Implementing dual model systems

Implementing Archetype Based Systems

Background

• Using templates• Queries• Archetypes• Storing openEHR instances

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Using templates

• There are 2 different definitions for what a template is:–Ocean templates–Zilics templates

• Currently there are a lot of open source projects regarding openEHR– Templates can not yet be created with open

source tools

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Using templates

• For open source (non profit) projects, the only alternative is to edit XML ‘by hand’– both ocean and zilics templates schemas are

public– Open EHR-Gen is working on that

• Other commercial approaches usually transform the archetypes to their own model to simulate templates

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Using templates

• Export the schema from a template is not viable– for medium sized template 1,5mb (for

comparison, HL7 CDA schema is only around 700kb)

• Currently templates mix clinical with GUI• Templates specifications are currently

changing– Not yet defined, but in the future they will be

(specialized) archetypes 5

Queries

• Also ADL queries syntax is not defined yet (AQL, A-Path…).

• Neither AQL and A-Path can yet be considered standard– AQL is a prototype inside of Ocean template

designer– A-Path is a proposal from Zilics

• AQL has more ‘buzz’

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Archetypes

• Not a single archetype repository– CKM (primary source)– NEHTA (Australia)– SKL (Sweden)

• Same archetype in different repositories?• Missing archetypes?• Governance?• Repository for multiple models?

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Storing openEHR data instances

• openEHR does not say anything about how data should be stored– Objects?– XML?– Relational datasources (SQL)?– Tokyo/Kyoto cabinet?– RDF triplets?

• Most of open source projects use XML data sources– openEHR XML schemas are public 8

Our philosophy

• Archetypes (separating knowledge from systems) is a very powerful methodology.– Putting the clinical knowledge on the focus

• Archetype based systems are the future…

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…but we can not throw our current systems data!

Looking at the play field…

• For archetype definition:– Multiple models available– Multiple available repositories (and not all

openEHR)– Most standards can take benefit from using

archetypes

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Looking at the play field…

• For legacy data integration:– Not use templates, use archetypes

(specialized o not)– When importing legacy data, you want to use

all current data– Current data in relational form

• Generate unified XML views from distributed data sources

– Output is XML (archetype data instances)– If both input and output are XML

• Use Xquery (and XPath) 11

IBIME

• Leaded by PhD. Prof. Montserrat Robles

• Ten years of experience in the field of Biomedical Informatics

• ≈ 20 members

• Funded by Regional, National and European R&D projects and technology transfer

http://www.ibime.upv.es12

http://www.ibime.upv.es/

IBIME Group (UPV)

• LinkEHR Archetype Editor– Archetype edition– Reference model independence– Open Source

• LinkEHR Integration Archetype Editor– Legacy datasource mapping– XQuery scripts automatic generation

• EHRFlex (EHR Viewer)

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LinkEHR Archetype Editor

• Any model can be imported• Tested models: openEHR, ISO 13606, HL7

CDA, ASTM CCR and CDISC ODM. Therefore, it is possible to define archetypes based on these models.

• Archetype creation driven by the reference model

• Includes a syntactic and semantic validator.• Connection with CKM• In the works: sample instance generator, CDA

and openEHR specific editors… 14

LinkEHR Integration Archetype Editor

• To generate XML documents conforming to the reference model is necessary to define how archetypes sources of data are related: mappings or correspondences.

• The user must specify how to calculate from one or several values of the data source the value of an attribute of the archetype.

• The data sources can be relational, XML or archetypes (working on it :)

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EHR Viewer (EHRflex)

• EHRflex is an archetype-based EMR system.– Independent of the reference model.– Uses web technologies (Google Web Toolkit).– Automatic generation of archetype-based

interfaces for view and edit clinical data.– Open source project.


Open source project: http://ehrflex.sourceforge.net/

http://ehrflex.sourceforge.net/

Real Experiences

• Hospital General Universitario de Valencia

– Pangea-LE implementation for over 5 years

• Integration of distributed data sources (more than

25 databases).

• Virtual Federated EHR viewer.

– Full migration to EN13606 EHR Extracts in

development.

