cost of information capture is estimated to be over $50 billion annually. A significant portion of this cost is likely to be due to inefficienciesSydney 24-25 AprilTimaru Eye Clinic

The need to analyse more healthcare datato observe trends and patterns within the historical record of one patientto enable the use of clinical guidelines and decision support tools: evidence based health careto perform clinical auditto inform management and commissioning decisionsto support epidemiology, research and teachingSydney 24-25 AprilTimaru Eye Clinic

The need to share more healthcare datawith other clinicians in the same teamclinical firms, practice partnerships or nursing shiftswith other healthcare professionsdoctors, nurses, physiotherapists, midwives, dieticians...with other disciplinesa diabetic patient may also be under: ophthalmology, nephrology, orthopaedics, chiropody, wheelchair clinic.with other institutionswith patients and their familiesSydney 24-25 AprilTimaru Eye Clinic

Growing numbers of concepts

Around half of the concepts believed to exist in the world (500,000) are in the medical domain Sydney 24-25 AprilTimaru Eye Clinic

In one audit of paper records(UK 1995)36% of casenotes not immediately availableMultiple records for same patient in 75% of hospitals30% of history sheets inadequate20% of prescriptions illegible40% of handwritten discharge medication sheets illegibleSydney 24-25 AprilTimaru Eye Clinic

Gartners Vision for Healthcare: The Next 10 yearsAnalyzed the future of Healthcare on a two axis continuum: Accountability for Payment (Single Purchaser Vs Consumers are Purchasers multiple purchasers) Standards and Structured Data (Blurry islands of data Vs Robust data sharing)Sydney 24-25 AprilTimaru Eye Clinic

Healthcare 2010 MatrixFrom Gartners HealthcareAccountability for PaymentStructured DataStandardsSydney 24-25 AprilTimaru Eye Clinic

A: Rational

Rationing

You get what you want and Big Brother will pay

B: Free Market

You can get what you can pay for

C: Irrational Rationing

Brute force rationing

D: Wild Wild West

Healthcare by advertising and promotions

All stakeholders would benefit from Structured Data standardsUnder both centralized and user pays models, Healthcare provision gets more rational and fairer with structured data standardsSydney 24-25 AprilTimaru Eye Clinic

into this

How to achieve Healthcare Standards?Natural Language ProcessingControlled VocabulariesKnowledge Based ModelsExchange of SummariesSydney 24-25 AprilTimaru Eye Clinic

ISO TC215Has been used as a forum for proponents of other standards workContinues, but will probably follow rather than lead.Sydney 24-25 AprilTimaru Eye Clinic

Natural language processing (NLP)

Natural language processing (NLP), or natural language understanding (NLU), can turn free text into structured data. However without prior agreement on the meaning of terms used, its usefulness is limited

Sydney 24-25 AprilTimaru Eye Clinic

Controlled VocabulariesSNOMED International, a division of the College of American Pathologists oversees the strategic direction and scientific maintenance of the Systematized Nomenclature of Medicine, better known as SNOMED. Several version, RT, CT Includes REED Codeshttp://www.snomed.orgSydney 24-25 AprilTimaru Eye Clinic

The International Classification of Disease - ICD The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization's Ninth Revision, International Classification of Diseases (ICD-9). ICD-10-CM was developed following a thorough evaluation by a Technical Advisory Panel and extensive additional consultation with physician groups, clinical coders, and others to assure clinical accuracy and utilityICD is copyright to WHOSydney 24-25 AprilTimaru Eye Clinic

SnomedThere are several versionThe latest, named SNOMED Clinical Terms (abbreviated SNOMED CT), combines the robust strength of in specialty medicine, including pathology, the richness of Clinical Terms Version 3 (also known as Read Codes V3) in primary care.

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Growth of SNOMED (from www.SNOMED.org)Sydney 24-25 AprilTimaru Eye Clinic

the Logical Observation Identifiers Names and Codes (LOINC)

Copyright 1995 - 2001, Regenstrief Institute.

The Regenstrief Institute (www.regenstrief.org) maintains the LOINC database and its supporting documentation.

