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Transcript of VMR: the HL7 virtual Medical Record Standard May 16, 2013 Health eDecisions All Hands Call Claude...
![Page 1: VMR: the HL7 virtual Medical Record Standard May 16, 2013 Health eDecisions All Hands Call Claude Nanjo David Shields.](https://reader035.fdocuments.in/reader035/viewer/2022062303/5514d61a55034693478b522d/html5/thumbnails/1.jpg)
vMR: the HL7 virtual Medical Record Standard
May 16, 2013Health eDecisions All Hands Call
Claude NanjoDavid Shields
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Presentation Goal
• Provide a broad general understanding of the vMR
• Describe the motivation for such a model
• Describe the high-level organizational structure of the vMR
• Describe the relationship between the vMR and CCDA documents
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Why do we need a vMR?
Motivation and Important Model Features
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Background
• A “holy grail” of clinical informatics is scalable, interoperable CDS
• Key requirement for interoperable CDS and re-use of CDS knowledge resources = use of a common patient data model– Referred to as a “Virtual Medical Record” or vMR
(Johnson et al., AMIA Annu Symp Proc, 2001)
• Lack of a common vMR has been a major barrier to sharing knowledge and scaling CDS
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Example Challenge without VMR
Observation Blood PressureCode = BP Systolic = 120 mmHg
Value = 120/80 mmHg Diastolic = 80 mmHg
Observation Vital Sign Code = BP Type = BP Observation Value = 120/80 Code = SBP Units = mmHg Value = 120 mmHg Observation Code = DBP Value = 80 mmHg
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Blood Pressure in the vMR<observationResult>
<templateId root=""/><id root=""/><observationFocus code="" codeSystem="" displayName="Blood Pressure"/><observationEventTime low="" high=""/><relatedClinicalStatement>
<targetRelationshipToSource code="" codeSystem="" displayName="PartOf"/><observationResult>
<id root="" extension=""/><observationFocus code="" codeSystem="" displayName="Systolic BP"/><observationValue>
<physicalQuantity value="120" unit="mmHg"/></observationValue>
</observationResult></relatedClinicalStatement><relatedClinicalStatement>
<targetRelationshipToSource code="" codeSystem="" displayName="PartOf"/><observationResult>
<id root="" extension=""/><observationFocus code="" codeSystem="" displayName="Diastolic BP"/><observationValue>
<physicalQuantity value="80" unit="mmHg"/></observationValue>
</observationResult></relatedClinicalStatement>
</observationResult>
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Purpose and Design Principles
• Designed specifically and solely for CDS– Not intended for persistence or provenance
as medical document
• Lightweight and engineered for computability (over human readability)
• Compromise between clinical detail and broad generalization– 80/20 rule– Favors model stability
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Features of the vMR – Part I
• Core datatypes based on simplified ISO 21090, also known as HL7 datatypes R2
• Loosely based on CCD and the HL7 Clinical Statement– Gave base classes business-friendly names– Promoted negation and mood to explicit
classes to reduce possible errors– Resolved confusion around CDA code,
effective-time, and status– Removed less useful attributes for CDS
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Features of the vMR – Part II
• Extensible– Attribute/Template extension mechanism– Entity and Clinical Statement Relationships– Also considering class extension mechanism
• UML specializations• Schema extensions
• Designed to allow flattening of hierarchical structure for easier computation
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vMR Goal
• Provide common information model upon which interoperable clinical decision support resources (e.g., rules) can be developed
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Project History
• Analysis of data required by 20 CDS systems from 4 countries (Kawamoto et al., AMIA 2010)
• Refinement of vMR via implementation within OpenCDS
• Adopted in September 2011 as Informative Specification
• Enhancements balloted in May 2013 to address Health eDecision pilot feedback and to better support order set authoring based on an review of existing CPOE system implementations
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Structural Organization of the vMR
