Kaiser Permanente Standards Summit

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A Brief Review of CIMI Plans and Goals

• Kaiser Permanente Standards Summit
• September 7-8 , 2011
• Stanley M. Huff, MD

London CIMI Meetings November 29, 2011 Stanley M
Huff, MD Chief Medical Informatics Officer
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The Ultimate Value Proposition of CIMI

• Sharing of
• Data
• Information
• Applications
• Decision logic
• Reports
• Knowledge

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Clinical System Approach

• Intermountain can only provide the highest
  quality, lowest cost health care with the use of
  advanced clinical decision support systems
  integrated into frontline workflow

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• Newborns w/ hyperbilirubinemia

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Decision Support Modules

• Antibiotic Assistant
• Ventilator weaning
• ARDS protocols
• Nosocomial infection monitoring
• MRSA monitoring and control
• Prevention of Deep Venous Thrombosis
• Infectious disease reporting to public health

• Diabetic care
• Pre-op antibiotics
• ICU glucose protocols
• Ventilator disconnect
• Infusion pump errors
• Lab alerts
• Blood ordering
• Order sets
• Patient worksheets
• Post MI discharge meds

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Strategic Goals

• Minimum goal Be able to share applications,
  reports, alerts, protocols, and decision support
  with ALL GE customers
• Maximum goal Be able to share applications,
  reports, alerts, protocols, and decision support
  with anyone in the WORLD

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Order Entry API (adapted from Harold Solbrig)
Application
Update Medication Order
Interface
Service
Update PharmacyOrder WHERE orderNumber 4674
MUMPS Database
Data
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Order Entry API Different Client, Same Service
(adapted from Harold Solbrig)
Application
Update Medication Order
Interface
Service
Update PharmacyOrder WHERE orderNumber 4674
MUMPS Database
Data
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Order Entry API Different Server, Same Client
(adapted from Harold Solbrig)
Application
Update Medication Order
COS
Interface
Update PharmacyOrder WHERE orderNumber 4674
Service
GE Repository
Oracle Tables
Data
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Order Entry API (adapted from Harold Solbrig)
. . .
Application
Interface
Service
Data
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From Ben Adida and Josh Mandel
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What Is Needed to Create a New Paradigm?

• Standard set of detailed clinical data models
  coupled with
• Standard coded terminology
• Standard APIs (Application Programmer
  Interfaces) for healthcare related services
• Open sharing of models, coded terms, and APIs
• Sharing of decision logic and applications

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Clinical modeling activities

• Netherlands/ISO Standard
• CEN 13606
• United Kingdom NHS
• Singapore
• Sweden
• Australia
• openEHR Foundation
• Canada
• US Veterans Administration
• US Department of Defense
• Intermountain Healthcare
• Mayo Clinic

• HL7
• Version 3 RIM, message templates
• TermInfo
• CDA plus Templates
• Detailed Clinical Models
• greenCDA
• Tolven
• NIH/NCI Common Data Elements, CaBIG
• CDISC SHARE
• Korea

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Clinical Information Modeling Initiative

• Goal
• Meet the needs of the clinical modeling community
  everyone contributing, benefiting, and actively
  involved

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Clinical Information Modeling Initiative

• Mission
• Improve the interoperability of healthcare
  systems through shared implementable clinical
  information models.

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Clinical Information Modeling Initiative

• Goals
• Shared repository of detailed clinical
  information models
• Using a single formalism
• Based on a common set of base data types
• With formal bindings of the models to standard
  coded terminologies
• Repository is open and models are free for use at
  no cost

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Goal Models that support multiple contexts

• Messages
• Services
• Decision logic (queries of EHR data)
• EHR data storage
• Clinical trials data (clinical research)
• Normalization of data for secondary use
• Creation of data entry screens
• Natural Language Processing

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Information Model Ideas
Repository of Shared Models in a Single Formalism
Initial Loading of Repository
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Roadmap (some parallel activities)

• Choose a single formalism
• Choose the initial set of agreed data types
• Define strategy for the core reference model and
  our modeling style and approach
• Development of style will continue as we begin
  creating content

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Roadmap (continued)