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What is a KB Model?Knowledge representation (KR) model - capable of expressing instances of domain knowledge, e.g.Sydney 24-25 AprilTimaru Eye Clinic

Examples of KB ModelsGEHR Object Model (GOM)CEN ENV 13606HL7 v3 RIMCORBAmed interface modelsSydney 24-25 AprilTimaru Eye Clinic

Now reduced to GEHR Object Model/CEN ENV 13606/ CORBAmed

HL7 v3 RIM

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CEN/TC 251 ENV13606PT-26 Part 1: Extended Architecture and Domain Model for the Electronic Healthcare Record PT-27 Part 2: Domain TermlistPT-28 Part 3: Distribution Rules PT-29 Part 4: Messages for Exchange of Information Sydney 24-25 AprilTimaru Eye Clinic

ENV13606 a practical generic EHCR StandardAre types of1contains1..*Are types of1..*Variousspecialisedtypes ofdata itemSydney 24-25 AprilTimaru Eye Clinic

Limited uptake by industry, because:a) incomplete or have offered only partial coverage of the healthcare domain;b) unnecessarily complex;c) too generic, leaving the various implementations too much variability in how the models are applied to a given domain;d) flawed, with some classes and attributes not implementable as published;e) requiring expensive re-engineering of systems;f) containing features not required by the purchasers of clinical systems.Sydney 24-25 AprilTimaru Eye Clinic

The Good European Health Record (GEHR): OriginsSam Heard in N London in the 70s, Alan Maskens in Belgium, David Lloyd LondonHighly idealistic concept of Good RecordBreak from CEN in 1995Separate developments:Australian GEHRUK Support A project and Synex projectsSydney 24-25 AprilTimaru Eye Clinic

Australian GEHR Sam Heard and Thomas Beale returned to OzSet up Australian GEHR Emphasized the archetype concept Developed the Kernel conceptSydney 24-25 AprilTimaru Eye Clinic

Key features of GEHRIt is an architectural modelHas to be implemented in all compliant systemsStill developing nowhere implementedHas three elementsThe GEHR Object Model (GOM)Clinical ArchetypesTransactions Sydney 24-25 AprilTimaru Eye Clinic

The GOMIs an actual implementationWritten in the Object Orientated programming language EiffelWould run in the background in all compliant applicationsRecognizes two generic sorts of transaction: Persistence and EventThe transaction is the exchange unitPopulated by clinical archetypesSydney 24-25 AprilTimaru Eye Clinic

ArchetypesAre templates for clinical concepts e.g. blood pressure, Therefore define and standardize dataWould be stored on archetype servers for downloading and use in compliant systemsWould be expressed in XML format for exchange between GEHR systemsSydney 24-25 AprilTimaru Eye Clinic

Memorandum of UnderstandingbetweenCEN/TC 251 (CEN) and the openEHR Foundation (openEHR)CEN and openEHR agree to collaborate on a project to develop a multi-part standard for Electronic Health Record Communication based on the ENV 13606 and developments of the Good Electronic Health Record (GEHR) by openEHR. http://www.openehr.org/Sydney 24-25 AprilTimaru Eye Clinic

CEN/TC251 EN 13606EHRCOMEHRCOM - NWIPMotivationCEN/TC 251 ENV13606ISO/TC 215 collaborationHL7 version 3 RIM harmonisationCEN/TC251 Common Components (PT 41, 42)Synapsis, GEHR EU projectsGEHR Australia projectTaskforce meeting in Aix-en-Provence in November 2001Sydney 24-25 AprilTimaru Eye Clinic

The new standard must provide for the purposes of the four original parts:a generic information model for the EHR; a mechanism by which the semantic content inherent in the structural representation of the EHR (external to any terminology system used) can reliably be shared; properties in the EHR that are needed to represent the intended sensitivity of the entries in it and the kinds of persons that should be allowed to access them;the interactions that need to take place between requesting and responding processes or systems to enable EHR communication to take place.Sydney 24-25 AprilTimaru Eye Clinic

Why Health Level Seven? 1Physical 2Data Link 3Network 4Transport 6Presentation 5Session 7ApplicationSydney 24-25 AprilTimaru Eye Clinic

HL7 MissionTo provide standards for the exchange, management and integration of data that supports clinical patient care and the management, delivery and evaluation of healthcare services.globalSpecifically, to create flexible, cost effective approaches, standards, guidelines, methodo- logies, and related services for interoperability between healthcare information systems.Sydney 24-25 AprilTimaru Eye Clinic

