Modelling Patterns Review & Suggestions

Dr Linda Bird

16th August 2012

Modelling Layers

Reference Model

Modelling PatternsSchedule,Address,Material

Observation,Action Clinical List

Event Summary,Assessment

Clinical Models Medication Item Blood Pressure Medication List Discharge Summary

Add Specialty Context

Paediatric Medication Item

Neonatal Blood Pressure

Nephrologist Medication List

Cardiology Discharge Summary

CLUSTER ENTRY SECTION COMPOSITION

Add Care Setting Context

G.P. Dispensed Medication Item

Home Blood Pressure

Outpatient Clinic Current Medication

List

Inpatient Discharge Summary

Add Implementation Purpose Context

Dispensed Medications GUI

Neonatal Blood Pressure in EHR

Current Medication List in EHR

Discharge Summary Doc or Message

Add Use Case Context

Dispensed Medication Item

Standing Blood Pressure

Current Medication List

Medication Reconciliation Report

• openEHR• NHS LRA• SNOMED CT• results4Care DCMs• IMH CEMs• MOHH LIM• VA’s Discernables • EN13606 Association• HL7 v3 RIM

Modelling Patterns Review

1. Clinical Statement Types2. Isosemantic model structure

– key concept, qualifiers, modifiers

3. Clinical processes events links4. History of Events5. Order state machine and care flow mapping6. Composition/Document7. Clinical Model Patterns

– Reference Range Set, Schedule, Material (Device, Medication), Score/Assessment Scale

Modelling Patterns Types

1. Clinical Statement Types2. Isosemantic model structure

– key concept, qualifiers, modifiers

3. Clinical processes events links4. History of Events5. Order state machine and care flow mapping6. Composition/Document7. Clinical Model Patterns

– Reference Range Set, Schedule, Material (Device, Medication), Score/Assessment Scale

class extract package constrained classes

extended

demographics

PARTICIPATION

ATTESTATION_INFO{leaf}

- attested_view: ED [0..1]- proof: ED [0..1]- reason_for_attestation: CD.CV- target: II.Uuid.Ref [1..*]- time: TS

constraints{target must exist within extract}{attester is of type FUNCTIONAL_ROLE}{reason for attestation LRA vocab}

CLUSTER{leaf}

- structure_type: CS

constraints{name value}{cluster structure type LRA vocab}{meaning is undefined}

COMPOSITION{leaf}

- contribution_id: II [0..1]- session_time: IVL_TS- territory: CS [0..1]

constraints{name value}{composer is of type FUNCTIONAL_ROLE}{there exists one and only one other_participations instance representing the record target (i.e. subject of care)}

RELATED_PARTY{leaf}

- party: II.Uuid.Ref [0..1]- relationship: CD.CV.SCT

constraints{relationship code type LRA vocab}

CONTENTEHR_EXTRACT{leaf}

- authorising_party: II [0..1]- ehr_id: II- ehr_system: II- rm_id: ST- subject_of_care: II- time_created: TS

constraints{rm_id is 13606}

ELEMENT

- value: ANY

ENTRY{leaf}

- act_id: II [0..1]- uncertainty_expressed: BL.Null

constraints{uncertainty expressed has nullFlavor}{meaning undefined}{entry items may only contain elements}{subject_of_information_category undefined in LRA}{subject_of_information_category no default in LRA}{act_status is undefined in LRA}{no relationship type conflict in LRA}{name value}{information_provider is of type FUNCTIONAL_ROLE}

EXTRACT_CRITERIA{leaf}

- all_versions: BL [0..1]- archetype_ids: II [0..*]- max_sensitivity : CS [0..1]- multimedia_included : BL [0..1]- other_constraints: ED [0..1]- time_period : IVL [0..1]

constraints{all_versionsDefault}{all_versionsDefined}{other_constraintsDefined}

FUNCTIONAL_ROLE

- healthcare_facil ity: II.Uuid.Ref [0..1]- mode: CS [0..1]- performer: II.Uuid.Ref

constraints{function is undefined in LRA}{mode LRA vocab}{service setting is undefined in LRA}

