Transcript EHCR Architecture

GP2GP Clinical Semantics
Leo Fogarty
Russell Hotel 12/12/03
Nature of health records
• Collection of information about the health of a
person
• Contains entries made
– On one or more occasions
– By one or more authors
• A person may have many health records
– A combination of health records for the same person is
a health record
– A copy of all or part of a health record is a health record
Purposes of health records
• Care of the patient
– Informing and reminding care providers
– Organising thinking and decision making
– Communicating with other care providers
• Care of the population
– Clinical, social and therapeutic research
– Epidemiology and strategic planning
• Support for providers
– Professional education and training
– Financial, contractual and legal
• Support for provider organisations
– Financial, contractual and legal
– Planning services
Content & structure of health
records
• Notes
– Free form narrative (and cryptic abbreviations)
– Documents with agreed conventions
– Completed forms
• Reports
– Letters and text reports
– Structured numeric reports
– Pictures, graphs and tracings
• Structures
– Problem lists and alerts
– Episode summaries
– Coding for classification and grouping
• Supporting information
– Dates, times, people, places and signatures
– Demographics
Records, Readers, Authors
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Introversion, Extroversion and Idleness
Obsessives and Creatives
Bible Scholars and Cynics
Navigators and Head Bangers
Informatic Ignorance and Wisdom
Solomons and Grundies
Electronic health records
• Health records in electronic form
– CPR, EPR, EHCR, EHR, EMR, PMR, …
• Purposes
– As for health records
– “Electronic” adds or subtracts value
• Contents
– As for health record
– “Electronic” reuse may reduce duplication
• Structure
– Document, message and data
– Narrative, code terminologies and templates
Elements of Clinical Information
Which sit in a context
which might include:
Relating to an ongoing Problem:
Chest Pain
Which was constructed
during an event:
Surgery Consultation
A Heading:
“Past History”
or
Which all sits in a document:
“Referral Letter”
Modifying Information:
Q= “Possible”
The Record of Patient
Information as Text:which is human-readable
and easily communicable
The inclusion of codes:
XE2uV Ischaemic Heart Disease
Which may be qualified as:
X793b Mild
X78th First Episode
A Construction
Date: 04/02/2000
Dear Dr: Prunesquallor A
DISCHARGE NOTE
Surname:
BEAUHARNAIS
Unit No: 123451
DoB: 01/01/22
First name:
JOSEPHINE
NHS: 1234567895
Primary Diagnosis:
Pelvic malignancy
Secondary Diagnoses:
Anaemia unspecified
D21z.
Haematuria
K197.
Additional Information \
Instructions
Discharged On:
02/02/2000
Date of Op/Proc
Urethral Catheterisation
Urethral Catheterisation
Urethral irrigation of bladder
M478a
M478a
M471
07/01/00
08/01/00
08/01/00
Other blood transfusion NOS
Diagnostic Cytoscopy (Rigid)
& Bladder Biopsy
X339
M451c
09/01/00
10/01/00
For palliative care.
OPD Follow Up Weeks
Signed:
Maggie
Bell
Print Name:
Maggie
Bell
Designation:
Ward: Deene B
Admitted On:
07/01/2000
Complications:
Operations &
Procedures
Address:
5 Whitehall
KETTERING
NORTHANTS
NN00 1OO
Kettering General Hospital
Rothwell Road, Kettering
Northants NN16 8UZ
Tel: 01536 492000
Clinical Practitioner
Consultant: Zhivago Y
Positional Syntax Approach
ADT
A D T M essage
C hapter
M SH
M essage H eader
2
EVN
EventType
3
P ID
P atientIdentification
3
[P D 1]
A dditionalD em ographics
3
[{N K1 }] N extofKin /A ssociated
P arties
P V1
P atientVisit
3
[P V2 ]
3
P atientVisit-A dditionalInfo.
3
[{O B X }] O bservation/R esult
7
[{A L1 }] A llergy Inform ation
3
[{D G 1 }] D iagnosis Inform ation
6
[{D R G }] D R G Inform ation
6
[{P R 1 }] P rocedures
6
[{G T1 }] G uarantorInform ation
6
[
{IN 1
Insurance Inform ation
6
[IN 2 ]
Insurance Inform ation -A ddit.
Info.
Insurance Inform ation -C ert.
