Meaningful records and meaningless boxes
David MarkwellPrincipal Consultant
The Clinical Information Consultancy Ltd
www.clininfo.co.uk
HL7 UK Conference 2007
RIM
Meaningless boxes?
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Meaningless boxes?
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Terminologies& classifications
Communicationspecifications
Applications & data storage
Data capture andUser interfaces
Information models archetypes and templates
Meaningful records
For health record information to be reusable it must be processable in a meaningful way by a variety of different applications
How should the ‘meaningless boxes’ be used to meet this objective?
Requirements for meaningful health records
Requirements for meaningful processing of health record information come from a variety of different sources including:– Clinicians involved in direct patient care– Epidemiologists and researchers– Service managers at local and national levels
To meet these varied requirements the health record content must be represented in ways that encompass multiple perspectives
Different perspectives on health information
Clinical discipline and specialty viewsDifferent ways of working and priorities affect
• Degree of detail that can be readily captured• Balance between data capture styles• Record content that needs to be displayed for review• Opportunities for effective use of decisions support• Reporting requirements
Specific process views
For example• Requesting and reporting investigations• Prescribing, dispensing and administration of medication• Managing immunisation programs• Referrals and appointment bookings
Integrating different perspectives
Specific perspectives are important– Specialty specific views support clinical users – Process specific views enable efficient and effective
delivery of services
Integration of multiple perspectives is important– The same information is often collected by, and
relevant to, many specialties and processes– Consistent representation of information is essential
to enable reuse of relevant information– Requirements for consistency are often ignored
when focusing attention on one process or specialty
Process and meaningful health record views
(slides 8-13 were hidden and not used in HL7UK Conference presentation)
Reusable, meaningful health records in the context of
The delivery of health care to a person or a population consists of various processes – Each process has specific requirements for data
collection and communication • For example, the process of providing routine immunisations
Health records contain information collected during various processes– The information collected is often relevant to and
related with multiple care delivery processes• For example, information about an immunisation may be
relevant determining the differential diagnosis for a subsequent febrile illness
Processes based requirements
Data requirements– Provide each party with sufficient information to fulfil their role– Track progress to confirm consistent completion– Identify exceptions
Data capture and communication requirements– Simplify capture of data essential to the process– Specify the requirements for communications that are essential
to the process Typical end result
– Forms, information structures and messages directly matching specific requirements with minimal requirements for data transformation
– Not ideal if the information needs to be reused by other related processes
An example of a process: Routine immunisation
Call person to immunisation clinic– Record call and booked appointment
Take and review history for contra-indications Decide on immunisation required Explain recommendation and obtain consent
– Record history, immunisation decision and consent Administer the appropriate quantity of the vaccine by
the appropriate route– Record details of the substance, quantity, batch number and
route of administration Arrange follow up for next step in course
– Submit required information to support claims and/or update central/shared immunisation registers
Health record requirements
Information requirements – Provide appropriate accurate information when and where it is
needed• To enable delivery of evidence-based personal care to individuals
• To enable more effective delivery of care to the wider population
– Allow incremental growth of ‘meaningful information’
Capture and communication requirements– Facilitate capture of information from which the meaning can be
determined without detailed knowledge of the specific data collection process
– Represent communications in ways that conserve ‘meaningful information’ derived from different processes and applications
An example of a meaningful health record view:Immunisation information
Questions a meaningful health record should be able to answer: What immunisations has this person had – and when? Has this person had an adverse reaction to a past immunisation? What immunisations are due or incomplete? Is this person up to date for immunisation against disease X? What percentage of a population completed their immunisations? Who received immunisations from a suspected faulty batch? Which members of the population are at risk from a current
outbreak of a disease due to out of date immunisation? Has this GP/PCT hit a target for coverage of the population? Have particular immunisations, routes or regimes been associated
with greater risks of side effects? … and many more …
Meaningful electronic health records
A meaningful health record makes it possible to answer relevant questions accurately and efficiently
Relevant questions that a health record may need to answer
It is impossible to enumerate every potentially relevant question (the number is huge and growing)
It is possible to identify general types of questionsFor example …– What information is known about this person?– Does this person have a particular item or collection of items of
information in their record?– How many incidents of a specified type have occurred to
members of a population (or selected subpopulation)?– Which members of a population have a particular item of
collection of items of information in their record? Each type of question can be refined
– different selection criteria – different ways in which to represent the answers
Illustration of a differences between ‘process view’ & ‘meaningful record view’ Are the following questions the same?
