Clinical templates, registries and e-terminologies from paper-based terminology systems to semantic interoperability

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Clinical templates, registriesand
e-terminologies from paper-based terminology
systems tosemantic interoperability

• Angelo Rossi Mori
• National Research Council, Rome - Italy
• HL7 / Vocabulary TC CEN / TC251 / WG II

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Contents

• key requisites for e-terminologies new roles for
  e-terminologies
• 4 kinds of e-terminologies
• usages, topics, actors
• 3 pillars for semantic interoperability
• (repositories, templates, value domains)

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Key requisites for e-terminologies

• support multiple usages of clinical data within
  information systems
• build coherent "families, each made of many
  specialised coding schemes
• restore continuum between content (values) and
  containers (data elements)
• achieve complete interoperability among
  applications

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Co-existence and specialisation

• co-existence of families of coding schemeswithin
  the same information system(each scheme is
  conceived to satisfy a purpose)
• specialised coding schemes differ
• by amount of details(e.g. classification vs
  nomenclature)
• by kind of details(e.g. classifications with
  various purposes)

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Specialisation of coding schemes

• each coding scheme is conceived for a precise
  purpose and context
• 4-digit ICD statistics
• LOINC orders / prescriptions
• SNOMED clinical detail
• CTP4 claims / reimboursement
• MeSH information retrieval
• ...

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3 levels of clinical expressions

• the same data should be represented
• by the appropriate system
• according to the actual task and purpose
• unconstrained, spontaneous text(it could be
  either dictated or typed text, or an entry from
  a predefined local vocabulary)
• entry of a detailed nomenclature
• class (grouping conceived for a purpose)

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clinical expressions in context

• task terminological phrase
• admission operation for lower third rectum
  cancer
• scheduling abdominoperineal amputation of rectum
  
• reporting low anterior resection of rectum
• with double stapling technique
• discharge other anterior resection of rectum,
  ICD-9-CM 48.63
• reimbours. operation for rectum cancer, DRG 147
• cost anterior resection of the rectum
• analysis with double stapling technique
• quality low anterior resection of rectum without
  temporary
• assurance colostomy and operation for lower
  third rectum cancer

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Different but coherent

• coherence among coding schemes
• unnecessary diversity shall be removed
• motivated diversity shall be fixed
• coherence between
• local expressions for "private" recording, and
• "public" expressions for communication and
  comparisons

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Representing a statement / fact

• huge pre-coordinated nomenclature
• combinatorial nomenclaturewith controlled
  post-coordination (one code)
• multi-axial nomenclature without rules to
  produce combined expressions and codes(repeat
  multiple values in one field)
• independent value domains for a set of related
  data elements (clinical template arranging
  multiple fields)

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New roles of e-terminology

• NO MORE "just labels"
• operational perspective of (clinical) data
• key for retrieval of operative datafrom master
  tables and knowledge bases
• internal tables, within applications
• commercial drug databases
• triggers, e.g. warnings and alarms
• Arden syntax, MLM and decision support
• ...

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Contents

• key requisites for e-terminologies new roles for
  e-terminologies
• 4 kinds of e-terminologies
• usages, topics, actors
• 3 pillars for semantic interoperability
• (repositories, templates, value domains)

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Usages, topics, actors - 1

• triggers for services within applications
• life-cycle states (messages, workflows,
  activities)
• names of messages and segments
• system developers
• HL7 maintains closed tables - CNE
• organisational administrative parameters
• sex, race, religion, dietary preferences
• facility managers
• HL7 maintains reference tables - CWE

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Usages, topics, actors - 2

• clinical / communication scheduling
• lab tests, document names, activity names
• master tables builders users
• HL7 endorses adequate domains
• clinical / recording
• findings, History Physical,
• assessments, diagnoses, health issues
• recording professionals
• HL7 registers compatible domains

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Contents

• key requisites for e-terminologies new roles for
  e-terminologies
• 4 kinds of e-terminologies
• usages, topics, actors
• 3 pillars for semantic interoperability
• (repositories, templates, value domains)

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The emerging needs

• satisfy needs of
• sub-communities (diabetes, cancer, ESRD)
• ad-hoc information flows (e.g. CDC, HCFA)
• assure more flexibility of messages and
  documents
• maintain control over the processthrough
  registration and support databasesi.e.
  decentralise but avoid the chaos
• achieve semantic interoperability

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3 pillars for real interoperability

• The emerging strategy is based on 3 pillars
• 1. data dictionaries and metadata registries,
• including names of observations (LOINC)
• 2. clinical templates
• 3. tables with enumerated value domains
• unresolved issue
• how to maintain the respective databases ?

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1. metadata registries

• Simple list of data elements
• with either answer-list or ranges of values
• (e.g. see names for observations in LOINC
• see also XDT/Germany, ISO 11179, ASTM E1384)
• Integrated repository
• with uniform representation of data elements
• Extension of the RIM
• each data element should be explicitly
• registered as a child / refinement of a RIM
  class,
• under control of the respective HL7-TC

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HL7 registered entry
elementary entry
RIM attribute
locally registered entry
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we will need further steps

• harmonise data elements and tables across
  different systems/organisations
• facilitate assignment of actual data elements of
  end-users to data elements adopted by secondary
  users(CDC, HCFA, )
• facilitate feedback from end-users to secondary
  users

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2. clinical templates

• to aggregate data elements from the repository
• (or from the RIM) into meaningful fragments
• i.e. building blocks
• to allow for flexible messages
• aggregates (and the related data elements)
• need a registration process
• under the control of HL7 TCs

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examples of aggregates

• batteries of lab tests
• blood pressure (systolicdiastolic)
• circumstances (patient's position, device)
• pathways in USAM-RIM (moodlinks table)
• DICOM-SR (templates context groups)
• clusters in ENV 13606-2
• clinical templates in HL7
• CMET in the HL7 HMD ?

