GP2GP Clinical Semantics

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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

3
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

4
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

5
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

6
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
Which sit in a context which might include
Relating to an ongoing Problem Chest Pain
Which was constructed during an event Surgery
Consultation
Which all sits in a document Referral Letter
A Heading Past History
Modifying Information Q Possible
or
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
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A Construction
DISCHARGE NOTE
Kettering General Hospital Rothwell Road,
Kettering Northants NN16 8UZ Tel [phone]
Date 04/02/2000
Dear Dr Prunesquallor A
Ward Deene B
Admitted On 07/01/2000
Primary Diagnosis
Pelvic malignancy
Secondary Diagnoses
Anaemia unspecified
D21z.
Discharged On 02/02/2000
Complications
Consultant Zhivago Y
 
 
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 Approach
Required
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Positional Syntax Approach
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One Representation on Receipt
Patient Details
Date of Birth
DISCHARGE LETTER
04/02/2000
Date of Event
Event Type
History
Examination
Investigations
Procedures
For palliative care.
Comment
Healthcare Professional
ZY
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What was Lost?

• Hospital Address
• Unit Number
• The Ward
• The dates of admission/discharge/operations/proced
  ures
• 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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Architecture ?

• Merriam Webster Definition a unifying or
  coherent form or structure a method or style of
  building

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GEHR (North) Simplified
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(No Transcript)
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ENV 13606 message structure
1
types of
contains
1
1..
1..
types of
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ENV13606 message data items
type of
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?