Tackling the Semantic

Interoperability challenge

Dipak Kalra

European Patient Summaries: What is next?

The context for sharing health summaries

Cro

ss

-bo

rde

r h

ea

lth

ca

re

Unscheduled care

(emergency,

unexpected)

Scheduled care

(planned by clinician,

arranged by patient)

Generic patient summary

Procedure referral summary?

Condition specific summaries

are needed,

including care plans

Continuity of care

for acute

exacerbations,

complications

(predictable, even if

not predicted)

Als

o u

se

ful fo

r w

ith

in-b

ord

er

he

alt

h c

are

These must be clinically driven, engaging multiple stakeholders

• Inpatient Mortality 11.1%

– Cardiology ward 7.8%

– General medical 13.2%

– Other ward 17.4%

Mortality for patients hospitalised with HF

Source: John Cleland, Suzanna Hardman, SHN WP1

What are we trying to do ?

• Develop a useful and credible electronic health record for use in patients

for HF, as an exemplar of other chronic conditions

• Starting with a Shared Care Summary

– This must contain basis for a reliable diagnosis

– This must support downstream care providers who may be unfamiliar with

the patient

Collation of Heart Failure Data-Sets & Guidelines

• Existing trial data-bases delivered

– Hull Life Lab Data-Base

– SICA-HF (FP7 funded epidemiology study of HF)

– UK National Audit Data-Base

• Heart Failure Guidelines Collated

– European Society of Cardiology

– American Heart Association/American College of Cardiology

– Heart Failure Society of America

– NICE Guidelines and Quality Standards

– SIGN

– Australia & New Zealand Guidelines

Source: John Cleland, Suzanna Hardman, SHN WP1

Is it heart failure? Key information needed for diagnosis and management

Source: John Cleland, Suzanna Hardman, SHN WP1

Proposal for a Heart Failure Summary

Items that Occasionally Change

• Aetiology: Coronary Artery Disease

• Prior Myocardial Infarction?: Yes: Anterior 2005

• Co-morbidity: Type 2 Diabetes and Arthritis

• Implanted Device: No (drop down of ICD, PM or CRT)

• ECG– Heart Rhythm: Sinus

– PR interval: 210msec

– QRS duration: 110msec

• Echocardiogram– LVEF: 32%

– Mitral regurgitation: moderate

– Other important valve disease: no

• Lung Function: – FEV1: 2.1 (83% of

predicted)

– FEV1/FVC: 75%

• Urine Protein: Trace

Source: John Cleland, Suzanna Hardman, SHN WP1

Proposal for a Heart Failure Summary

Symptoms

• Symptoms

– Orthopnoea: No

– Exertional Breathlessness: Moderate

– Ankle Swelling: No

– Fatigue Moderate

– Chest pains: No

– Cough: Fair

– Well-being: Good

– Sleep Quality Poor

– Snoring Yes

Items in grey are required less often

Source: John Cleland, Suzanna Hardman, SHN WP1

Proposal for a Heart Failure Summary

Items that Often Change

• Heart rate: 88 bpm

• Systolic BP: 144mmHg

• Diastolic BP: 102mmHg

• Weight: 69.8kg (BMI calculated……)

• Target ‘Dry’ Weight: 68.0kg

• Haemoglobin: 10.8g/dL– If Anaemic, Haematinic screen: Iron Deficiency

• Sodium: 138mmol/L

• Potassium: 4.0mmol/L

• Urea: 11.5mmol/L

• Creatinine: 137umol/L

• Albumin: 44g/dL

• BNP/NT-proBNP: 3,127ng/L

• Blood Glucose (Random): 7.2mmol/L

• HbA1c: 7.4%

Source: John Cleland, Suzanna Hardman, SHN WP1

Therapeutic Targets

Instructions

• ACE Inhibitor: Yes, Ramipril 5mg bd

• Angiotensin Receptor Blocker: Not required

• Beta-blocker: Yes, Carvedilol 25mg bd

• Spironolactone: Yes, 25mg/day

• Loop Diuretic: Bumetanide 2mg/day

• Ferrous sulphate: Yes, Stop in 3m

• Digoxin: Not required

• Anticoagulant: Not required

• Antiplatelet: Clopidogrel 75mg/day

• Exercise: Yes, for 20 min x 3/wk

Physiological Targets (may modify instructions)

• Symptom Control None or Mild

• Resting heart rate 50-70bpm

• Systolic BP 110-130mmHg

• Dry weight 68kg +/- 2kg

• HbA1c 6.5-8.5%

Source: John Cleland, Suzanna Hardman, SHN WP1

Discharge Instructions

• Double Carvedilol every 2wks until target achieved …

• Double Ramipril in one week to achieve target …

• Stop ferrous sulphate in 3months and re-check haemoglobin …

• Advise on dietary salt and exercise …

• Increase bumetanide in one month if …

Source: John Cleland, Suzanna Hardman, SHN WP1

Heart Failure summary template (openEHR format)

Source: Ian McNicholl, openEHR, SHN WP4

Overlap Terminologies / Information Models

Source: Stefan Schulz, Cati Martinez, SHN WP4

• Clinical Information models to be used without or with inexpressive terminologies

Clinical Terminologies

Clinical Information Models

• Terminologies to be used without information models

• Contextual statements (negation, plans, beliefs…) within terminologies

– SNOMED CT context model

– ICD 11 content model

• Local terminology within IMs

• Post-coordination within IMs

Suspected heart failure caused by ischaemic heart disease

• Three heterogeneous representations of the same

statement

• Three different atomic information entities

Organ Failure Diagnosis

Organ Heart

Status Suspected

Caused by

ischaemic

heart disease

Yes

No

Unknown

Diagnosis

Suspected heart failure caused

by ischaemic heart disease

x

Diagnosis

Heart Failure

Status

Suspected

Cause

Ischaemic heart

disease

Source: Stefan Schulz, Cati Martinez, SHN WP4

SHN Semantic Patterns approach

27

SEMANTICPATTERNS

SHNOntology

Framework

compliant with

Use cases: heart failure and

cardiovascular health

SHN Semantic Patterns approach

SHN Ontological Framework

SEMANTICPATTERNS

Heterogeneous Clinical Models

HOMOGENEOUS QUERY

DL Reasoning

A Semantic Pattern to represent a non-smoker

shn:EvaluationProcess

shn:InformationItem

sct:smoking

sct:InThePast

sct:Absent

‘describes situation’

‘has temporal context’

‘has finding context’

“information about patients without past history of smoking”

‘result from process’

Query pattern

NPH_CS_PT

Semantic Query Pattern

Semantic interoperability: key stakeholders who need to be

involved

• Patients, patient associations

• Clinicians, professional associations, clinical specialty associations

• Healthcare provider organisations

• Healthcare payers: public health authorities, insurers

• Health ministries

• Public health organisations

• EHR system vendors, medical device vendors, ICT infrastructure

vendors, Industry associations

• Pharma, research organisations

• Standards Development Organisations

• The European Commission, ONC, WHO, OECD...

For cross-border patient care, population health, comparisons, surveillance,

research, products and services

Information patients would like included in a long term condition summary