SNOMED Bound to (Information) ModelPutting terminology to work…

Koray Atalag MD, PhD, FACHIk.atalag@auckland.ac.nz

Senior Research Fellow (NIHI & ABI)openEHR Management Board Member

Vice Chair HL7 New ZealandMember HISO / SAG

HL7 NZ Workshop, 24 Jul 2015

Information Models

• Definitely NOT reference information models; – as in HL7 v3 RIM, openEHR/ISO13606 or FHIR resource ontology!

• Define how to capture/represent health information, not the actual concepts (that’s epistemology/ontology!)– e.g. FHIR Patient resource is concerned with how to capture patient

information, not define what patient means per se!

• Use terminology to define clinical meaning or bind valuesets• They may employ a number of formats and methods; inc.

– Spreadsheets, data dictionaries, mindmaps, UML, XSD, Archetypes, v3 & FHIR and even programming languages

• Examples: FHIR (HL7), Archetypes (openEHR), Detailed Clinical Models (DCM), Clinical Element Models (CEM-Intermountain)

Dealing with forms, Access databases

Dealing with forms, Access databases

From 2001!!!

http://pathos-web.sf.net

Using ASTM healthcare DTDs…No CDA, no archetype!

First class IM

Where in the interop stack?

• Technical/FormatNetwork & Data

Standards

• Syntax/SemanticsTerminology

Standards

• Process/IntegrationExchange Standards

• Structure/Advanced semanticsContent

Standards

SNOMED, ICD, ICPCLOINC, NZMT/NZULMATC / GMDN

UN/EDIFACTHL7 v2, v3, FHIRopenEHR/13606 Extract

HL7 FHIR, CDA, ASTM CCRopenEHR/13606/CIMIDICOM SR

TCP/IP, HTTPHTML, XMLRDF, JSON, DDL

Structure with terminology: SNOMEDInconsistencies due to different post-coordination of concepts

In a vasculitis physical examination: “Vascular exams: Carotid Right/Tender”

247348008 | tenderness (finding) | :363698007 | finding site | = 69105007 | Carotid artery structure (body structure) | : 24028007 | Right (qualifier value) |

_____________________________________________________________________________

301390006 | tenderness of cardiovascular structure | : 363698007 | finding site | = 69105007 | Carotid artery structure (body structure) |: 272741003 | laterality | = 24028007 | Right (qualifier value) |

_______________________________________________________________________________309655006 | On examination-artery (finding) | :

69105007 | Carotid artery structure (body structure) | : 24028007 | Right (qualifier) |:247348008 | tenderness |

_______________________________________________________________________________401050002 | Carotid artery finding (finding) | :

363698007 | finding site | = 69105007 | Carotid artery structure (body structure) | :272741003 | laterality | = 24028007 | Right (qualifier value) | :247348008 | tenderness |

The Sensible Wayto tackle structure from the point of implementers

The Sensible Wayto tackle structure from the point of implementers

The Sensible Wayto tackle structure from the point of implementers

The Sensible Wayto tackle structure from the point of implementers

Open specs, tools and content for representing health records & building EHR Systems– 20+ years of international experience (Good European Health Record - GEHR)– Origin and superset of ISO/CEN 13606 Standard– An MDA/MDD Software Engineering Paradigm (e.g. “Inside Systems” vs HIE)– Learning curve for implementers BUT easy on clinicians / modellers

Governed by openEHR Foundation (not-for-profit) I’m one of 4 elected Management Board members (end of 2014)

What’s different? Modelling method: separation of clinical and technical worlds Mature tooling, scientific research & reference implementations in

almost all programming languages

• Once in Gartner Hype Cycle!– Steady international community, maturing now – Underpins many national EHR programs (most Nordic, Brazil, Slovenia)

The Sensible Waycont.

The Sensible Waycont.

The Sensible Waycont.

The Sensible Waycont.

The Sensible Waycont.

The Sensible Waycont.

IM & Terminology

Terminology: Labels/codes attached to atomic concepts (mostly without clinical context)

– Diabetes Mellitus, ear ache, left hip, CT scan etc.

Some have hierarchy (ICD) & relationships (SNOMED)

Boundary Problem(overlap) Terminology binding

Information Model: structure and semantics of concrete clinical concepts with clinical context/provenance

– Health condition, lab test result, discharge summary, adverse reaction, prescription etc.

Terminology Binding‘A formally expressible connection between information model

representation and terminology representation of clinical statements recorded in the EHR’

Examples define a terminology subset

^ 1111000000132 |allergy event|:

246075003 |causative agent| =

< 373873005 |pharmaceutical / biologic product|

OR

< 105590001 |substance|

Two different types of terminology bindings:1) linking a data item to external terminology/ontology for

the purpose of defining its real-world meaning2) Linking data element values to external terminology

(e.g. a RefSet or terminology query)

Blood Pressure Measurement

mindmap representation of openEHR Archetype

1) Linking items to SNOMED to define clinical meaning

NZ Cardiac Registry: Medication2) Linking data element values to external terminology (NZULM)

Clinical Information Modeling Initiative

• Led by Stan Huff to address profiling needs• Develop a single curated repository of models• Using a single modelling formalism

– Selected Archetypes as starting point– Will harmonise with UML > Archetype Modeling Language (OMG is on

it!)

&• FHIR resources and Archetypes are closely related

– should avoid reinvention at all costs!– Also FHIR extensions/profiles <> openEHR Templates

• Archetype FHIR resource conversion is expected to be seamless– Archetypes are usually more detailed; as opposed to

• FHIR resources include most commonly used items (80/20 rule) with an option to extend as needed

• An opportunity exists for FHIR to leverage openEHR content, tooling and expertise– FHIRman says base resources are not enough!

• Oh did I just forget SNOMED?– Not really, both FHIR and openEHR allow for terminology bindings

(for data items which make sense to encode)

Conclusions

• Information Models key for putting SNOMED to work– Package structure, syntax and semantics in one go– Easy to transform and consume for implementers

• There’s no point coding every data element! – But SNOMED (and other terminology) play key role in:

• Advanced decision support (using ontology-like features/inferencing)• Analytics, research and reporting

• It requires effort, tools and training• Good news is (for implementers)– They don’t have to be concerned (terminologists and

modellers’ job!)– FHIR (inc. SNOMED bindings) sufficient for HIE

Questions?k.atalag@auckland.ac.nzwww.taniwha.org.nz