6
[IN 3 ]
Required
6
}
]
ADT
A D T M essage
C hapter
M SH
M essage H eader
2
EVN
EventType
3
P ID
P atientIdentification
3
P V1
P atientVisit
3
[{O B X }] O bservation/R esult
7
[A C C ]
A ccidentInform ation
6
[{D G 1 }] D iagnosis Inform ation
6
[UB 1 ]
UniversalB illInform ation
6
[{P R 1 }] P rocedures
6
[UB 2 ]
UniversalB ill92 Inform ation
6
Positional Syntax Approach
ADT
M SH
A D T M essage
M essage H eader
C hapter
2
SEQ LEN DT
R/O RP/# TBL# ITEM # ELEMENT NAME
1
1 ST
R
1 Field Separator
2
4 ST
R
76
2 Encoding
Characters
9 Message Type
EVN
EventType
3
P ID
P atientIdentification
3
9
7 CM
R
P V1
P atientVisit
3
10
20 ST
R
11
1 ID
R
103
10 Message Control
ID
11 Processing ID
12
8 ID
R
104
12 Version ID
1
3 ID
R
3
2
26 TS
R
5
60 CN
O
2
16 CK
3
20 CX
5
48 XPN R
[{O B X }] O bservation/R esult
7
[{D G 1 }] D iagnosis Inform ation
6
[{P R 1 }] P rocedures
6
R
99 Event Type Code
100 Date/Time of Event
188
103 Operator ID
105 Patient ID (External
ID)
106 Patient ID (Internal
ID)
108 Patient Name
Y
7
26 TS
11
106 XAD
2
1 ID
R
3
12 CM
O
7
60 XCN O
10
133 Assigned Patient
Location
137 Attending Doctor
8
60 XCN O
10
138 Referring Doctor
44
26 TS
O
174 Admit Date/Time
45
26 TS
O
2 ID
R
175 Discharge
Date/Time
570 Value Type
2
110 Date of Birth
Y
114 Patient Address
4
125
3 590 CE
R
14 200 TS
O
1
4 SI
R
2
2 ID
R
89
3
80 CE
R
88
4
40 ST
O
5
26 TS
R
6
2 ID
R
132 Patient Class
571 Observation
Identifier
582 Date/Time of the
Observation
391 Set ID - Procedure
230
392 Procedure Coding
Method
393 Procedure Code
394 Procedure
Description
395 Procedure
Date/Time
396 Procedure
Functional Type
One Representation on Receipt
Patient Details
Date of Event
History
JOSEPHINE BEAUHARNAIS
Date of Birth
Event Type
04/02/2000
Pelvic malignancy
01/01/22
Anaemia unspecified (D21z.)
DISCHARGE LETTER
Haematuria (K197.)
Examination
Investigations
Procedures
Urethral Catheterisation (M478a)
Urethral Catheterisation (M478a)
Urethral irrigation of bladder (M471)
Other blood transfusion NOS
(X339)
Diagnostic Cytoscopy (Rigid) & Bladder Biopsy (M451c)
Comment
For palliative care.
Healthcare
Professional
ZY
What was Lost?
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Hospital Address
Unit Number
The Ward
The dates of admission/discharge/operations/procedures
Clinical Heading Context
– Significant loss of clinical meaning
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Healthcare Professional Names
Healthcare Professional Roles
Attestation
Identification of Management Plan/Intention
In short: - CONTENT and CONTEXT
Semantic Interoperability Needs
• Clinical Coding Schemes
– Clinical Concepts
– Drugs
• People, Places and Roles
• Aggregations
– Templates/Archetypes/Clusters
• Dates
• Architectural Containment and “Glue”
Architecture ?
• Merriam Webster Definition: a unifying or
coherent form or structure; a method or style of
building
GEHR (North) Simplified
EHCR
Transactions
EHCR
Extract
List of
Transaction
Types
List of Item
Types
Content
Category
Observation
Item
Item
Collection
ENV 13606 message
structure
EHCR message
1
EHCR extract
types of
contains
1..
*
1
original
component
complex
1..
*
folder
composition
headed
section
cluster
record component
types of
link item
data item
ENV13606 message
data items
Plain/HTML text
structured coded
quantifiable observation
medication
type of
record
component
physical entity reference
external data reference
data item
event
types
of
person identifier
person name
language
address
telecom
patient related party
related location
community defined
GEHR (South)
CDA at RIM level
Information model – EHR
Containers
Information model – Clinical
statements
GP2GP Language
• Coding Schemes
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Read
EMIS
Multilex
Local
• Consultation Categories (Headings)
GP2GP Language Architecture
Names
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Level Codes
Composition Names
Document Names
Compound Names
Link Names
GP2GP Language Qualifiers
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Problem Status
Epidocity
Medication Mood
Secondary Status Terms
GP2GP Language Major
Modifiers
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Certainty/Negation
Action Status
Significance
Subject of Information
Sensitivity
Validity
GP2GP Project Outcome
• NHSIA Project 1/6/01-31/5/03
• V3 Messaging successful
• Four (Now five) suppliers implemented in
test bed circumstances
• One supplier implemented same system
transfer “for real”
• Further piloting happening
• Quo Vadis?