The NeedA logical model
With a strong community behind itThat is clinically viableThat is expressiveThat is structured and computableThat supports reasoningThat informs FHIR profilesThat supports “closing the quality feedback cycle”That is implementable
The Problem (I) Often conflated with a physical model such as FHIR
Often implied and not explicit vMR + QDM QUICK QI Core QUICK’ DAF SDC
Too many variants out there RIM QDM vMR QUICK/QIDAM/QUICK’ CEM CIMI FHIM SNOMED/LOINC/RxNORM …
The Problem (II)Unclear boundary between terminology and model
Unclear boundary between expression language and model
Often inconsistent Patient has diabetes (Condition)
Presence implied Patient does not have diabetes (Observation)
Absence explicit
Pre-coordinated/conflated semantics
Incomplete or just ‘too hard’
Scope hard to define. Need some boundaries.
Exploration Areas for LM Collaboration
What is a Logical Model?
How does it differ from a physical model like FHIR?
How does it differ from a reference model like CIMI Core?
How does it align with clinical terminologies/ontologies such as SNOMED CT?
How far does it align with clinical terminologies/ontologies such as SNOMED CT? Bindings only? At model level too?
How can it be implemented?
How can it be leveraged for Quality Improvement
Can we better align (or eliminate) variants and how?
Time FrameFirst set of meeting to last 8 weeks
Begin exploration of model/terminology alignment Focus: Alignment of CIMI ‘Observation Result’ with SNOMED
Observable Model Use Case: Systolic BP Goal: Implement simple prototype illustrating alignment of
approaches Last meeting of series on 10/13
Group to decide how to proceed after 10/13
Question: Should group disband and regroup under the CIMI Modeling Task Force? Should group remain as an exploratory task force looking at longer term questions?
Assumptions: TerminologyTaken from: http://opencimi.org/policies_cimi
SNOMED CT is the primary reference terminology
LOINC is also approved as a reference terminology
SNOMED relationship concepts will be used to define the parent-child relationships in the models
Assumption: ModelsTaken from: http://opencimi.org/policies_cimi
CIMI models shall, by design, include SNOMED CT content
Goal: Enable use of the SNOMED CT concept model to support translation of data from pre coordinated to post coordinated representations
Proposal: NamingOverlapping naming has led to confusion about the collaborative and/or competitive nature of CIMI and SNOMED
The SNOMED/LOINC Observable Model has a significant development history, and has specific, documented meaning
An alternative yet intuitive name for a complementary CIMI effort can reduce confusion and perceived competition
Possibilities CIMI Observation Result Model CIMI Assertion Model
Proposal: Separation of Concerns
Clearly and reproducibly delineate a separation of the semantics of the terminology from the semantics of the higher-order models
Use a simple nested structure to differentiate observable model attributes surfaced by CIMI
All surfaced attributes are defined with respect to the SNOMED/LOINC observable model, although CIMI may define “friendly” preferred names for use within the CIMI model
Simpler to understand and implement while “using the SNOMED CT concept model to support translation of data from pre coordinated to post coordinated representations”
Example: Simple nested Structure
Subject of informationCodeReasonMethodResult
observation
Subject of informationObservable*ReasonMethod*Result
assertion
Subject of informationReasonResult
assertion
Code/ExpressionMethodOther surfaced attributes
observable
Separate the terminology model attributes from higher-level model attributes
Existing model
Renamed model
Separated model
1 1
Alternative Names
Subject of informationReasonResult
observation result
Code/ExpressionMethodOther surfaced attributes
discernable
Intuitive names that do not overlap can reduce confusion and perceived competition
assertion/observable
observation result/observable
observation result/discernable 1 1
Subject of informationReasonResult
assertionCode/ExpressionMethodOther surfaced attributes
observable
1 1
Subject of informationReasonResult
observation result
Code/ExpressionMethodOther surfaced attributes
observable
1 1
Subject of informationReasonResult
assertionCode/ExpressionMethodOther surfaced attributes
discernableassertion/discernable1 1
Defining CIMI Surfaced AttributesProvide algorithmic support for translation between pre- and post-coordinated forms.
SNOMED Templates are one possibility
XSL, Xquery, and other options are possible
Moving forwardHow do we turn these ideas into reality?
Naming
Separation of concerns
Define surfaced attributes and pre/post coordination transformation specification
Add any necessary concepts to a CIMI extensionCIMI has obtained a SNOMED CT extension
identifierCIMI is committed to create a Terminology
Authority to review and submit concepts to IHTSDO as appropriate
Selected Initial Use Case
Representing a “systolic blood pressure taken from the right brachial artery using a blood pressure cuff while the patient is supine and at rest”
271649006|Systolic blood pressure (observable entity)|: 704318007|Property type (attribute)| = |Pressure (property) (qualifier value)|, 704319004|Inheres in (attribute)| = 67170007|Lumen of artery (body structure)|, 704327008|Direct site (attribute)| = (17137000|Structure of brachial artery (body structure): 272741003|Laterality (attribute)| = 24028007|Right (qualifier value)|), 246501002|Technique (attribute)| = 37931006|Auscultation (procedure)|, 424226004|Using device (attribute)| = 70665002|Blood pressure cuff, device (physical object)|, 704326004|Precondition (attribute)| = (40199007|Supine body position (finding)|, 704326004|Precondition (attribute)| = (128975004|Resting state (finding)|)
SNOMED Post Coordinated Expression
Prototype Next Steps
CIMI Team working on development of a CIMI ADL representation of CEM Systolic Blood Pressure model
CIMI systolic BP model to be represented using AML
VA Team to build SNOMED CT ‘template’
Group to determine how to map the two models in ADL/AML
VA Team to explore and develop transformation between iso-semantic representations
Group to review approach
Convergence Centralize logical model efforts and profile development under CIMI
umbrella? Will CIMI be an HL7 Working Group? Need central governance to prevent fragmentation
Derive FHIR profiles from CIMI logical model DCM profiles Foundational profile
Bottom up/top down approach Multi-layered logical model DCM (Serum Creatinine) Mid-level logical model(s) (QuantitativeLabResult Observation Result)
Moving beyond assertion models E.g., procedures and procedure requests E.g., Composite orderables …
Cross CollaborationHL7/FHIM participation in CIMI logical model
effort
CIMI/HL7 participation in terminology efforts (SNOMED, LOINC, RxNORM). Eg.,Extension of SNOMED CTDevelopment of observable modelDevelopment of procedure modelDevelopment of orderable catalog
Validation & AdoptionEncouraging use of CIMI profiles (not just plain FHIR
resources) in HSPC and SMART-on-FHIR projects
Validate logical model use cases for clinical quality improvement in HSPC and SMART-on-FHIR projects
Who else needs to be targeted for implementation and validation Argonaut Epic, Allscripts, Cerner, VA Others
Does HSPC reach a broad enough community?