GP2GP Clinical Semantics Leo Fogarty Russell Hotel 12/12/03.
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Transcript of GP2GP Clinical Semantics Leo Fogarty Russell Hotel 12/12/03.
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GP2GP Clinical Semantics
Leo Fogarty
Russell Hotel 12/12/03
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Nature of health records
• Collection of information about the health of a person
• Contains entries made– On one or more occasions– By one or more authors
• A person may have many health records– A combination of health records for the same person is
a health record– A copy of all or part of a health record is a health
record
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Purposes of health records• Care of the patient
– Informing and reminding care providers– Organising thinking and decision making– Communicating with other care providers
• Care of the population– Clinical, social and therapeutic research– Epidemiology and strategic planning
• Support for providers– Professional education and training– Financial, contractual and legal
• Support for provider organisations– Financial, contractual and legal– Planning services
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Content & structure of health records
• Notes– Free form narrative (and cryptic abbreviations)– Documents with agreed conventions– Completed forms
• Reports– Letters and text reports– Structured numeric reports– Pictures, graphs and tracings
• Structures– Problem lists and alerts– Episode summaries– Coding for classification and grouping
• Supporting information– Dates, times, people, places and signatures– Demographics
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Records, Readers, Authors
• Introversion, Extroversion and Idleness
• Obsessives and Creatives
• Bible Scholars and Cynics
• Navigators and Head Bangers
• Informatic Ignorance and Wisdom
• Solomons and Grundies
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Electronic health records
• Health records in electronic form– CPR, EPR, EHCR, EHR, EMR, PMR, …
• Purposes– As for health records– “Electronic” adds or subtracts value
• Contents– As for health record– “Electronic” reuse may reduce duplication
• Structure– Document, message and data– Narrative, code terminologies and templates
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Elements of Clinical Information
The Record of Patient Information as Text:- which is human-readable and easily communicable
The inclusion of codes:
XE2uV Ischaemic Heart Disease
Which may be qualified as:
X793b Mild
X78th First Episode
Which sit in a context which might include:
A Heading:“Past History”
orModifying Information:Modifying Information:Q= “Possible”Q= “Possible”
Which all sits in a document:
““Referral Letter”Referral Letter”
Which was constructed during an event:
Surgery ConsultationSurgery Consultation
Relating to an ongoing Problem:
Chest PainChest Pain
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A ConstructionDISCHARGE NOTE Kettering General Hospital
Rothwell Road, KetteringNorthants NN16 8UZ
Tel: 01536 492000Dear Dr: Prunesquallor A
Date: 04/02/2000 Surname:
BEAUHARNAISUnit No: 123451
First name: JOSEPHINE
DoB: 01/01/22
NHS: 1234567895
Address: 5 WhitehallKETTERINGNORTHANTSNN00 1OO
Ward: Deene B
Admitted On: 07/01/2000
Discharged On: 02/02/2000
Consultant: Zhivago Y
Primary Diagnosis: Pelvic malignancy
Secondary Diagnoses: Anaemia unspecified D21z.
Haematuria K197.
Complications:
Operations & Procedures
Urethral Catheterisation
Urethral Catheterisation
Urethral irrigation of bladder
Other blood transfusion NOS
Diagnostic Cytoscopy (Rigid) & Bladder Biopsy
M478a
M478a
M471
X339
M451c
Date of Op/Proc
07/01/00
08/01/00
08/01/00
09/01/00
10/01/00
Additional Information \ Instructions
For palliative care.
OPD Follow Up Weeks
Signed: Maggie Bell
Print Name: Maggie Bell
Designation: Clinical Practitioner
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Positional Syntax ApproachADT ADT Message Chapter
MSH Message Header 2
EVN Event Type 3
PID Patient Identification 3
[PD1] Additional Demographics 3
[ { NK1 } ]Next of Kin / Associated Parties
3
PV1 Patient Visit 3
[ PV2 ] Patient Visit - Additional Info. 3
[ { OBX } ]Observation/Result 7
[ { AL1 } ] Allergy Information 3
[ { DG1 } ]Diagnosis Information 6
[ { DRG } ]DRG Information 6
[ { PR1 } ]Procedures 6
[ { GT1 } ]Guarantor Information 6
[
{ IN1 Insurance Information 6
[ IN2 ] Insurance Information - Addit. Info.
