Virtual Medical Record (vMR): A Simplified RIM-Based Data Model for CDS

HL7 Work Group Meeting, San Diego, CA September 2011 Kensaku Kawamoto, MD, PhD Director, Knowledge Management and Mobilization Assistant Professor, Department of Biomedical Informatics University of Utah [email protected]

Background

• A “holy grail” of clinical informatics is scalable, interoperable CDS • Key requirement for interoperable CDS and re-use of CDS knowledge resources = use of a common patient data model – Referred to as a “Virtual Medical Record” or vMR (Johnson

et al.

,

AMIA Annu Symp Proc

, 2001) • Lack of a common vMR is a major barrier to sharing knowledge and scaling CDS – Known as the “curly braces” problem in Arden Syntax

Example Challenge without VMR

Observation Code = BP Value = 120/80 mmHg Blood Pressure Systolic = 120 mmHg Diastolic = 80 mmHg Observation Code = BP Observation Code = SBP Value = 120 mmHg Observation Code = DBP Value = 80 mmHg Vital Sign Type = BP Value = 120/80 Units = mmHg

vMR Goal

• Provide common information model upon which interoperable clinical decision support resources (e.g., rules) can be developed • Desired attributes: – VMR instances can be derived from HL7 V3 artifacts, in particular CCD and Pedigree instances – VMR instances can be populated from HL7 V2 messages, in particular for laboratory data – Leverage Detailed Clinical Models – Capable of being easily understood and used by clinicians/analysts without significant V3 training

Project History

• Analysis of data required by 20 CDS systems from 4 countries • Analysis of HL7 CCD, Pedigree, Clinical Statement, and other relevant models • Use of greenCDA/greenCCD as an example approach to simplification • Trial implementation of vMR via OpenCDS • Under ballot for September 2011 Work Group cycle – Domain Analysis Model – GELLO implementation guide

class dataTypes

Simplified ISO 21090 Data Types

iso-21090-datatypes-simplified-vmr:: ANY iso-21090-datatypes-simplified-vmr:: QTY

iso-21090-datatypes-simplified-v mr::IVL_INT

+ low :INT [0..1] + high :INT [0..1] + lowIsInclusive :boolean [0..1] + highIsInclusive :boolean [0..1]

iso-21090-datatypes-simplified-v mr::IVL_PQ

+ low :PQ [0..1] + high :PQ [0..1] + lowIsInclusive :boolean [0..1] + highIsInclusive :boolean [0..1]

iso-21090-datatypes-simplified-v mr::IVL_RTO

+ low :RT O [0..1] + high :RT O [0..1] + lowIsInclusive :boolean [0..1] + highIsInclusive :boolean [0..1]

iso-21090-datatypes-simplified-v mr::IVL_REAL

+ low :REAL [0..1] + high :REAL [0..1] + lowIsInclusive :boolean [0..1] + highIsInclusive :boolean [0..1]

iso-21090-datatypes-simplified-v mr::IVL_TS

+ low :T S [0..1] + high :T S [0..1] + lowIsInclusive :boolean [0..1] + highIsInclusive :boolean [0..1]

iso-21090-datatypes-simplified-v mr::AD

+ part :ADXP [1..*] + use :CS [0..*]

iso-21090-datatypes-simplified-v mr::CD

+ codeSystem :string + code :string + codeSystemName :string [0..1] + displayName :ST [0..1]

iso-21090-datatypes-simplified-v mr::CS

+ code :string

iso-21090-datatypes-simplified-v mr::EN

+ part :ENXP [1..*] + use :CS [0..*]

iso-21090-datatypes-simplified-v mr::II

+ root :string + extension :string [0..1]

iso-21090-datatypes-simplified-v mr::ST

+ value :string

iso-21090-datatypes-simplified-v mr::TEL

+ useablePeriodOriginalT ext :string [0..1] + value :string + use :CS [0..*] + capabilities :CS [0..*]

iso-21090-datatypes-simplified-v mr:: BL

+ value :boolean

iso-21090-datatypes-simplified-v mr::INT

+ value :int

iso-21090-datatypes-simplified-v mr::PQ

+ value :decimal + unit :string

iso-21090-datatypes-simplified-v mr:: REAL

+ value :decimal

iso-21090-datatypes-simplified-v mr:: RTO

+ numerator :PQ + denominator :PQ

iso-21090-datatypes-simplified-v mr::TS

+ value :string

iso-21090-datatypes-simplified-v mr::XP

+ value :string

iso-21090-datatypes-simplified-v mr::ADXP

+ type :CS

iso-21090-datatypes-simplified-v mr::ENXP

+ type :CS + qualifier :CS [0..*]

CDS Inputs

class cdsInput CDSContext

+ cdsSystemUserType :CD [0..1] + cdsSystemUserPreferredLanguage :CD [0..1] + cdsInformationRecipientType :CD [0..1] + cdsInformationRecipientPreferredLanguage :CD [0..1] + cdsSystemUserTaskContext :CD [0..1] +cdsContext 0..1

+vmrInput 1

v mr::VMR

+ templateId :II [1..*]