A Bit of HL7 History ...1997: The Australian Federal Govt. endorses HL7 as the healthcare messaging standard.2000: HL7 V2.4 released with support for Australian requirements and XML encoding.1987: Interested users in the US start work on a standard - Health Level Seven.1990: First standard (V2.1)1993/94: First International Affiliates join.1994: HL7 becomes ANSI-accredited.More than 93% of all organisations in the US with Health IT use HL7!Sydney 24-25 AprilTimaru Eye Clinic

Order, Report & Inform: The classic HL7 paradigm FeaturesIntent to communicateFor a specific purposeOften to a specific person or organisationInformation content determined by intentInformation necessary for a requestInformation from a requested serviceInformation about a distinct eventStorage is secondary to communicationA record of a requestA report of a serviceTherefore Messages shaped by communication requirementsVariety of requirements variety of messagesSydney 24-25 AprilTimaru Eye Clinic

HL7 Version 3New Reference Information ModelNew Data TypesNew messaging paradigmSydney 24-25 AprilTimaru Eye Clinic

Purpose of a RIMA reference information model helps establish the meaning of the entities (objects) that participate in communicationIt describes the allowed relationships between objectsIt shows the relationship between coded attributes and vocabulary (terminology)It is the basis for creation of specific information modelsSydney 24-25 AprilTimaru Eye Clinic

Outline of the RIM--Pattern Recognitionform_cddose_qtyroute_cdMedicationvalueObservationtype_cdsequence_nbrpriority_nbrAct_Relship110..*0..*10..*0..*0..10..*0,10..*110..*10..*form_cdhandling_cddanger_cdMaterialbirthdate_tmrLiving_subject......Sydney 24-25 AprilTimaru Eye Clinic

Doc vs. Msg. The great thing about documents is that you know what they are.Documents have legal standing, if defined by a signature.Care-givers are (still) trained in the creation of documents.Sydney 24-25 AprilTimaru Eye Clinic

HL7s Clinical Document ArchitectureApril, 1996: 1st ad hoc meetingJan. 1997: 1st meeting as HL7 SIGJul. 1997: Operation Jumpstart at Kona MansionSept. 1997: Initial presentation to HL7 Jan. 1998: Formation of KEGSept. 1998: HL7 adopts XML as a V3 msg syntax, first formal review of PRAJan. 2000: SIG promoted to TCApril 2000: 2nd HL7 HIMSS demo HL7 XMLMay 2000: Second committee level ballot passesPRA changed to CDASept 2000: Membership ballot passes unanimousSydney 24-25 AprilTimaru Eye Clinic

CDA documents are human readableThis principle means that CDA documents are human readable using: a) widely-available and commonly deployed XML-aware browsers and print drivers and b) a generic CDA style sheet written in a standard style sheet language.CDA documents are machine processable at the highest level of shared semanticsLevel OneLevel TwoLevel Three

What are CDA documents?Sydney 24-25 AprilTimaru Eye Clinic

A CDA document is a defined and complete information object Persistence: A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements. Stewardship: A clinical document is maintained by a person or organization entrusted with its care. Potential for authentication: A clinical document is an assemblage of information that is intended to be legally authenticated. Wholeness: - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document. Human readability: A clinical document is human readable.Sydney 24-25 AprilTimaru Eye Clinic

The CDA DocumentA CDA document is comprised of a header, referred to as the CDA Header", and a body referred to as the CDA Level One Body". Sydney 24-25 AprilTimaru Eye Clinic

The CDA Header & BodyThe CDA Header identifies and classifies the document and provides information on authentication, the encounter, the patient, and the provider. The body contains the clinical report.Sydney 24-25 AprilTimaru Eye Clinic

CDA HeaderThere are four logical components of the CDA Header: Document information;Encounter data;Service actors (providers); and Service targets (patients). Sydney 24-25 AprilTimaru Eye Clinic

CDA BodyThe body has either sections or a non-XML blobSydney 24-25 AprilTimaru Eye Clinic

CDA LevelsThis proposal defines a multi-level architecture where each level is derived from a more basic level. Levels are distinguished by the degree of granularity of the markup. Clinical content remains constant, regardless of the extent of added markup.Sydney 24-25 AprilTimaru Eye Clinic

Relationship to HL7 messagesA CDA document is a defined and persistent information object that can exist outside of a messaging context and/or can be a payload within an HL7 message. Sydney 24-25 AprilTimaru Eye Clinic