ITEM

- obs_time: IVL_TS [0..1]

constraints{item category undefined in LRA}{emphasis undefined in LRA}

LINK

- follow_link: BL- nature: CS- target: II.Uuid.Ref

constraints{follow_link default value false}{l inks allowed only one target in LRA}{target exists}{nature LRA vocab}

RECORD_COMPONENT

- archetype_id: ST [0..1]- meaning: CD.CV [0..1]- name: ST- orig_parent_ref: II [0..1]- policy_ids: II [0..*]- rc_id: II.Uuid- sensitivity: CS [0..1]- synthesised: BL

constraints{synthesised defaults to false}{sensitivity LRA vocab}

SECTION{leaf}

constraints{sections may only contain (by value) other sections}

AUDIT_INFO{leaf}

- committer: II.Uuid.Ref- ehr_system: II- previous_version: II [0..1]- reason_for_revision: CD.CV [0..1]- time_committed: TS- version_set_id: II [0..1]- version_status: CS [0..1]

constraints{version status LRA vocab}{reason for revision LRA vocab}

IDENTIFIED_ENTITY

-criteria 0..*

-members

0..*

-l inks

0..*0..1

-feeder_audit

0..1

-subject_of_information

0..10..1

-info_provider 0..1

0..1

-other_participations

0..*

-items

0..*-all_compositions

0..*

0..1

-attestations 0..*

0..1

-committal 1..1

0..1

-composer 0..1 0..1

-other_participations

1..*

-content

0..*

-parts

0..*

0..1

-attester 1..1

-demographic_extract 0..*

NHS LRA Care Components Reference Model

NHS LRA – ELEMENT patternsclass extract package derived classes

ITEM

ELEMENT

- value: ANY::ITEM- emphasis: CD.CV [0]- item_category: CS [0]- obs_time: IVL<TS> [0..1]::RECORD_COMPONENT- name: SC- archetype_id: ST [0..1]- rc_id: II- meaning: CD.CV [0..1]- synthesised: BL- policy_ids: SET<II> [0..1]- sensitivity: INT [0..1]- orig_parent_ref: II [0..1]

constraints::ITEM

{ item category undefined in LRA }{ emphasis undefined in LRA }::RECORD_COMPONENT

{ synthesised defaults to false }

ACTIVITY_ELEMENT

constraints{meaning is a procedure}{value is null}

OBSERVATION_ELEMENT

PROPERTY_OBSERVATION_ELEMENT{leaf}

constraints{name value}{meaning is observable}{value type not allowed to be time based}{coded value is observation value}

FINDING_OBSERVATION_ELEMENT{leaf}

constraints{name value}{meaning is a finding}{value is null}

INVESTIGATION_ACTIVITY_ELEMENT{leaf}

constraints{name value}{meaning is an investigation}

MATERIAL_ACTIVITY_ELEMENT{leaf}

constraints{name value}{meaning is a substance procedure}

GENERAL_ACTIVITY_ELEMENT{leaf}

constraints{name value}{meaning is a general activity procedure}

UNBOUND_DATA_ELEMENT{leaf}

constraints{name value}{meaning undefined}

COMPONENT_RELATIONSHIP_ELEMENT{leaf}

constraints{name value}{value defines dependency}{must have exactly 2 links}{value is coded data}{one link to subject}{one link to object}{coded meaning from LRA vocab}{meaning is defined}

BOUND_DATA_ELEMENT

constraints{meaning is coded data}{meaning is defined and is not null}

RECORD_ARTEFACT_ELEMENT{leaf}

constraints{name value}{meaning is a record artefact}{value must be null}

MATERIAL_ENTITY_ELEMENT{leaf}

constraints{meaning is a material}{name value}{value is type QTY}{obs_time is undefined in LRA}

NHS LRA – ELEMENT Domain ModelsFinding Observations• AllergyOrAdverseReactionEvent • AllergyOrAdverseReactionPropensity • DiagnosisName • GenericFindingObservation • GenericProblemAndIssue • RisksExpectationsOrGoals

Property Observations• BloodPressureObservation • BloodSugarObservation • BodyHeightObservation • BodySurfaceAreaObservation • BodyWeightObservation • DiastolicPressureObservation • GenericPropertyObservation • PulseRateObservation

General ActivitiesGenericAdmissionEvent GenericDischargeEvent GenericProcedure SpecimenCollection