– Did this person complete the routine immunisation process against disease X?
– Is this person’s appropriately immunised against disease X?
Not really – One is ‘process’ question the other is a ‘meaning’ question
The answers are related but may differ– Evidence of the effectiveness of the vaccine given may change
so the cover is no longer effective– Immunisation may be done and recorded in other situations
• For example, an A&E department or travel clinic
An immunisation in any situation is still an
immunisation
Requirements for accuracy and efficiency
Accuracy – includes– Precision
• Reducing the risk of false positives
– Completeness• Reducing the risk of false negatives
Efficiency – includes– Ease
• Time and expertise needed to pose questions
– Frequency• How often does a question need to be answered
– Rapidity • How quickly is an answer needed
Retrieval
Display
Capture
Reportingand analysis
StoredEHR Content
CommunicationsStored Content
Other EHR systems
A simplified overview of health record information
flows
DecisionSupport
What functions determine the requirements for processable health record content?
Retrieval as a determiner of data content and representation
A meaningful health record makes it possible to answer relevant questions accurately and efficiently
In order to answer relevant questions information must be selectively retrieved so it can be displayed or analysed
Therefore retrieval requirements are clearly an important determiner of requirements for data content and representation
Display as a determiner of data content and representation
Display requirements can be phrased as questionsFor example– General: What information is held about this person?– Specific: What allergies does this patient have?– Population: Which patients require follow up?
Display is one of the underlying requirements for selective retrievalDisplay retrieval requires– High performance - rapid responses– Clear rendering and layout of responses– Integration with data capture in the user interface
Data capture as a determiner of data content and representation
Effective data capture is vitally important– It needs to be easy in terms both of
• the time and effort require; and• the way it fits in with working practices
Data capture is only worthwhile if the data captured can be usefully reusedTherefore – Data capture does not define the requirements for
data content and representation – Data capture needs to be designed to meet
requirements for subsequent retrieval
Alternative modes of data entry are good servants but poor masters
• Approaches to data entry need to be tailored to
the way different groups of clinicians work and
think• A common approach to the user interface• But not one size fits all
• As the following examples illustrate the same
information may be captured in different ways• How does this affect content and representation?
Different ways to capture the same meaning (1)Simple check-boxes
Suggests a Model of Use consisting of codes assigned values of “true”, “false” or “unknown”.
Different ways to capture the same meaning (2)
Selection of terms
Suggests a Model of Use consisting of individual coded statements with associated text
Different ways to capture the same meaning (3)Free text with natural language processing
Suggests a Model of Use consisting of text tagged with relevant codes.
Answering questions based on data capture representations
• If information is represented according to the way it is
captured it may be difficult to answer simple questions• Does the patient have a family history of diabetes
mellitus? … expands to …• Do they have a family history form in which ‘diabetes mellitus’ is
checked as present?• Do they have a family history record in which the code for ‘FH
diabetes mellitus’ is present?• Do they have text that is tagged with the code for ‘diabetes
mellitus’ in the context of a section of text tagged as ‘family
history’?• ... there are also other data capture representations to consider
Data capture and meaningful records
Reuse of information captured in different ways should be supported by enabling transformation from specific data capture forms to a common ‘model of meaning’
For example– The results of the preceding data capture illustrations should be
transformed to a common model of meaning that allows questions about family history of asthma, diabetes mellitus and heart disease to be answered consistently
The model of meaning should – Encapsulate essential contextual information
• i.e. family history, absence/presence
– Represent appropriate and available detail– Allow general questions to be reliably answered by records that
may contain more detailed representations• e.g. “family history or type 2 diabetes mellitus”
Communication as a determiner of data content and representation
Communication requires the sending system to selectively retrieve the information to be sent
There is no point in communicating information that is not retrievable on the recipient system– Reuse of communicated information requires selective retrieval
Therefore, communication requirements are secondary to requirements for reuse and retrieval
Possible exception: A communication specification may be the only source of requirements for data that is captured specifically to populate a message, has a specific role in the receiving system and is not reused for any other purposes.