CDA SchematicClinical DocumentSydney 24-25 AprilTimaru Eye Clinic

CDA Levels & RIM SemanticsLevels are distinguished by the degree of markup granularity and the degree to which conformant documents use RIM-derived markup. Level One CDA documents specify RIM semantics only in the CDA Header. Level Two CDA documents will specify RIM semantics in the CDA Header and in the structural components (sections and nested sub-sections) of the document body. Level Three CDA documents will specify RIM semantics for the complete contents of the document. Sydney 24-25 AprilTimaru Eye Clinic

Digital Imaging and Communications in Medicine (DICOM)Formed in 1983 by American College of Radiology (ACR) and the National Electrical Manufacturers Associationpermitting the transfer of medical images in a multi-vendor environment, facilitating the development and expansion of picture archiving and communication systems and interfacing with medical information systems.Dicom and HL7 CDA now attempting alignmentSydney 24-25 AprilTimaru Eye Clinic

Definitions of TemplateHL7 : A template in the broadest sense is simply a constraint on a more generic model. C. Peter Waegeman:Templates typically consist of hierarchically arranged sections and subsections that impose structure on the data collected according to some external information modelA template is a repeating pattern at any level of complexity above datatypesSydney 24-25 AprilTimaru Eye Clinic

CEN/TC251 EN 13606EHRCOMExperiences from several organisations will be used:Industry, HL7, GEHR, Synapsis.Industries, Universities, OrganisationsSydney 24-25 AprilTimaru Eye Clinic

HL7 group is looking atGEHR ArchetypesCEN Archetypes 3M Information ModelsSNOMED/DICOM Microglossary

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ConvergenceThe general model can thus be described as "containers and content". In this analysis, the "container" can be equated with: Documents (including in the web sense of a unit of information transmission) The unit of committal to a record systems The unit of security setting The unit of transmission The container is called a "transaction" in GEHR, and a "component" in CEN 13606, and a CDA in HL7The fact that numerous initiatives have the same general model means that at least a basic level of standards convergence is possible, and also that the model can be considered widely acceptable.Sydney 24-25 AprilTimaru Eye Clinic

HES: What is it?HES: clinical notes (documents)/data sent by a healthcare provider to other providers at other healthcare facilities. A snapshot of the patients health eventIncludes: referrals and discharge summariesKey elements: Summaries care givenOutlines plan of continuing careIncludes requests for services and reasonsData types: structured data, free text, images and multimediaInformation centric2Sydney 24-25 AprilTimaru Eye Clinic

Why HES?HES provides the standard architecture for effective electronic transmissions of clinical / health data between providersProvides a credible foundation architecture for evolution towards electronic healthcare record4Based on standardStakeholdersupportSydney 24-25 AprilTimaru Eye Clinic

How is HES related to CDA?CDA L1 provides an immediate starter model for HESIn working on the HES, we are working directly on a design for the level two and three CDA22Sydney 24-25 AprilTimaru Eye Clinic

ONTOLOGIES, THE SEMANTIC WEB AND BIOMEDICINEJJ Michon, M.D.Dept. of OphthalmologyDuke University School of MedicineE-mail: micho001@mc.duke.eduSydney 24-25 AprilTimaru Eye Clinic

A Web Based Approach:Whats wrong with the current Web ?Computers great at processing syntax, not semanticsBurden of accessing and processing information is still on humansCurrent Web is primarily a tool for communications and displaySydney 24-25 AprilTimaru Eye Clinic

Web DesiderataUniversal expressive power--common languages such as HTML, TCP/IPSyntactic interoperability-parse data into representation for processingSemantic interoperability--make data human and machine understandable through mappings and content analysisSydney 24-25 AprilTimaru Eye Clinic

Semantic WebNeed to allow machine processing of Web documentsNeed structured collections of information and sets of inference rulesSydney 24-25 AprilTimaru Eye Clinic

Resource Description Framework (RDF)RDF as a layer on top of XMLRDF is an XML application that structures the metadata in a Web documentRDF does for computers what HTML does for humans--follows links to find information of interestA data model (object & relationships) is easily represented in RDF

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HTML & XML TagsHTML-Display

etc.XML-Semantics (limited)

etc=> METADATASydney 24-25 AprilTimaru Eye Clinic

OntologiesIn philosophy, a systematic account of existenceIn informatics: -Specification of a shared conceptualization about the world -Objects and concepts that exist in a domain and their relationships =>Facilitate knowledge processing, sharing and reuseSydney 24-25 AprilTimaru Eye Clinic