Material ActivitiesGenericSpecimen MeasurementDevice ProductOrSubstance

Investigation ActivitiesBloodPressureMeasurement BodyHeightMeasurement TemperatureMeasurement

Unbound DataAdviceForPatient CourseTiming FutureEventTime InterpretationRange

NHS LRA – ENTRY Domain Models• GenericClinicalNarrative • GenericAdmissionEvent • GenericFinding • HealthcareActionPlan • GenericProblemAndIssue • GenericProcedure • GenericProperty • MedicationReviewPlan • ProductOrSubstance • ProductOrSubstanceRelatedActivity • ProvisionOfInformationAndAdvice • RecommendationActivity • AllergyOrAdverseReactionEvent • GenericAdmissionProspect • AllergyOrAdverseReactionPropensity • GenericDischargeEvent • BloodPressure

• BloodSugar • GenericTransfer • BodyHeight • GenericTransferProspect • BodySurfaceArea • RisksExpectationsAndGoals • BodyWeight • ProvisionOfAdviceAndInformation • Diagnosis • FluidIntakeRate • GenericAssessment • SubjectOfCareObservations • GenericInvestigation • PulseRate • Temperature • TreatmentDevice

NHS LRA – e.g. Temperature ENTRYcomposite structure Temperature

«PROPERTY_OBSERVATION_ELE...TemperatureObserv ation

«INVESTIGATION_ACTIVITY_EL...TemperatureMeasurement

IsResultantObservationOf

HasAnnotation

«UNBOUND_DATA_ELEMENT»Text

«ENTRY»Temperature

- name: SC {readOnly}- rc_id: II- synthesised: BL- uncertainty_expressed: BL {readOnly}

HasClinicalContext

«UNBOUND_DATA_ELEMENT»UnboundGenericFinding HasClinicalContext

«FUNCTIONAL_ROLE_CHOICE»InformationProviderChoice

«FUNCTIONAL_ROLE_CHOICE»OtherParticipationsChoice

«RELATED_PARTY_CHOICE»SubjectOfInformationChoice

«FINDING_OBSERVATION_ELEM...GenericFindingObserv ation

0..*

«SUBJECT»

0..*«OBJECT»

0..*

«SUBJECT»

0..*

«OBJECT»

0..1«SUBJECT»

0..1«OBJECT»

0..1«SUBJECT»

0..*

«OBJECT»

0..*«OBJECT»

-items

1

0..*

-items

0..*

0..1

0..1

-items0..*

-items0..*

-items

0..1

0..*

«OBJECT»

NHS LRA – e.g. Temperature ENTRY

• Subject of Information (Participation)• Information Provider (Participation)• OtherParticipation (Participation)• TemperatureObservation (PropertyObservation)• TemperatureMeasurement (InvestigationActivity)• Text (UnboundDataElement)• UnboundGenericFinding (UnboundDataElement)• GenericFindingObservation (FindingObservation)

composite structure TemperatureObserv ation

«PROPERTY_OBSERVATION_ELEMEN...TemperatureObserv ation

- archetype_id: ST [0]- meaning: CD.CV- name: SC {readOnly}- obs_time: IVL<TS> [0..1]- orig_parent_ref: II [0]- policy_ids: SET<II> [0]- rc_id: II- sensitivity: INT [0]- synthesised: BL- value: PQ

«INVESTIGATION_ACTIVITY_ELEME...TemperatureMeasurement

- archetype_id: ST [0]- meaning: CD.CV.SCT- name: SC {readOnly}- obs_time: IVL_TS [0..1]- orig_parent_ref: II [0]- policy_ids: SET<II> [0]- rc_id: II.Uuid- sensitivity: INT [0]- synthesised: BL- value: ANY {readOnly}

IsResultantObservationOf

HasAnnotation

«UNBOUND_DATA_ELEMENT»Text

- archetype_id: ST [0]- name: SC {readOnly}- obs_time: IVL<TS> [0]- orig_parent_ref: II [0]- policy_ids: SET<II> [0]- rc_id: II.Uuid- sensitivity: INT [0]- synthesised: BL- value: ED.Text

