Healthcare Informatics Standards

1
Healthcare Informatics Standards

• An Electronic Health Record Developers
  Perspective
• The 4th International HyTime Conference
• Montreal, Canada
• August 20, 1997
• Jason P. Williams
• Oceania, Incorporated
• jwilliams_at_oceania.com

2
Todays 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

3
Document Model
4
Why Standards? The Vendor Perspective

• better patient care
• concentration on core competencies
• product interoperability
• benefits to the client
• internal benefits

5
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

6

• SNOMED
• X-ray examination (PROCEDURE) performed on arm
  (SITE) makes known a fracture (RESULT-FINDING)
• ICD-9
• fracture 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
• cant just pick one!

7
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

8

• MSH\ADT1MCMLABADTMCM198808181126SECURITY
  ADTA01MSG00001P2.3ltcrgt
• EVNA01198808181123ltcrgt
• PIDPATID12345M11JONESWILLIAMAIII196106
  15MC1200 N ELM STREETGREENSBORONC27401-102
  0GL(919)379-1212(919)271-3434
  SPATID123450012M10123456789987654NCltcrgt
• NK1JONESBARBARAKWIFENKNEXT OF KINltcrgt
• PV11I2000201201004777LEBAUERSIDNEYJ.
  SURADMA0ltcrgt
• Patient William A. Jones, III was admitted on
  July 18, 1988 at 1123 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.

9
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

10
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)

11
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

12
SGML Meeting Healthcare Informatics Needs

• information exchange
• information retrieval and reporting
• system and platform independence
• long-term access and preservation

13
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

14
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)

15
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

16
Oceania and Structured Data

• clinicians create structured sentences
• each word encoded based on its role in the
  sentence
• interface terminology optimized for clinicians
  (charting languagecharting terms, browsing
  interface, data entry)
• clinicians should not have to know about structure

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18
Oceania and SGML

• representing WAVE documents internally
• providing browser interface to vocabulary
• ancillary data drug information, clinical
  practice guidelines
• benefits to Oceania clients

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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

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Oceania DTD Design Questions

• granularity
• retrieval purposes vs. document exchange
• attributes vs. elements
• negation and clinical documentation
• specificity vs. generality

22
DTD Development to Date

• an ongoing, iterative process
• many individuals from different functional areas
• engineering, clinical informatics, product
  development
• more than one DTD

23
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)

24
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

25
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

26
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

27
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.