An Ophthalmic Imaging OntologyEach medical image may belong to a Web document, with multiple elements and attributes (clinical, technical, etc.). Coordinated with DICOM Working Group 9 and the American Academy of Ophthalmology (details at www.ectalk.org). DICOM (Digital Imaging & Communications in Medicine) is an international standard for the transmission of digital images across multiple imaging equipment platforms (details at www.nema.org)Requirement for physician (JJM) to model clinical image domain concepts, attributes, relationshipsSydney 24-25 AprilTimaru Eye Clinic

Public Health and the Eye 15 M Americans have diabetes; 700K have proliferative retinopathy (65K new cases annually); 500K have macular edema (75K new cases annually)3 M Americans have glaucoma; 1 M are undiagnosed; 2% of those 40+ have glaucoma; this rate is 5.5% among African-AmericansAge-related macular degeneration causes visual loss in 400K Americans 65+ annually; the population fraction of those 65+ is going to double in the next 25 yearsOrganizing and aggregating metadata is a critical task in using images effectively to identify and treat those with blinding eye diseaseSydney 24-25 AprilTimaru Eye Clinic

RESULTS-RDF SCHEMA OUTLINEClass structure of schema in ProtegeFirst 35 lines of XML schema (out of >1500)Sydney 24-25 AprilTimaru Eye Clinic

RESULTS--STRUCTURED DATA INPUT IN REPRESENTATIVE IMAGE SUBCLASSESInstance data and form excerpt from class Disc_Image (with clinically relevant fields for glaucoma)Instance data and form excerpt from class Angio_Image (with fields for fluorescein angiography)Sydney 24-25 AprilTimaru Eye Clinic

SCHEMA-BASED MACHINE INFERENCE: NVD > 1/3 DA + VH=HIGH RISK PROLIFERATIVE RETINOPATHY => LASER REQUIREDSydney 24-25 AprilTimaru Eye Clinic

The Polyontology ProblemOntologies must interlinkalmost all are subset descriptions of realityNeed to allow agents to navigate KBs via ontologiesNeed shared representations for interoperabilitySydney 24-25 AprilTimaru Eye Clinic

DAML (DARPA Agent ML)Goal of Web as fully distributed KB Agent markup language to allow semantic interoperability similar to XMLs syntactic interoperabilityExplicit representation of servicesSydney 24-25 AprilTimaru Eye Clinic

The Ultimate Goal - The Web as universal knowledge baseSydney 24-25 AprilTimaru Eye Clinic

Further ConvergenceCDA from HL7 and Transaction from CEN/GEHR/CORBA and DICOM object become oneOpen source, pervade industry and yet be stand aloneFacilitate third world health careFacilitate private developerCompliance is use...Sydney 24-25 AprilTimaru Eye Clinic

Clinical Guidelines and Decision SupportThere are already a number of engines that deliver these services to EHRsIt is important that there is a level of the standard where the access and report are non evaluativeHealth XML with data objects and containers could do thatClinical Guidelines should not be intrinsicTimaru Eye ClinicSydney 24-25 April

Containers and ObjectsAccess Control techniques may be part of the new standardOntologies can be local or sharedMeaning is partly defined by useBaseline inter-operability by having a shared design for containers and objectsThe applications arrange objects in patterns that are good to think and work withSydney 24-25 AprilTimaru Eye Clinic

If such a standard was achievedHow services were conducted and controlled would be entirely localBy going with the developments, Health Care Professionals can help guide outcomePossibility for regaining control of our work environments through transparent practiceAccess to the huge resource of shared dataTimaru Eye ClinicSydney 24-25 April

The transcending benefitThe same communication standard for all technological levels and culturesMight prove a catalyst for global healthcareMight prove an access route for free decision support, ie a global medical servicecreating a currency for healthcare - who can know where it would lead...Sydney 24-25 AprilTimaru Eye Clinic

THANK YOU FOR YOUR ATTENTION !Sydney 24-25 AprilEmail: mikemair@ihug.co.nzTimaru Eye Clinic

With thanks for help and slides:Klaus VeilThomas BealePeter SchoeffelLiora AlschulerJJ MichonJane CurryC. Peter Waegemann.and others