HasClinicalContext

«UNBOUND_DATA_ELEMENT»UnboundGenericFinding

- archetype_id: ST [0]- name: SC {readOnly}- obs_time: IVL<TS> [0..1]- orig_parent_ref: II [0]- policy_ids: SET<II> [0]- rc_id: II- sensitivity: INT [0]- synthesised: BL- value: ANY

HasClinicalContext

«FINDING_OBSERVATION_ELEMENT»GenericFindingObserv ation

- archetype_id: ST [0]- meaning: CD.CV- name: SC {readOnly}- obs_time: IVL<TS> [0..1]- orig_parent_ref: II [0]- policy_ids: SET<II> [0]- rc_id: II- sensitivity: INT [0]- synthesised: BL- value: ANY {readOnly}

0..1«SUBJECT»

0..1

«OBJECT»

0..1

«SUBJECT»

0..*

«OBJECT»

0..*«SUBJECT»

0..*

«OBJECT»

0..*

«SUBJECT»

0..*

«OBJECT»

0..*«OBJECT»

0..*«OBJECT»

NHS LRA – e.g. TemperatureObservation ELEMENT

NHS LRA – e.g. TemperatureObservation ELEMENT (mindmap)

openEHR – ENTRY patterns

• OBSERVABLE ENTITY• CLINICAL FINDING

– Finding method: PROCEDURE– Interprets: PROCEDURE– Interprets: OBSERVABLE ENTITY

• PROCEDURE– Has focus: CLINICAL FINDING

SNOMED CT

SNOMED CT – Observable (draft)

SNOMED CT – Observable (draft)

• Root concept• Data• Qualifier• State

results4Care DCMs

• Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction Summary, Admit/AdminDiagnosis

• Key, Item, Qualifier, Modifier, Attribution

IMH CEMs

MOHH LIM• ENTRY

– Observation Entry (Observable Name/Value)• Heart Rate/ Blood Pressure / Blood Glucose

– Clinical Finding• Problem Diagnosis Entry• Adverse Reaction Entry• Alert Entry

– Activity• Pharmacy Activity Entry

– Pharmacy Order Entry– Pharmacy Dispense Entry– Pharmacy Administration Entry

• Investigation Activity Entry– Investigation Order Entry– Investigation Result Entry

• Procedure Entry (Reference Pattern)• CLUSTER

– Pharmacy Item / Investigation Test Item

IsoSemantic Models – Example Instances

e.g. “Suspected Lung Cancer”

IsoSemantic Models – Compositional Grammar

Problem Diagnosis = $ProblemDiagnosisName: 246090004|associated_finding|= (404684003|clinical_finding|:

63698007|finding_site|=($BodySite: 272741003|laterality|=$Laterality), 246112005|severity|=$Severity),

408729009|finding_context|=$FindingContext

EN13606 Association

HL7 v3 RIM

1. Clinical Statement Types2. Isosemantic model structure

– key concept, qualifiers, modifiers

3. Clinical processes events links4. History of Events5. Order state machine and care flow mapping6. Composition/Document7. Clinical Model Patterns

– Reference Range Set, Schedule, Material (Device, Medication), Score/Assessment Scale

Modelling Patterns Types

1. Clinical Statement Types2. Isosemantic model structure

– key concept, qualifiers, modifiers

3. Clinical processes events links4. History of Events5. Order state machine and care flow mapping6. Composition/Document7. Clinical Model Patterns

– Reference Range Set, Schedule, Material (Device, Medication), Score/Assessment Scale

• openEHR– Observation, Evaluation, Instruction, Action, Admin Entry

• MOHH– Observation, Finding, Activity (Medication, Laboratory), Administration

• NHS LRA– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,

General), Material Entity– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....

• Intermountain/GE– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction

Summary, Admit/AdminDiagnosis, ...

• SNOMED CT– Observable Entity, Clinical Finding, Procedure, ...

• HL7 v3– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial

Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)

Clinical Statement TypesReviewed

• openEHR– Observation, Evaluation, Instruction, Action, Admin Entry

• MOHH– Observation, Finding, Activity (Medication, Laboratory), Administration

• NHS LRA– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,

General), Material Entity– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....

• Intermountain/GE– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction

Summary, Admit/AdminDiagnosis, ...