6
[ IN3 ] Insurance Information - Cert. 6
}
]
[ ACC ] Accident Information 6
[ UB1 ] Universal Bill Information 6
[ UB2 ] Universal Bill 92 Information 6
Required
ADT ADT Message Chapter
MSH Message Header 2
EVN Event Type 3
PID Patient Identification 3
PV1 Patient Visit 3
[ { OBX } ]Observation/Result 7
[ { DG1 } ]Diagnosis Information 6
[ { PR1 } ]Procedures 6
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Positional Syntax ApproachADT ADT Message Chapter
MSH Message Header 2
EVN Event Type 3
PID Patient Identification 3
PV1 Patient Visit 3
[ { OBX } ]Observation/Result 7
[ { DG1 } ]Diagnosis Information 6
[ { PR1 } ]Procedures 6
SEQ LEN DT R/O RP/# TBL# ITEM # ELEMENT NAME
1 1 ST R 1 Field Separator
2 4 ST R 2 Encoding
Characters
9 7 CM R 76 9 Message Type
10 20 ST R 10 Message Control
ID
11 1 ID R 103 11 Processing ID
12 8 ID R 104 12 Version ID
1 3 ID R 3 99 Event Type Code
2 26 TS R 100 Date/Time of Event
5 60 CN O 188 103 Operator ID
2 16 CK 105 Patient ID (External
ID)
3 20 CX R Y 106 Patient ID (Internal
ID)
5 48 XPN R 108 Patient Name
7 26 TS 110 Date of Birth
11 106 XAD Y 114 Patient Address
2 1 ID R 4 132 Patient Class
3 12 CM O 133 Assigned Patient
Location
7 60 XCN O 10 137 Attending Doctor
8 60 XCN O 10 138 Referring Doctor
44 26 TS O 174 Admit Date/Time
45 26 TS O 175 Discharge
Date/Time
2 2 ID R 125 570 Value Type
3 590 CE R 571 Observation
Identifier
14 200 TS O 582 Date/Time of the
Observation
1 4 SI R 391 Set ID - Procedure
2 2 ID R 89 392 Procedure Coding
Method
3 80 CE R 88 393 Procedure Code
4 40 ST O 394 Procedure
Description
5 26 TS R 395 Procedure
Date/Time
6 2 ID R 230 396 Procedure
Functional Type
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One Representation on Receipt
DISCHARGE LETTER04/02/2000
BEAUHARNAISJOSEPHINE 01/01/22
ZY
Urethral Catheterisation Urethral Catheterisation
Urethral irrigation of bladder Other blood transfusion NOS
Diagnostic Cytoscopy (Rigid) & Bladder Biopsy
(M478a) (M478a)
(M471) (X339)
(M451c)
(D21z.)Pelvic malignancy Anaemia unspecified Haematuria (K197.)
For palliative care.
Patient Details
Date of Event Event Type
History
Examination
Investigations
Healthcare Professional
Procedures
Comment
Date of Birth
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What was Lost?• Hospital Address• Unit Number• The Ward• The dates of admission/discharge/operations/procedures• Clinical Heading Context
– Significant loss of clinical meaning
• Healthcare Professional Names• Healthcare Professional Roles• Attestation• Identification of Management Plan/Intention• In short: -
CONTENT and CONTEXT
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Semantic Interoperability Needs
• Clinical Coding Schemes– Clinical Concepts– Drugs
• People, Places and Roles• Aggregations
– Templates/Archetypes/Clusters
• Dates• Architectural Containment and “Glue”
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• Merriam Webster Definition:Merriam Webster Definition: a unifying or coherent form or structure; a method or style of building
Architecture ?Architecture ?
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GEHR (North) Simplified
EHCR
EHCR Extract
Transactions
List of Transaction
Types
Content
Category Observation
Item Item Collection
List of Item Types
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ENV 13606 message structure
types of
1contains
1..*
types of
1..*
EHCR extract
original compone
nt complex
record component
link item
data item
folder
composition
headed section
1
EHCR message
cluster
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ENV13606 message data items
record component data item
type of
Plain/HTML text
structured codedquantifiable observationmedication
physical entity reference
external data reference
event
person identifier
person name
language
address
telecom
patient related party
related location
community defined
types of
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GEHR (South)
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CDA at RIM level
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Information model – EHR Containers
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Information model – Clinical statements
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GP2GP Language
• Coding Schemes– Read– EMIS– Multilex– Local
• Consultation Categories (Headings)
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GP2GP Language Architecture Names
• Level Codes
• Composition Names
• Document Names
• Compound Names
• Link Names
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GP2GP Language Qualifiers
• Problem Status
• Epidocity
• Medication Mood
• Secondary Status Terms
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GP2GP Language Major Modifiers
• Certainty/Negation
• Action Status
• Significance
• Subject of Information
• Sensitivity
• Validity
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GP2GP Project Outcome
• NHSIA Project 1/6/01-31/5/03• V3 Messaging successful• Four (Now five) suppliers implemented in
test bed circumstances• One supplier implemented same system
transfer “for real”• Further piloting happening• Quo Vadis?