Sistema LinkEHR 21Other uses EHRcommunication

EHRviewer

Legacydata sources

Map

Standardization

Archetype

ProprietaryXML

Standardized

XML

LinkEHR-Ed

Real Experiences

EHR petition

Integration

Pangea-LEXML

Real Experiences

• Hospital de Fuenlabrada (Madrid)

– Use of openEHR and EN13606 archetypes for

pressure ulcer nursing control.

• The archetype creation methodology was

evaluated.

• Both reference models were compared and tested.

Real Experiences

• Hospital de Fuenlabrada (Madrid)

– Use of EN13606 for medication conciliation

between primary and specialised care.

• Agreed definition of a primary-care summary

archetype.

• Communication of normalised legacy data to

support patient transitions between primary care

and the hospital.

Real Experiences

• The semantic interoperability of the Patient Summary is being tested between the Hospital General Universitario in Valencia (HGUV) and the Hospital de Fuenlabrada in Madrid.– Based both on the Spanish and epSOS definition of

the contents of the Patient Summary.

– The information is communicated using the CEN EN13606 norm.

Real Experiences

Hospital de Fuenlabrada

Madrid

Hospital General Universitario

Valencia

Communication of standardizedEN13606 informationEHR

Server

EHRServer

Methodology

1. Agree a concept definition and define the archetype

• We have used two different definitions

– Spanish National Patient Summary– epSOS Patient Summary final dataset

• They can be easily edited or modified with open source archetype editors like LinkEHR-Ed

http://www.linkehr.com

Methodology

2. Map the archetype to original/legacy data

• With these mappings we can automatically generate transformation programs for the EHR system.

XML

ExistingEHR systems

Methodology

3. Deploy the transformation program in the EHR server

• Set up a standard EN13606 extract server in both hospitals to generate and communicate the standardized information

– Transformation is applied on demand– Web-service based– Includes a standard EN13606 web viewer

EHRServer

XMLEN13606Standard

Information

MappedArchetype

VHHIS

FHHIS

EHRServer

MappedArchetype

EHR viewer

Real Experiences

• Virgen del Rocío Hospital– HL7 CDA can be archetyped. Archetypes can

be used as templates for HL7.– HL7 CDA has some characteristics that do not

follow Object Oriented Modelling, but are XML Schema specifications. Archetypes are only applicable to OO models, so some tweaks had to be implemented.

– LinkEHR can use CDA archetypes to generate valid CDA instances of existing data.

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MML-openEHR-HL7 CDA Project

• Research stay at Yoshihara Laboratory in Kyoto University

• My thesis work: How we can integrate between different standards?

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• Different parts of the world with different standards

• Same illness!

Work

• Can MML concepts be represented as archetypes?

• Can we generate correct MML XML from the MML archetypes?

• Can we map MML to other standards?

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MML concepts as archetypes

• MML has two kinds of concepts: Common concepts (support) and content modules (clinical concepts).

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Common formats Content module

Address Patient Information

Personalized Info Basic clinical

ID Surgery Record

Name Diagnosis Record

External reference Lifestyle Information

Creator Clinical Summary

… …

MML concepts as archetypes

• An archetype was created for each concept on common and content modules– 9 archetypes for common concepts– 12+1 archetypes for content modules

• The extra archetype is a reused concept

• Archetypes do not follow openEHR model

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Example

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Work

• Can MML concepts be represented with archetypes?



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Correct MML from archetypes

• For demostration, some MML archetypes were mapped with constant values and with a sample data source

• The example data instances were modified so they have japanese writing (kanji, hiragana)

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Result

Original XML<patientSummary>

<extractTime>2010-12-21T12:14:05</extractTime>

<id>ID01</id>

<demographics>

<patientName> 被記 </patientName>

<patientSurname> 載者 </patientSurname>

<dateOfBirth>1974-06-12</dateOfBirth>

<gender>M</gender>

</demographics>

</patientSummary>

Result XML<?xml version="1.0" encoding="UTF-8"?><mmlNm:Name mmlNm:repCode="A“ mmlNm:tableId="MML0025"> <mmlNm:family> 載者 </mmlNm:family> <mmlNm:given> 被記 </mmlNm:given> <mmlNm:fullname> 被記 , 載者 </mmlNm:fullname> </mmlNm:Name>

XQuery

Work

• Can MML concepts be represented with archetypes?