• SNOMED CT– Observable Entity, Clinical Finding, Procedure, ...

• HL7 v3– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial

Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)

Clinical Statement Types(Observation)

• openEHR– Observation, Evaluation, Instruction, Action, Admin Entry

• MOHH– Observation, Finding, Activity (Medication, Laboratory), Administration

• NHS LRA– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,

General), Material Entity– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....

• Intermountain/GE– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction

Summary, Admit/AdminDiagnosis, ...

• SNOMED CT– Observable Entity, Clinical Finding, Procedure, ...

• HL7 v3– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial

Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)

Clinical Statement Types(Finding)

• openEHR– Observation, Evaluation, Instruction, Action, Admin Entry

• MOHH– Observation, Finding, Activity (Medication, Laboratory), Administration

• NHS LRA– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,

General), Material Entity– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....

• Intermountain/GE– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction

Summary, Admit/AdminDiagnosis, ...

• SNOMED CT– Observable Entity, Clinical Finding, Procedure, ...

• HL7 v3– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial

Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)

Clinical Statement Types(Activity)

• openEHR– Observation, Evaluation, Instruction, Action, Admin Entry

• MOHH– Observation, Finding, Activity (Medication, Laboratory), Administration

• NHS LRA– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,

General), Material Entity– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....

• Intermountain/GE– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction

Summary, Admit/AdminDiagnosis, ...

• SNOMED CT– Observable Entity, Clinical Finding, Procedure, ...

• HL7 v3– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial

Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)

Clinical Statement Types(Administration)

• Property Observation (property-value pair)• Clinical Finding (name)• Activity (orders, procedures, etc)• Administration (X ?)

CIMI ENTRY Pattern Suggestions

• openEHR– Observation: the observation of any phenomenon or state of interest to do

with the patient (eg diagnosis, goal, adverse reaction).• NHS LRA

– Property Observation: Used to represent the results of investigations undertaken to find out more information about a patient's state of health or wellbeing and device or procedure related parameter settings. (Meaning-value pairs)

• SNOMED CT– Observable Entity: represents a question or procedure which can produce

an answer or a result. Used to code elements on a checklist or any element where a value

• EN13606 Association– Observation/Inspection: Used to define all that can be documented about a

specific state of a process in the Patient System at a point in time using the faculties of seeing, hearing, tasting, touching, smelling, or directly via a medical device or service.

Property Observation (Existing Definitions)

Used to represent the results of observations or investigations undertaken to find out more information about a patient’s state of health or wellbeing, and device or procedure related settings.

Comments:• E.g. Heart rate, Blood glucose, Glasgow Coma Scale• Represents the common name-value or question-answer pattern• Supports isosemantic representation of Observation Names that

may include method, patient_state, device, location and other related information in pre or post-coordinated form.

Property Observation(Suggested CIMI Definition)

• openEHR– Evaluation: the Opinion category , including problem/diagnosis, risk

assessment, scenario, goal and recommendation• NHS LRA

– Finding Observation: used to represent both normal and abnormal clinical states found on examination or deduced from clinical reasoning (e.g. 'clear sputum', 'diabetes mellitus') and events to which the patient or service user may have been to subject (e.g. 'physical abuse', 'exposure to mercury').

• SNOMED CT– Clinical Finding: represent the result of a clinical observation, assessment or

judgement, and include both normal and abnormal clinical states• EN13606 Association

– Evaluation/Consideration: Used for the documentation about an inferred process in the patient system using observations, expertise and knowledge, or about plans with, or risk assessments about, the Patient system

Clinical Finding(Existing Definitions)

Used to represent clinical states found on examination or deduced from clinical reasoning (e.g. ‘diabetes mellitus’, ‘clear sputum’), and events to which the patient may have been subject (e.g. ‘physical abuse’, ‘exposure to mercury’).

Comments:• E.g. Diagnosis, Adverse Reaction, Alert• Supports isosemantic representation of Clinical Finding Names

that may include body location, laterality, causative agent and other related information in pre or post-coordinated form.

Clinical Finding(Suggested CIMI Definition)

• openEHR– Action: Information recorded due to the execution of an instruction by some

agent– Instruction: Actions to be performed in the future.