• Create an open shared repository of models
• Requirements
• Find a place to host the repository
• Select or develop the model repository software
• Create model content in the repository
• Start with existing content that participants can
  contribute
• Must engage clinical experts for validation of
  the models

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Roadmap (continued)

• Create a process (editorial board?) for curation
  and management of model content
• Resolve and specify IP policies for open sharing
  of models
• Find a way of funding and supporting the
  repository and modeling activities
• Create tools/compilers/transformers to other
  formalisms
• Must support at least ADL, UML/OCL, Semantic Web,
  HL7
• Create tools/compilers/transformers to create
  what software developers need
• Examples XML schema, Java classes, CDA
  templates, greenCDA, RFH, SMART RDF, etc.

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Selected Decisions
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Decisions (London, Dec 1, 2011)

• We agree to create and use a single logical
  representation (the CIMI core reference model)
  comprising one or more models as the basis for
  interoperability across formalisms.
• We approve ADL 1.5 as the initial formalism in
  the repository using OpenEHR Constraint Model
  noting that modifications are required.
• The corresponding Archetype Object Model will be
  included and adapted as the CIMI UML profile
• The CIMI UML profile will be developed
  concurrently as a set of UML stereotypes, XMI
  specification and transformations

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Decisions (London, Dec 1, 2011)

• We will create a workplan to say how we review
  and update the Constraint Model, reference models
  and languages including HL7 Clinical Statement
  Pattern and Entry model of 13606 / OpenEHR. The
  workplan to be approved in January.
• The CIMI information model as described in the
  UML profile must be consistent with the evolving
  AOM. We will ensure this consistency by creating
  a single technical working group.

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Definition of Logical Model

• Models show the structural relationship of the
  model elements (containment)
• Coded elements have explicit binding to allowed
  coded values
• Models are independent of a specific programming
  language or type of database
• Support explicit, unambiguous query statements
  against data instances

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Definition of Logical Model (cont)

• Models shall specify a single unit of measure
  (unit normalization)
• Models can support inclusion of processing
  knowledge
• Models can support recommend defaults
• Models can specify assumed values of attributes
  (meaning of absence of the item)
• Examples can be created for the model

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Isosemantic Models
Precoordinated Model (CIMI deprecated Model)
HematocritManual (LOINC 4545-0)
HematocritManualModel
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data
Post coordinated Model (CIMI preferred Model)
Hematocrit (LOINC 20570-8)
HematocritModel
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data
quals
Hematocrit Method
HematocritMethodModel
Manual
data
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Isosemantic Models

• CIMI is committed to isosemantic clinical models
  in terms of both
• The ability to transform CIMI models into
  iso-semantic representations in other
  languages/standards (e.g. OWL, UML, HL7)
• The ability to transform CIMI models between
  iso-semantic representations that use a different
  split between terminology pre-coordination versus
  structure.

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Isosemantic Models (cont)

• Only include isosemantic models in the repository
  when they are useful
• Re-use of transforms by other enterprises
• Re-use of transforms by other processes
• Lab data transforms
• Data normalization for clinical trials or
  secondary use
• Repository requirement
• Know which models are part of the same
  isosemantic family
• Transform rules may be reused based on type of
  model
• Only difference may be terminology mapping

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Terminology

• SNOMED CT will be the primary reference
  terminology
• LOINC was also approved as a reference
  terminology
• In the event of overlap, SNOMED CT will be the
  preferred source
• CIMI will propose extension to the reference
  terminologies when needed concepts do not exist
• CIMI will maintain the extensions until they are
  accepted by the RT organization

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Terminology (cont)

• The primary version of models will only contain
  references (pointers) to value sets
• We will create tools that read the terminology
  tables and create versions of the models that
  contain enumerated value sets

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Three Task Forces

• Glossary
• Reference Model
• Clinical Models

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Some Principles

• CIMI DOES care about implementation. There must
  be at least one way to implement the models in a
  popular technology stack that is in use today.
  The models should be as easy to implement as
  possible.
• Only use will determine if we are producing
  anything of value
• Approve Good Enough RM and DTs
• Get practical use ASAP
• Change RM and DTs based on use