New York State Center of Excellence in Bioinformatics Life Sciences R T U New York State Center of Excellence in Bioinformatics Life Sciences R T U.

New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U AMIA 2006 Panel: The Future of HL7 Referent Tracking through HL7 ? Washington, DC, USA. November 14, 2006 Werner CEUSTERS Center of Excellence in Bioinformatics and Life Sciences University at Buffalo, NY, USA New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Americas future New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Evolution of Obesity in the US Morbidity and Mortality Weekly Report. September 15, 2006 / Vol. 55 / No. 36. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Worldwide HL7-membershipUnited States New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Puzzle There seems to be a striking correlation between the increase in obesity incidence and HL7 activity. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Before solving that puzzle: My short personal history New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Since April 2006 Center of Excellence in Bioinformatics & Life Sciences Buffalo, NY New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Buffalo ???? Are you out of your mind ??? New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Well, I might be crazy but Im not stupid. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Correlation versus Causality AB X New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U My hypothesis about HL7 and Obesity HL7Obesity causes New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Argument 1: Advice from the Surgeon General The Nation must take an informed, sensitive approach to communicate with and educate the American people about health issues related to overweight and obesity. ACTION: The Nation must take action to assist Americans in balancing healthful eating with regular physical activity.physical activity New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Argument 2: HL7 says The truth about the real world is constructed through a combination (and arbitration) of such attributed statements only, and there is no class in the RIM whose objects represent "objective state of affairs" or "real processes independent from attributed statements. As such, there is no distinction between an activity and its documentation. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Therefore: Americans think that watching sports is as good as doing sports New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U... or reading about sports New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U What is the problem ? A message to mapmakers: highways are not painted red, rivers don't have county lines running down the middle, and you can't see contour lines on a mountain. William Kent, Data and Reality. First published by North Holland in Republished in 1998 by 1stBooks. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U What HL7 lacks: a realist view of the world 1.The world exists as it is prior to a cognitive agents perception thereof; 2.Cognitive agents build up through observations cognitive representations of the world; 3.To make these representations publicly accessible in some enduring fashion, these agents create representational artifacts that are fixed in some medium. Smith B, Kusnierczyk W, Schober D, Ceusters W. Towards a Reference Terminology for Ontology Research and Development in the Biomedical Domain. Proceedings of KR-MED 2006, November 8, 2006, Baltimore MD, USA New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U But beware ! These concretizations are NOT supposed to be the representations of these cognitive representations; concept representation (Despite the fact there is an IMIA WG on this) We should not be in the business of New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U But beware ! These concretizations are NOT supposed to be the representations of these cognitive representations; They are representations of the corresponding parts of reality They are like the images taken by means of a high quality camera; New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U They are not (or should not be) like the paintings of Salvador Dali Non-canonical (although nice looking) anatomy New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U The sad consequences Too much focus on concepts, information models, data models, Hence the many mistakes in concept-based terminologies; Also many ambiguities in electronic patient records in which such terminologies are used. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U A widespread misconception A variety of clinical terminology standards exist in the health care system, giving meaning to raw data and allowing for semantic interoperability. Systemized Nomenclature of Medicine (SNOMED) clinical terms are one example of a clinical reference terminology that provides for semantic interoperability. Pharmacotherapy. 2005;25(8): New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U /07/ closed fracture of shaft of femur /07/ Fracture, closed, spiral /07/ closed fracture of shaft of femur /07/ Accident in public building (supermarket) /07/ Essential hypertension /12/ benign polyp of biliary tract /03/ closed fracture of shaft of femur /03/ Accident in public building (supermarket) /04/ Other lesion on other specified region /05/ Essential hypertension 29822/08/ Closed fracture of radial head 29822/08/ Accident in public building (supermarket) /04/ closed fracture of shaft of femur /04/ Essential hypertension PtIDDateObsCodeNarrative /12/ malignant polyp of biliary tract Three references of hypertension for the same patient denote three times the same disease. If two different fracture codes are used in relation to observations made on the same day for the same patient, they might refer to the same fracture The same type of location code used in relation to three different events might or might not refer to the same location. If the same fracture code is used for the same patient on different dates, then these codes might or might not refer to the same fracture. The same fracture code used in relation to two different patients can not refer to the same fracure. If two different tumor codes are used in relation to observations made on different dates for the same patient, they may still refer to the same tumor. Using codes does not prevent ambiguities as to what is described: how many disorders are listed? New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Consequences Very difficult