• NHS LRA– Activity: Used to record treatment procedures, investigation procedures,

administrative procedures and the provision of advice and information to patients and carers

• SNOMED CT– Procedure: Activities performed in the provision of health care

• EN13606 Association– Instruction/Order: used to define all that can be documented about the

intended actions with the aim to change the state or process in the Patient System

– Action/Intervention: is used to define all that can be documented about events that changed (or could change) states or processes in the Patient System

Activity(Existing Definitions)

Used to record activities that have been, are being, or are to be performed, including treatments, investigations, administrative procedures and the provision of advice or information.

Comments:• E.g. Medication Activity (Requested, Dispensed, Administered),

Investigation Activity (Requested, Performed)• Supports isosemantic representation of Activity Names, which

may include body location, priority, context and other related information in pre or post-coordinated form.

Activity(Suggested CIMI Definition)

Property Observation (property-value): Used to represent the results of observations or investigations undertaken to find out more information about a patient’s state of health or wellbeing, and device or procedure related settings.

• E.g. Heart rate, Blood glucose, Glasgow Coma Scale

Clinical Finding (name): Used to represent clinical states found on examination or deduced from clinical reasoning (e.g. ‘diabetes mellitus’, ‘clear sputum’), and events to which the patient may have been subject (e.g. ‘physical abuse’, ‘exposure to mercury’).

• E.g. Diagnosis, Adverse Reaction, Alert

Activity: Used to record activities that have been, are being, or are to be performed, including treatments, investigations, administrative procedures and the provision of advice or information.

• E.g. Medication Activity (Requested, Dispensed, Administered), Investigation Activity (Requested, Performed)

CIMI Modelling Patterns (Suggested Definitions)

• Heart Rate - Property Observation• Body Mass Index – Property Observation• Apgar Score – Property Observation• Glucose Tolerance Test Result – Property Observation• Adverse Reaction – Clinical Finding• Medication order - Activity• Problem list – List (Section) of Clinical Finding (+ ?)• Care Giver Reported Nausea – Clinical Finding• Wound Culture Result – Activity + Property Observation?

CIMI Call For Clinical Models

• Property Observation to: – Finding: ‘has interpretation’– Activity: ‘results in’

• Activity to:– Activity: ‘has instruction’, ‘depends on’, ‘must occur before’, etc– Clinical Finding: ‘has focus’, ‘results in’– Property Observation: ‘results in’

• Clinical Finding to:– Property Observation: ‘reason for’– Activity: ‘finding method’, ‘is indication for’

Where to from here?– Review of Existing Approaches (e.g. NHS, ISO, SNOMED)– Proposal for CIMI

LINKS between Models (Suggestions)

NHS LRA – Component Relationship Vocabulary (draft)

EN13606:3 Link Nature

Code MeaningLINK-A0 is related toLINK-B0 is confirmed byLINK-C0 is related to the same problem or health issueLINK-D0 is related to the same plan of care, act or episodeLINK-E0 is a related documentation

EN13606:3 Link Role

Code MeaningLINK-A1 unspecified linkLINK-A2 suggests (tentatively related to)LINK-A2i is suggested byLINK-A3 re-occurrence or repeat ofLINK-B1 endorses (agrees with, confirms, verifies) LINK-B2 disagrees with (e.g. another opinion)LINK-B3 permits (sanctions, authorises)

LINK-B3i permitted by LINK-B4 assumes responsibility for LINK-B5 declines (refuses, cancels)LINK-B6 consents toLINK-B6i consented by LINK-C1 cause (interpretation)LINK-C1i caused byLINK-C2 revised interpretationLINK-C3 evidence for LINK-C3i justified byLINK-C4 evidence againstLINK-C4i countered by LINK-C5 indicated by LINK-C5i indication for LINK-C6 contra-indicated byLINK-C6i contra-indication for