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Simplified ISO 21090 Data Types
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vMR-Specific Core Types Support Expressivity and Model Stability
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Clinical Statement Central to vMR
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Example Clinical Statement
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Progressive Specialization
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Core Data Structures in vMR
• Entities• People, places, and things
• Clinical Statement• Clinical activities
• Root of vMR is the Patient • (an EvaluatedPerson)
• A Patient may have other associated EvaluatedPersons (e.g., family history)
• An EvaluatedPerson has associated Clinical Statements
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Relationships in the vMR– Related Entity
• Example: MMR Vaccine– Relationship of following is “PartOf” above
» Measles Vaccine» Mumps Vaccine» Rubella Vaccine
– XML Example:<substanceAdministrationEvent> <substance> <substanceCode code="" codeSystem="" displayName="MMR Vaccine"/> <relatedEntity> <targetRole code="" codeSystem="" displayName="PartOf"/> <administrableSubstance> <substanceCode code="" codeSystem="" displayName="Measles Vaccine"/> </administrableSubstance> </relatedEntity> </substance></substanceAdministrationEvent> 19
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Relationships in the vMR (cont.)– Related Clinical Statement
• Example: Blood Pressure Observation– Relationship of following is “PartOf” above
» Systolic Blood Pressure» Diastolic Blood Pressure
– XML Example:<observationResult>
<observationFocus code="" codeSystem="" displayName="Blood Pressure"/>
<relatedClinicalStatement>
<targetRelationshipToSource code="" codeSystem="" displayName="PartOf"/>
<observationResult>
<observationFocus code="" codeSystem="" displayName="Systolic BP"/>
<observationValue>
<physicalQuantity value="120" unit="mmHg"/>
</observationValue>
</observationResult>
</relatedClinicalStatement>
</observationResult>20
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Relationships in the vMR (cont.)
– Entity Relationship To Clinical Statement• Example: Lab Diagnostic Procedure
– Relationship of following is “SubjectOf” above» Sputum Sample» Blood Sample
– XML Example:<procedureEvent>
<procedureCode code="" codeSystem="" displayName="Culture and Sensitivity"/>
<relatedEntity>
<targetRole code="" codeSystem="" displayName=“SubjectOf"/>
<specimen>
<id extension="" root=""/>
<entityType code=“” codeSystem=“” />
<description value="arterial blood" />
</specimen>
</relatedEntity>
</procedureEvent>
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Groups of Clinical Activities
• AdverseEvent
• Encounter
• Goal
• Observation
• Problem
• Procedure
• SubstanceAdministration
• Supply
• Communication (TBD)22
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Handling ‘Mood’• UndeliveredProcedure
– Never performed
• ProcedureProposal– Proposed but not yet ordered
• ProcedureOrder– Ordered
• ScheduledProcedure– Scheduled but not yet delivered
• ProcedureEvent– Delivered and recorded
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Handling NegationInd as Classes
• AdverseEvent/DeniedAdverseEvent
• Problem/DeniedProblem
• ObservationResult/UnconductedObservation
• SupplyEvent/UndeliveredSupply
• Etc…
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Why Not Just Use the CCDA as the vMR?
• CCDA does not include all needed information– E.g., Family history model suitable for CDS
• CCDA is not sufficiently intuitive for direct use by CDS knowledge authors
• CCDA is deeply nested and verbose, which adds performance penalties in volume production
HOWEVER:• CCDA can be mapped into the vMR, which has a simpler
structure that is more conducive to evaluation• The vMR and CCDA are complimentary and intended for
different purposes
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Problem Model – CCD vs. VMR
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From CCDA to vMR
• CCDA can be transformed into a vMR but not vice-versa (vMR is a ‘subset’ of CCDA)
• CDS Services should operate on one model. The vMR was designed for this purpose.
• Transformation path from CCDA to vMR should be documented (or transform should be provided)
• Separate CCDA-to-vMR service with service composition?
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Further Information
vMR:
http://wiki.hl7.org/index.php?title=Virtual_Medical_Record_(vMR)