to: Count the number of (numerically) different diseases Bad statistics on incidence, prevalence,... Bad basis for health cost containment Relate (numerically the same or different) causal factors to disorders: Dangerous public places (specific work floors, swimming pools), dogs with rabies, HIV contaminated blood from donors, food from unhygienic source,... Hampers prevention ... New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Purpose: explicit reference to the concrete individual entities relevant to the accurate description of each patients condition, therapies, outcomes,... Proposed Solution: Referent Tracking Now! That should clear up a few things around here ! Ceusters W, Smith B. Strategies for Referent Tracking in Electronic Health Records. J Biomed Inform Jun;39(3): New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U 78 Numbers instead of words Method: Introduce an Instance Unique Identifier (IUI) for each relevant particular (individual) entity New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U John Does John Smiths liver tumor was treated with RPCIs irradiation device John Does liver tumor was treated with RPCIs irradiation device The principle of Referent Tracking #1 #3 #2 #4 #5 #6 treating person liver tumor clinic device instance-of at t 1 #10 #30 #20 #40 #5 #6 inst-of at t 2 inst-of at t 2 inst-of at t 2 inst-of at t 2 inst-of at t 2 New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U EHR Ontology collaboration New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Advantage: better reality representation /07/ closed fracture of shaft of femur /07/ Fracture, closed, spiral /07/ closed fracture of shaft of femur /07/ Accident in public building (supermarket) /07/ Essential hypertension /12/ benign polyp of biliary tract /03/ closed fracture of shaft of femur /03/ Accident in public building (supermarket) /04/ Other lesion on other specified region /05/ Essential hypertension 29822/08/ Closed fracture of radial head 29822/08/ Accident in public building (supermarket) /04/ closed fracture of shaft of femur /04/ Essential hypertension PtIDDateObsCodeNarrative /12/ malignant polyp of biliary tract IUI-001 IUI-003 IUI-004 IUI-005 IUI-007 IUI-002 IUI-012 IUI distinct disorders New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Does HL7 support this ? New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U At first sight: yes Definition of Entity: A physical thing, group of physical things or an organization capable of participating in Acts, while in a role. Entity.id:: SET (0..*) Definition: A unique identifier for the Entity. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U On closer inspection: no ! (just one example) Discussion: An entity is a physical object that has, had or will have existence. Rationale (under determinerCode): An Entity may at times represent information This does not need to be a problem if for each entity it is specified whether it is a first order thing in reality or an information object (second order entities are also real!) New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U So what is uniquely identified and how ? The double confusion in HL7-RIM X = information about X X = observation of X But clearly, the following entities are all distinct: The pimple on my nose; The observing of the pimple on my nose by that man; That man asserting the existence of the pimple on my nose; The information-object in the record which refers to the pimple on my nose; New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Some claim: all these distinctions are in HL7 In HL7, we assert that Peter has a UML symbol with an object instance identifier assigned to "his disease" that includes an instance identifier assigned to his "type of disease". But then: Once consensus builds around the subject of concern, the patient can be said to "have" a specific disease. It can be said that "over time" the UML symbol instance identifier for the "concern" becomes the UML symbol instance identifier for the "disease. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Who is then sick: the clinician or the patient ? In HL7, we assert that Peter has a UML symbol with an object instance identifier assigned to "his disease" that includes an instance identifier assigned to his "type of disease". But then: Once consensus builds around the subject of concern, the patient can be said to "have" a specific disease. It can be said that "over time" the UML symbol instance identifier for the "concern" becomes the UML symbol instance identifier for the "disease. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Im not stupid, but why dont I understand this? Advice given: You might study Charles Peirce's work on observation. It underlies much of the 20th century scientific methodology including the study of semiotics. The engineers who have studied Pierce or his students as part of their engineering studies seem to take to UML very easily. Those that don't, seem to have trouble with the concept of symbol manipulation and instance identifier assignment. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U Well, I did, and what do I read ? One singular deception which often occurs, is to mistake the sensation produced by our own unclearness of thought for a character of the object we are thinking of. Instead of perceiving that the obscurity is purely subjective, we fancy that we contemplate a quality of the object which is essentially mysterious. C. S. Peirce, How to Make our Ideas Clear. Popular Science Monthly 12 (January 1878), New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U There is hope My question: What kind of identifiers is the RIM using and what kind of identifiers go in HL7 messages. And moreover, what kind of identifiers are used in what place in object-oriented paradigms, UML- objects, etc. There is a big confusion here ! New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U The answer We agree very strongly in this area. I have been suggesting for many years that these proxy identifiers not be used as "object instance identifiers." Fortunately, more HL7 V3 people are beginning to agree and the ii datatype will soon allow us to differentiate between proxy instance identifiers and the truly arbitrary object instance identifiers known as UUID, GUID, or other similar constructs. New York State Center of Excellence in Bioinformatics & Life Sciences R T U New York State Center of Excellence in Bioinformatics & Life Sciences R T U But at least until then is a Picasso interpretation of a Dali painting HL7-RIM