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.

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

HL7 Work Group Meeting, San Diego, CASeptember 2011

Kensaku Kawamoto, MD, PhD

Director, Knowledge Management and MobilizationAssistant Professor, Department of Biomedical Informatics

University of Utahkensaku.kawamoto@utah.edu

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 Blood PressureCode = BP Systolic = 120 mmHg

Value = 120/80 mmHg Diastolic = 80 mmHg

Observation Vital Sign Code = BP Type = BP Observation Value = 120/80 Code = SBP Units = mmHg Value = 120 mmHg Observation Code = DBP Value = 80 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

Simplified ISO 21090 Data Types class dataTypes

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

iso-21090-datatypes-simplified-vmr::XP

+ value :string

iso-21090-datatypes-simplified-vmr::ADXP

+ type :CS

iso-21090-datatypes-simplified-vmr::ENXP

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

iso-21090-datatypes-simplified-vmr::AD

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

iso-21090-datatypes-simplified-vmr::CD

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

iso-21090-datatypes-simplified-vmr::CS

+ code :string

iso-21090-datatypes-simplified-vmr::EN

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

iso-21090-datatypes-simplified-vmr::II

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

iso-21090-datatypes-simplified-vmr::IVL_INT

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

iso-21090-datatypes-simplified-vmr::IVL_PQ

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

iso-21090-datatypes-simplified-vmr::IVL_RTO

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

iso-21090-datatypes-simplified-vmr::IVL_REAL

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

iso-21090-datatypes-simplified-vmr::INT

+ value :int

iso-21090-datatypes-simplified-vmr::IVL_TS

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

iso-21090-datatypes-simplified-vmr::PQ

+ value :decimal+ unit :string

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

iso-21090-datatypes-simplified-vmr::REAL

+ value :decimal

iso-21090-datatypes-simplified-vmr::RTO

+ numerator :PQ+ denominator :PQ

iso-21090-datatypes-simplified-vmr::ST

+ value :string

iso-21090-datatypes-simplified-vmr::TEL

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

iso-21090-datatypes-simplified-vmr::TS

+ value :string

iso-21090-datatypes-simplified-vmr::BL

+ value :boolean

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]

CDSInput

+ templateId :II [0..*]

CDSResource

+ cdsResourceType :CD+ resourceContents :anyType

v mr::VMR

+ templateId :II [1..*]

+cdsContext

0..1

+vmrInput 1 +cdsResource 0..*

CDS Outputs class cdsOutput

CDSOutput

v mr::VMR

+ templateId :II [1..*]

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

+simpleOutput 0..1+vmrOutput 0..1

vMR Payload class v mr

ClinicalStatement

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

Entity

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

ClinicalStatementEntityInRoleRelationship

+ role :CD

ClinicalStatementRelationship

+ targetRelationshipToSource :CDEv aluatedPerson

+ birthTime :TS [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]

EntityRelationship

+ targetRole :CD+ relationshipTimeInterval :IVL_TS [0..1]

VMR

+ templateId :II [1..*]

Person

+ name :EN [0..*]+ address :AD [0..*]+ telecom :TEL [0..*]

+patient 1

+relatedEntity0..*

+relatedClinicalStatement0..*

+clinicalStatement

0..*

+relatedEntityInRole

0..*

Example Clinical Statement class problem

Problem

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

DeniedProblem

ClinicalStatement

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

ProblemBase

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

BodySite

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

+relatedClinicalStatement 0..*

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

Decision Support Service

Decision Support Service

Knowledge Modules

Knowledge Modules

Institution A Institution A

Client Decision Support Apps

Client Decision Support Apps

Patient Data Sources

Patient Data Sources

Queries for required ptdata

Queries for required ptdata

Institution B Institution B

Client Decision Support Apps

Client Decision Support Apps

Patient Data Sources

Patient Data Sources

Queries for required ptdata

Queries for required ptdata

Conclusions about patientConclusions about patient

Patient data, knowledge modules to use

Patient data, knowledge modules to use

Trigger

Standard Interface:HL7/OMG Decision Support Service Standard

(http://hssp-dss.wikispaces.com)

Standard Data Models:HL7 Virtual Medical Record (vMR) Standard

[ http://wiki.hl7.org/index.php?title= Virtual_Medical_Record_(vMR) ]

Standard Interface:HL7/OMG Decision Support Service Standard

(http://hssp-dss.wikispaces.com)

Standard Data Models:HL7 Virtual Medical Record (vMR) Standard

[ http://wiki.hl7.org/index.php?title= Virtual_Medical_Record_(vMR) ]

CDS Services – Example

Decision Support Service

Decision Support Service

EHR SystemEHR System Patient Data Sources

Patient Data Sources

Pt dataPt

dataCCDCCD

VMRVMREval.

ResultEval.

Result

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