CDSInput

+ templateId :II [0..*] +cdsResource 0..*

CDSResource

+ cdsResourceType :CD + resourceContents :anyType

class cdsOutput

CDS Outputs

CDSOutput

+vmrOutput 0..1

v mr::VMR

+ templateId :II [1..*] +simpleOutput 0..1

dataTypes:: iso-21090-datatypes-simplified-vmr::ANY

class v mr VMR

+ templateId :II [1..*]

vMR Payload

EntityRelationship

+ targetRole :CD + relationshipT imeInterval :IVL_T S [0..1] +relatedEntity 0..*

Entity

+ id :II + templateId :II [0..*] + entityT ype :CD [0..1] 0..* +relatedEntityInRole

Person

+ name :EN [0..*] + address :AD [0..*] + telecom :T EL [0..*] +patient 1

Ev aluatedPerson

+ birthT ime :T S [0..1] + ethnicity :CD [0..*] + gender :CD [0..1] + race :CD [0..*] + preferredLanguage :CD [0..1] + age :PQ [0..1] + isDeceased :BL [0..1] + ageAtDeath :PQ [0..1]

ClinicalStatementEntityInRoleRelationship

+ role :CD

ClinicalStatementRelationship

+ targetRelationshipT oSource :CD +relatedClinicalStatement 0..* +clinicalStatement 0..*

ClinicalStatement

+ id :II + templateId :II [0..*] + dataSourceT ype :CD [0..1]

class problem

Example Clinical Statement

DeniedProblem

ProblemBase

+ problemCode :CD + problemEffectiveTime :IVL_TS [0..1] + diagnosticEventTime :IVL_TS + affectedBodySite :BodySite [0..*]

Problem

+ importance :CD [0..1] + severity :CD [0..1] + problemStatus :CD + ageAtOnset :PQ [0..1] + wasCauseOfDeath :BL [0..1] +relatedClinicalStatement 0..*

BodySite

+ bodySiteCode :CD + laterality :CD [0..1]

ClinicalStatement

+ id :II + templateId :II [0..*] + dataSourceType :CD [0..1]

vMR Ballot Reconciliation – Overview

• Domain Analysis Model – 47 affirmative, 2 negative • GELLO implementation guide – 34 affirmative, 0 negative

vMR – Future Directions

• Additional implementation guides – Existing/underway: GELLO, v2 implementation guides – XML, Drools, other implementation guides (e.g., Arden?) • Template specifications – For standard data models (e.g., CCD, Pedigree, Care Plan) – For common types of CDS (e.g., drug-drug interactions, vaccine forecasting, family history risk analysis) • Transformations to/from standard models • Alignment with relevant ongoing HL7 work (e.g., CSP, RFH, detailed clinical models) • Version 1.1 based on implementation experience (e.g., via OpenCDS)

OpenCDS

• Standards-based, open-source clinical decision support (CDS) Web service – Uses HL7 Decision Support Service (DSS) interface – Uses standard data payloads (e.g., CCD, VMR) – Uses standard internal data model (VMR)

OpenCDS – Architectural Overview

Standard Interface: HL7/OMG Decision Support Service Standard Trigger Patient data, knowledge modules to use HL7 Client Decision required pt data Virtual Medical Record (vMR) Patient Data Sources Standard [ http://wiki.hl7.org/index.php?title= Institution A Decision Support Service Client Decision Support Apps Queries for required pt data Patient Data Sources Institution B Knowledge Modules

CDS Services – Example

Eval. VMR Result Decision Support Service CCD EHR System Pt data Patient Data Sources

Current OpenCDS Collaborators

            University of Utah HLN Consulting, LLC Apelon, Inc.

Intermountain Healthcare Veterans Health Administration Wolters Kluwer Health EBSCO Univ. of NC at Chapel Hill Main Line Health Stanford University Keona Health Mass. General Hospital            Hospital Universitario Virgen del Rocío, Spain MaRS Innovation, Canada SmartCare, Africa Emetra AS, Norway Visumpoint, LLC Genesys, LLC df8health Religent, Inc.

IsoDynamic, Inc.

Calcudos.com, Inc.

CogniTech Corporation

Key Components of OpenCDS

• Standard interfaces and data models – Reference implementation of HL7/OMG DSS interface – vMR data model – Data mappers (e.g., for CCD  vMR) • Reference DSS knowledge management framework – JBoss Drools and associated authoring/knowledge management tools – Full-featured terminology support – A “domain specific language” for intuitive knowledge authoring – Knowledge repository and knowledge sharing service • DSS “wrappers” for other CDS engines

NQF Measure 31 for Meaningful Use

OpenCDS Implementation – Denom.

OpenCDS Implement. – Underlying Details

OpenCDS Implementation – Decision Table

www.opencds.org

Backup Slides

Key Benefits of Approach

• Builds on robust open-source community and resources • Provides standard architectural framework for integrating various CDS knowledge resources • Supports full life cycle of knowledge authoring, testing, maintenance, and execution • Provides an open-source framework for collaboration and innovation in CDS – Freely available under Apache 2.0 license

DSS Invocation - Wrapper

NQF knowledge module vMR payload

DSS Invocation - Payload

Age & gender Past encounters Past mammographies

DSS Response - Wrapper

NQF evaluation result NQF evaluation result payload using vMR

DSS Response - Payload

Denominator criteria met Numerator criteria met