Communication of meaningful records
Information with the same meaning may be represented differently in different systems and in different messages– To meet different use cases in term of levels of detail– To benefit from proprietary optimisations– To utilise different communication standards appropriate to
specific requirements
Communications of health record information should be based on (or transformable to) a common model of meaning– A common model of meaning offers a shared view allowing
consistent retrieval of data irrespective of its point of origin
Meaningful electronic health records
A meaningful health record makes it possible to answer relevant questions accurately and efficiently
The primary drivers for the data content and representation of health records are– The questions that are deemed to be relevant – The accuracy and efficiency necessary to adequately
address those questions
RetrievalRequirements
DisplayRequirements
CaptureRequirements
Reportingand analysis
Requirements
EHR ContentRequirements
CommunicationsRequirements
Content Requirements
Other EHR systems
Requirements arise from the questions that
need to be answered
DecisionSupport
Requirements
RetrievalRequirements
‘Posing question
s’
Requirements for a commonmodel of meaning
A model of meaning into which data captured in different ways can be transformed is required to support – Consistent processing within an application that
collects similar data in different ways• ‘Semantic operability’
A common model of meaning in which data from different application can be shared is required to support – Communications between applications which employ
different internal models of meaning• ‘Semantic interoperability’
What should a common model of meaning look like
A virtual view of information that can be used as a point of reference for questions
Ensure that similar information can be retrieved in similar ways– Avoid special cases in which particular information is
only accessible using particular queries• This does not preclude specialised views but it does require
that the information is also accessible using the general view
– Avoid multiple representations of similar information based on process or level of detail• The model of meaning should tolerate different levels of
details within the common structure
Templates and other constraints
Templates and archetypes act as useful constraints to information models that can assist many aspects of health record system specificationIncluding– Design of data capture screens and protocols,– Design and implementation of health record repositories,– Message design and message instance validation.
Like other information models these structures should be bound to terminologies to make them meaningful– Structural constraints should not be assumed to encapsulate
meaning– Instances of information that conform to structural constrants
should be reliably transformed to a common model of meaning to enable comparability with other representations of similar information
Starting point for a common model of meaning
The HL7 DSTU ‘Guide to the use of SNOMED CT with HL7v3’ (TermInfo) is a starting point from which to develop a common model or meaning– It discusses many general issues encountered at the boundary
between information models and terminology models– It identifies specific issues at the boundary between ‘HL7
Clinical Statements’ and ‘SNOMED CT Terms’ and specifies rules and guidance for dealing with many of these issues.
– It provides a point of reference – rather than a finished work – since it remains subject to evolutionary improvement
Similar work is needed in respect of– Other information models (e.g. EN13606 and OpenEHR)– Any additional terminologies used in health records
Reusable meaningful records depend on rules for assembling meaningless boxes into a consistent inclusive ‘model of meaning’
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Progress In the last year …
– Two relevant standards were passed in DSTU ballots• HL7 Clinical Statements
• HL7 Guide to Use of SNOMED CT in HL7v3
– Ownership of SNOMED CT passed to the IHTSDO• International Health Terminology Standards Development Organisation
Recently …– An IHTSDO project to specify SNOMED CT Machine Readable
Concept Model constraints was launched– Work started on approaches to binding SNOMED CT to
EN13606 archetypes and openEHR templates
There are stronger signs of practical convergence between EHR related standards today than in the past– … but much remains to be done
Conclusions Reusable heath records need to support
selective retrieval to answer relevant questions, accurately and efficiently
Selective retrieval requirements are the primary driver for specification of the content of the EHR
A common model of meaning is essential to enable effective retrieval
Specifications concerned with capture and communication of health record information need to enable transformation to an agreed common model of meaning
Meaningful records from meaningless boxes
Thank you for your attention– Any questions?
– Contact details• www.clininfo.co.uk• www.cliniclue.com