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a potential clinical example

• template name description of duodenoscopy
• data element value domain (for duodenoscopy)
• lumen normal, spasm, stenosis,
• contents blood, biliary stones, parasites,
• wall rigid, decreased distensibility,
• mucosa atrophic, granular, hyperemic,
• hemorrhage mucosal bleeding, varices,
• flat lesions aphta, infiltration,
• protrusions papule, polyp,
• ... (from Nomenclature of
  Digestive Endoscopy, OMED, 1994)

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Example of legal requirements

• template name data items for nursing file
• data elements
• Care of hygiene
• Care of mobility
• Care of elimination
• Care of food
• Food by probe
• Specific care of the mouth
• Handling emotional problem
• Care for disorientated patient
• ...
• (Belgian law of 14.08.1987)

• Vital parameter registration
• Physical parameter registration
• Surveillance of tractions, plasters
• Withdrawal of blood
• Administration of medications
• Surveillance of drips
• Care for closed wound
• Care for open wound

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3. Value domains

• Hundreds of explicit tables
• with enumerated value domains
• admitted values for each data element
• of the RIM and of the repository,
• considering restrictions due to clinical
  templates
• "e-terminologies in context"
• coordinated by HL7 vocabulary TC

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a Cluster in CEN 13606-2

• "original component complex
• used to aggregate data items and/or other
  clusters
• to represent a compound concept.
• EXAMPLES.
• A blood pressure measurement consisting of
  systolic and diastolic pressure,
• a collection or closely related clinical
  findings,
• results of a battery of laboratory
  investigations,
• a treatment schedule consisting of several
  individually specified preparations or dosages.

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kinds of Clusters (CEN 13606-2)

• a set of closely inter-related symptoms (e.g. a
  cough productive of discoloured sputum and
  blood)
• a single act of physical examination which
  generates more than one value (e.g. heart
  sounds, a blood pressure taken lying and
  standing)
• a set of quantities constituting a single test
  (e.g. a differential white cell count)
• a set of entries that might often be represented
  in a table (e.g. auditory evoked potentials)
• a single healthcare action that had two or more
  purposes or consequences.

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battery in HL7 1/4

• battery
• a set of one or more observations
• identified as by a single name and code number,
• and treated as a shorthand unit
• for ordering or retrieving results
• of the constituent observations.
• Vital signs, electrolytes, routine admission
  tests, and obstetrical ultrasound are all
  examples.

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battery in HL7 2/4

• "Vital signs (conventionally) consist of
• diastolic and systolic blood pressure,
• pulse, and respiratory rate.
• Electrolytes usually consist of
• Na, K, Cl-, and HCO3-.
• Routine admission tests might contain
• CBC, Electrolytes, SMA12, and Urinalysis.
• (Note that the elements of a battery for our
  purposes may also be batteries). "

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battery in HL7 3/4

• "Obstetrical ultrasound is a battery made up of
• traditional component measurements and the
  impression,
• all of which would be returned as separate
  results
• when returned to the requestor.
• A test involving waveform recording (such as an
  EKG)
• can be represented as a battery made up of
• results of many categories, including
• digital waveform data, labels and annotations to
  the data,
• measurements, and the impression. "

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battery in HL7 4/4

• "The word battery is used in this specification
  synonymously with the word profile or panel.
• The individual observation elements
• within a battery may be
• characteristic of a physiologic system
• (e.g., liver function tests),
• or many different physiologic systems.

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structure of a Template 1/2

• GLOBAL INFORMATION
• global name of the template (with code)
• global interpretation or score
• global purpose / criterion for aggregation
• parent template (and kind of refinement)
• global circumstances for the template as a whole
  (e.g. features of the sample, position of
  patient)
• either pre-defined (e.g. type of sample, device)
• or as slot to be instantiated (e.g. date of
  sampling)
• common parameters that apply to each member,
• either fixed (e.g. units) or variable

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structure of a Template 2/2

• INFORMATION ON MEMBERS of the template
• (they can be other templates)
• complete name of member, with code (from an
  agreed pre-existing coding system)
• value of the member (with units, if relevant)
• parameters that will assume a different value for
  each member (e.g. time of sampling for each value
  of a glucose tolerance test)

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3-speed standard process

• 1. usual ballot in HL7
• 2. registration of data elements and CMETs
• (and messages/docs) by Committee
• 3. registration of CMETs (and messages/docs) by
• national affiliates
• government agencies
• disease networks (e.g. cancer registries, ESRD)
• member organisations

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3 components of messages/docs

• data elements ( definitions, value domains)from
  RIM or from a data dictionary
• arrangements into a message/document(parsing
  rules and tools)i.e. developed according to HMD
• "quality", i.e. adequacy to task(all and only
  the needed data elements),assured by ballot or
  registration