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Mapping to other standards

• Only MML clinical modules need to be mapped, support module classes will be inserted on the archetypes before mapping

• A project was proposed: mapping between openEHR-MML-HL7 CDA

• Transform data from MML and HL7 CDA into openEHR XML data and store it with opereffa

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Proposed system

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Opereffa

openEHR HL7 CDAMML

openEHR

TransformTransform Transform Transform

Where to start?

• We have the MML archetypes, we can choose openEHR archetypes to create the transformation from openEHR MML

• A set of openEHR archetypes was selected from CKM (public online archetype repository)

• Already existing Japan related openEHR archetypes

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Mapping

• Few MML concepts have similar scope that openEHR archetypes…– MML Diagnosis record ≈ openEHR-EHR-

Evaluation.problem-diagnosis– MML Progress course ≈ openEHR-EHR-

SECTION.soap.v1

• But mostly don’t!– Missing archetypes– Multiple archetypes to represent only one concept– Different granularity or internal structure– Different codes!

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Missing archetypes

• Some concepts on MML are not represented yet with openEHR archetypes or information is Japan specific– MML Health Insurance module?– Japanese names?– Subjective archetypes?

• Create new openEHR archetypes when needed

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Multiple archetypes to represent one concept

• For the patient identification, 10 archetypes where chosen.• 8 from the openEHR repository:

– openEHR-DEMOGRAPHIC-PERSON.person.v1– openEHR-DEMOGRAPHIC-PARTY_IDENTITY.person_name.v1– openEHR-DEMOGRAPHIC-ADDRESS.address.v1– openEHR-DEMOGRAPHIC-CLUSTER.person_additional_data_iso.v1– openEHR-DEMOGRAPHIC-CLUSTER.person_identifier_iso.v1– openEHR-DEMOGRAPHIC-CLUSTER.person_death_data_iso.v1– openEHR-DEMOGRAPHIC-CLUSTER.person_birth_data_iso.v1– openEHR-DEMOGRAPHIC-CLUSTER.biometric_identifier_iso.v1

• 2 provided by Kobayashi Shinji:– openEHR-EHR-CLUSTER.person_name-japan.v1– openEHR-EHR-CLUSTER.address-japan.v1

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Different granularity

MML concepts openEHR archetypes

Text or XHTML complex structures on archetypes

Detailed structures Simple_text

Codes with qualifiers (laterality…) Coded_text with only one code!

Mandatory attributes Optional attributes

Boolean (finished?) Care Stage

… …

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Join or split fields on the mapping process…

…but also, suggest improvements to current openEHR archetypes!

Different codes

• Both MML and openEHR archetypes rely on internal terminologies– Valid status– Valid texts or codes

• Make table mappings between them– E.g. sex

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openEHR MML

Male male

Female female

Intersex or indeterminate other

Not declared/inadequately described unknown

openEHR

at0010

at0011

at0012

at0013

Work to be done

• Create the mappings between the openEHR archetypes and the remaining MML archetypes

• Finish and check the validity of the openEHR to MML transformation– Generate valid instances from openEHR archetypes

for testing

• MML to openEHR archetypes.– Usually, several openEHR archetypes were mapped

to only one MML concept…– …so one MML concept can be mapped to different

openEHR archetypes50

Going back to the point

• How to use openEHR nowadays?– Start a new platform

• Open source solutions• Commercial products

– Integrate?• Templates XML schema export is experimental and

does not work very well• However, integrating archetypes is ok

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Recommendations

• If no templates have been developed, wait to specifications to go out

• If there are some templates developed with ocean template editor:– Wait until openEHR official template

specifications go out. Some kind of translation mechanism should be provided by ocean

– Translate current templates to archetypes– Look to Portugal template based legacy data

integration project 52

Implementing dual model systems

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