Code MeaningLINK-C7 trigger for LINK-C7i triggered byLINK-C8 manifestation of LINK-C8i manifested byLINK-C9 sequel (consequence, progression)LINK-C10 intended (aim, goal, target, hoped for, desired)LINK-C11 anticipated (predicted)LINK-C12 to be avoided (at risk of, fear of, prophylaxis)LINK-D1 outcomeLINK-D2 has pre-conditionLINK-D3 evaluation (assessment, milestone)LINK-D4 contributes to or fulfils goal, plan or actLINK-D5 revised state of the same act LINK-D6 sub-task of LINK-E1 documented by (is documented within)LINK-E1i documents (describes, reports)LINK-E2 summarisesLINK-E3 supplementsLINK-E4 excerptsLINK-E5 derived fromLINK-E6 has reference ranges LINK-E7 identified within (study product)

• OBSERVABLE ENTITY• CLINICAL FINDING

– Finding method: PROCEDURE– Interprets: PROCEDURE– Interprets: OBSERVABLE ENTITY

• PROCEDURE– Has focus: CLINICAL FINDING

... And many other ‘Linkage’ concepts

SNOMED CT

• Clinical Finding– Finding site <<442083009|Anatomical or acquired body structure|

– Associated morphology << 4975500|Morphologically abnormal structure|

– Associated with <<404684003|Clinical Finding|, 71388002|Procedure|, 272379006|Event|, 410607006|Organism|, 105590001|Substance|, 260787004|Physical object|, 78621006|Physical force|, 373873005 |Pharmaceutical / biologic product|

– Severity <= 272141005 |Severities|

– Clinical course <= 288524001|Courses|

– Episodicity <= 288526004|Episodicities|

– Interprets << 363787002|Observable entity|, 108252007|Laboratory procedure|, 386053000|Evaluation procedure|

– Has interpretation << 260245000|Findings values|

– Pathological process == 263680009|Autoimmune|, <<441862004|Infectious process|

– Has definitional manifestation << 404684003|Clinical finding|

– Occurrence < 282032007|Periods of life|

– Finding method <= 71388002|Procedure|

– Finding informer <<420158005|Performer of method|, 419358007|Subject of record or other provider of history|

SNOMED CT Concept Model

• Procedure– Procedure site << 442083009|Anatomical or acquired body structure|

– Procedure morphology <<49755003|Morphologically abnormal structure|

– Method <<129264002|Action|

– Procedure device <<49062001|Device|

– Access <=309795001|Surgical access values|

– Direct Substance <<105590001|Substance|, 37387305|Pharmaceutical / biologic product|

– Priority <=272125009|Priorities|

– Has focus <<404684003|Clinical finding|, 71388002|Procedure|

– Has intent <=363675004|Intents (nature of procedure values)|

– Recipient category <<125676002|Person|, 35359004|Family|, 133928008|Community|, 105455006|Donor for medical or surgical procedure|, 389109008|Group|

– Revision status <<261424001|Primary operation|, 255231005|Revision - value|, 257958009|Part of multistage procedure|

– Route of administration <<284009009|Route of administration value|

– Surgical approach <=103379005|Procedural approach|

– Using energy <<78621006|Physical force|

– Using substance <<105590001|Substance|

SNOMED CT Concept Model

• Property Observation to: – Finding: ‘has interpretation’– Activity: ‘results in’

• Activity to:– Activity: ‘has instruction’, ‘depends on’, ‘must occur before’, etc– Clinical Finding: ‘has focus’, ‘results in’– Property Observation: ‘results in’

• Clinical Finding to:– Property Observation: ‘reason for’– Activity: ‘finding method’, ‘is indication for’

Where to from here?– Review of Existing Approaches (e.g. NHS, ISO, SNOMED)– Proposal for CIMI

LINKS between Models (Suggestions)

– All• Participations: subject, information provider• Elements: Timing• Elements: Clinical Status

– Property Observation• Participations: observer• Cluster (Isosemantic ): Property (name, descriptors)• Cluster: Result (name, value, details, interpretation, reference range)• Links: observing activity, interpretation, is indication of, other

– Finding• Participations: finder• Cluster (Isosemantic ): Finding Item (name, descriptors)• Cluster: Finding Details (details)• Links: finding method, finding procedure, is indication of

– Activity• Participations: performer• Cluster (Isosemantic): Activity Item (name, descriptors)• Element: Activity Identifier(s)• Cluster: Activity Details (details)• Links: has instruction, depends on, must occur before

CIMI Modelling Pattern Attributes(Suggestion)

Property Observation

Heart Rate Example

Clinical Finding

Activity

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