Healthcare Informatics StandardsAn Electronic Health Record Developer’s

Perspective

The 4th International HyTime Conference

Montreal, Canada

August 20, 1997

Jason P. Williams

Oceania, Incorporated

jwilliams@oceania.com

Today’s Topics

• changing healthcare informatics models

• healthcare informatics standards– language and vocabulary– Health Level Seven (HL7)

• SGML and healthcare informatics

• Oceania and SGML

• Oceania and HyTime architectural forms

Document Model

YearlyPhysicalReport3/2/97

Longitudinal Patient Record

Knee PainReport11/7/96

IntermittentFeversReport1/2/94

VitalsImmunizations

Why Standards? The Vendor Perspective

• better patient care

• concentration on core competencies

• product interoperability

• benefits to the client

• internal benefits

Healthcare Informatics Standards

• vocabulary and language – SNOMED, ICD– READ, MESH, others– NLM UMLS (meta-thesaurus)

• information / data representation– HL7, DICOM, – SGML, XML, RDBMS, others

• medical conventions

SNOMEDX-ray examination (PROCEDURE) performed on arm

(SITE) makes known a fracture (RESULT-FINDING)

ICD-9fracture of radius and ulna [arm], upper end, closed =

813.00

• many other examples to choose from• each optimized for different purposes• each purpose needs to be addressed by vendors• can’t “just pick one!”

Health Level Seven (HL7)

• “Clinical, financial, and administrative data among healthcare oriented computer systems”

• messaging standard; “trigger event”

• HL7 defines message types and “structure”

• messages structure: header: segments: fields

MSH|^~\&|ADT1|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01|MSG00001|P|2.3|<cr>

EVN|A01|198808181123||<cr>

PID|||PATID1234^5^M11||JONES^WILLIAM^A^III||19610615|M||C|1200 N ELM STREET^^GREENSBORO^NC^27401-1020|GL|(919)379-1212|(919)271-3434 ||S||PATID12345001^2^M10|123456789|987654^NC|<cr>

NK1|JONES^BARBARA^K|WIFE||||||NK^NEXT OF KIN<cr>

PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||||ADM|A0|<cr>

Patient William A. Jones, III was admitted on July 18, 1988 at 11:23 a.m. by doctor Sidney J. Lebauer (#004777) for surgery (SUR). He has been assigned to room 2012, bed 01 on nursing unit 2000.

The message was sent from system ADT1 at the MCM site to system LABADT, also at the MCM site, on the same date as the admission took place, but three minutes after the admit.

HL7: The Positives

• Allows interaction with other systems– appointments and scheduling– lab results

• large areas of clinical content defined

• Version 3, Reference Information Model

• large user base

HL7: The Negatives

• mixture of content with representation standards

• many non-defined areas: Z segments

• very customized local implementations make extra-institutional exchange difficult

• document model not supported (not good with text)

The HL7 SGML SIG

• charter and design principles

• sample DTDs

• Kona Architecture Proposal

• interoperability between HL7 and SGML– SGML to encode HL7 messages?– Use of HL7 to contain and transport SGML

documents?

• “best of both” approach

SGML Meeting Healthcare Informatics Needs

• information exchange

• information retrieval and reporting

• system and platform independence

• long-term access and preservation

Information Exchange

• mobility of patients; emergency situations• changing nature of patient care• claims and claims attachments

– claims /attachments vs. clinical documentation– HIPAA (Health Insurance Portability and

Accountability Act) and HCFA

• SGML/XML and the WWW• intra-institutional and extra-institutional

exchange

Information Retrieval

• smarter full-text retrieval based on semantics

• enables implementation of document model

• preserving multiple views– clinician gets documents (context preserved)– population view

• (system / platform independence; longevity)

Oceania EMR: WAVETM

• allows creation and access of clinical data in documents

• documents and relational tables -- health summary view

• access to complete document contents not standardized

• vocabulary: clinical content knowledge base

Oceania and Structured Data

• clinicians create structured sentences

• each word encoded based on its role in the sentence

• interface terminology optimized for clinicians (charting language…charting terms, browsing interface, data entry)

• clinicians should not have to know about structure

Oceania and SGML

• representing WAVE documents internally

• providing browser interface to vocabulary

• ancillary data: drug information, clinical practice guidelines

• benefits to Oceania clients

Early DTD Development

• direct mapping from WAVE document structure

• based on CCKB user interface for threading

• granularity: word, based on sentence role

• attributes for codes and vocabulary

<!ELEMENT problem - -(problem-name,(description | evaluation-by | status | location | onset | episode | resolved | denied | previous-eval | previous-medications | . . .))

(see Kona web site)

Oceania DTD: Design Questions

• granularity

• retrieval purposes vs. document exchange

• attributes vs. elements

• negation and clinical documentation

• specificity vs. generality

DTD Development to Date

• an ongoing, iterative process

• many individuals from different functional areas– engineering, clinical informatics, product

development

• more than one DTD

Oceania and Architectural Forms

• standardizing implementations of SGML

• should not have to standardize the DTD

• multiple uses of architectural forms:– bridge multiple representations of the Oceania

documents– intra-institutional exchange– extra-institutional exchange (Kona)

Oceania Experience with the Kona Architecture

• the SOAP format and Oceania documents: the sections

• architectural mappings at different levels of granularity

• the Kona “code” and “mention”

• architectural “collisions”: same element; different contextual semantics

SGML Standards Family and Healthcare Informatics

• SGML will go forward: positives, momentum

• HL7 and SGML: future cooperation

• HyTime and others add to SGML implementation functionality

• what we need: collaboration with standards organizations, experience

Selected References

• Health Level Seven Standard. http://www.mcis.duke.edu/standards/HL7/hl7.htm

• Health Level Seven SGML SIG. http://www.mcis.duke.edu/standards/HL7/committees/sgml/index.html

• Kona Architecture Proposal to the HL7 SGML SIG. http://www.mcis.duke.edu/standards/HL7/committees/sgml/index.html

Selected References• Lincoln, Thomas L, Daniel J Essin, Robert Anderson,

Willis H Hare (1994). The Introduction of a New Document Processing Paradigm into Health Care Computing: A CAIT Whitepaper. Santa Monica, California: Rand Corporation. [Available at the HL7 SGML SIG website.]

• Morris, Jonathan A, Rachael Sokolowski, John E Mattison, David Riley (1997). Standard Generalized Markup Language (SGML) in Healthcare. Accepted for panel discussion at the Healthcare Information Management Systems Society (HIMSS) 1998 Conference in Orlando, Florida.