Logical Model CollaborationScope, proposal, and next steps

The NeedA logical model

With a strong community behind itThat is clinically viableThat is expressiveThat is structured and computableThat supports reasoningThat informs FHIR profilesThat supports “closing the quality feedback cycle”That is implementable

The Problem (I) Often conflated with a physical model such as FHIR

Often implied and not explicit vMR + QDM QUICK QI Core QUICK’ DAF SDC

Too many variants out there RIM QDM vMR QUICK/QIDAM/QUICK’ CEM CIMI FHIM SNOMED/LOINC/RxNORM …

The Problem (II)Unclear boundary between terminology and model

Unclear boundary between expression language and model

Often inconsistent Patient has diabetes (Condition)

Presence implied Patient does not have diabetes (Observation)

Absence explicit

Pre-coordinated/conflated semantics

Incomplete or just ‘too hard’

Scope hard to define. Need some boundaries.

Exploration Areas for LM Collaboration

What is a Logical Model?

How does it differ from a physical model like FHIR?

How does it differ from a reference model like CIMI Core?

How does it align with clinical terminologies/ontologies such as SNOMED CT?

How far does it align with clinical terminologies/ontologies such as SNOMED CT? Bindings only? At model level too?

How can it be implemented?

How can it be leveraged for Quality Improvement

Can we better align (or eliminate) variants and how?

Time FrameFirst set of meeting to last 8 weeks

Begin exploration of model/terminology alignment Focus: Alignment of CIMI ‘Observation Result’ with SNOMED

Observable Model Use Case: Systolic BP Goal: Implement simple prototype illustrating alignment of

approaches Last meeting of series on 10/13

Group to decide how to proceed after 10/13

Question: Should group disband and regroup under the CIMI Modeling Task Force? Should group remain as an exploratory task force looking at longer term questions?

Discussion to DateCIMI/SNOMED Observable Reconciliation

Slides from Keith Campbell

Assumptions: TerminologyTaken from: http://opencimi.org/policies_cimi

SNOMED CT is the primary reference terminology

LOINC is also approved as a reference terminology

SNOMED relationship concepts will be used to define the parent-child relationships in the models

Assumption: ModelsTaken from: http://opencimi.org/policies_cimi

CIMI models shall, by design, include SNOMED CT content

Goal: Enable use of the SNOMED CT concept model to support translation of data from pre coordinated to post coordinated representations

Proposal: NamingOverlapping naming has led to confusion about the collaborative and/or competitive nature of CIMI and SNOMED

The SNOMED/LOINC Observable Model has a significant development history, and has specific, documented meaning

An alternative yet intuitive name for a complementary CIMI effort can reduce confusion and perceived competition

Possibilities CIMI Observation Result Model CIMI Assertion Model

Proposal: Separation of Concerns

Clearly and reproducibly delineate a separation of the semantics of the terminology from the semantics of the higher-order models

Use a simple nested structure to differentiate observable model attributes surfaced by CIMI

All surfaced attributes are defined with respect to the SNOMED/LOINC observable model, although CIMI may define “friendly” preferred names for use within the CIMI model

Simpler to understand and implement while “using the SNOMED CT concept model to support translation of data from pre coordinated to post coordinated representations”

Example: Simple nested Structure

Subject of informationCodeReasonMethodResult

observation

Subject of informationObservable*ReasonMethod*Result

assertion

Subject of informationReasonResult

assertion

Code/ExpressionMethodOther surfaced attributes

observable

Separate the terminology model attributes from higher-level model attributes

Existing model

Renamed model

Separated model

1 1

Alternative Names

Subject of informationReasonResult

observation result

Code/ExpressionMethodOther surfaced attributes

discernable

Intuitive names that do not overlap can reduce confusion and perceived competition

assertion/observable

observation result/observable

observation result/discernable 1 1

Subject of informationReasonResult

assertionCode/ExpressionMethodOther surfaced attributes

observable

1 1

Subject of informationReasonResult

observation result

Code/ExpressionMethodOther surfaced attributes

observable

1 1

Subject of informationReasonResult

assertionCode/ExpressionMethodOther surfaced attributes

discernableassertion/discernable1 1

Defining CIMI Surfaced AttributesProvide algorithmic support for translation between pre- and post-coordinated forms.

SNOMED Templates are one possibility

XSL, Xquery, and other options are possible

Moving forwardHow do we turn these ideas into reality?

Naming

Separation of concerns

Define surfaced attributes and pre/post coordination transformation specification

Add any necessary concepts to a CIMI extensionCIMI has obtained a SNOMED CT extension

identifierCIMI is committed to create a Terminology

Authority to review and submit concepts to IHTSDO as appropriate

Validating the ProposalSystolic Blood Pressure Use Case

Selected Initial Use Case

Representing a “systolic blood pressure taken from the right brachial artery using a blood pressure cuff while the patient is supine and at rest”

271649006|Systolic blood pressure (observable entity)|: 704318007|Property type (attribute)| = |Pressure (property) (qualifier value)|, 704319004|Inheres in (attribute)| = 67170007|Lumen of artery (body structure)|, 704327008|Direct site (attribute)| = (17137000|Structure of brachial artery (body structure): 272741003|Laterality (attribute)| = 24028007|Right (qualifier value)|), 246501002|Technique (attribute)| = 37931006|Auscultation (procedure)|, 424226004|Using device (attribute)| = 70665002|Blood pressure cuff, device (physical object)|, 704326004|Precondition (attribute)| = (40199007|Supine body position (finding)|, 704326004|Precondition (attribute)| = (128975004|Resting state (finding)|)

SNOMED Post Coordinated Expression

Prototype Next Steps

CIMI Team working on development of a CIMI ADL representation of CEM Systolic Blood Pressure model

CIMI systolic BP model to be represented using AML

VA Team to build SNOMED CT ‘template’

Group to determine how to map the two models in ADL/AML

VA Team to explore and develop transformation between iso-semantic representations

Group to review approach

Next Steps for Collaborative Work

Towards Better Convergence

Convergence Centralize logical model efforts and profile development under CIMI

umbrella? Will CIMI be an HL7 Working Group? Need central governance to prevent fragmentation

Derive FHIR profiles from CIMI logical model DCM profiles Foundational profile

Bottom up/top down approach Multi-layered logical model DCM (Serum Creatinine) Mid-level logical model(s) (QuantitativeLabResult Observation Result)

Moving beyond assertion models E.g., procedures and procedure requests E.g., Composite orderables …

Cross CollaborationHL7/FHIM participation in CIMI logical model

effort

CIMI/HL7 participation in terminology efforts (SNOMED, LOINC, RxNORM). Eg.,Extension of SNOMED CTDevelopment of observable modelDevelopment of procedure modelDevelopment of orderable catalog

Validation & AdoptionEncouraging use of CIMI profiles (not just plain FHIR

resources) in HSPC and SMART-on-FHIR projects

Validate logical model use cases for clinical quality improvement in HSPC and SMART-on-FHIR projects

Who else needs to be targeted for implementation and validation Argonaut Epic, Allscripts, Cerner, VA Others

Does HSPC reach a broad enough community?