HL7 UK Results4Care about DCM information modelling, terminology binding, architecture, tooling, MDA

1. Implementing Detailed Clinical Models
HL7 UK Technical Committee Working Meeting
London, UK, 8-dec-2010
Michael van der Zel

2. Michael van der Zel
● Personality (MBTI) INFJ – Idealist, Perfectionist,
Chaotic
● “INFJs prefer the future and the pathway along which
they aspire for profundity.”
● University Medical Center Groningen, Netherlands
● HIT Architect, Information Systems (EHR-S)
● Results 4 Care, Netherlands
● Detailed Clinical Models (ISO), HL7 v3
● HL7 WG's: RIMBAA, EHR, ArB, Patient Care

3. Today in history
1931 Coaxial cable pattented
1965 First Ph.D. awarded by Computer Science Dept,
Univ. of Penna

4. Subject
● “Michael will present were DCM fits in other
architecture frameworks. After that he will present
about the specifics of the information model of a
DCM and a toolset for creating, validating, exporting
and transforming the DCM.”

5. Place of DCM in
What is
What is DCM? Architecture
Architecture?
Models
Place of DCM in
EHR-S FM
Gartner on
MDA
Some aspects 1. Guidelines
of Information 2. Info vs Terminology
Modelling 3. Granularity
MDA views
1. DCM
PtaR Case 2. Transformations
3. Use in Widget
DCM & MDA
Views 1. DCM Content Creator
DCM Tooling 2. DCM Model Creator
1. ISO DCM and others 3. Validation
2. NL DCM UML

6. What is DCM?

7. ???
“Detailed Clinical Models are not the same as
Detailed Clinical Models.”
“Detailed Clinical Models can be documented
using the ISO Detailed Clinical Model
formalism.”

8. Use of DCM
C M
D
Building Block
EHR / CR System
RIMBAA

9. What is Architecture?

10. The Architect
The Project leader

11. Architecture

12. IT Architecture
● Architecture is about setting the boundaries,
creating overview, understanding and coherence of
systems
● Different sets of views exist
● Each view has different focus
● The most common views are business, information,
application, technology
● Most also add implicit or explicit a level of detail for
each view

13. Place of DCM in Architecture

14. DCM in Architectural Viewpoints
● B. Blobel Generic
Component Model
● HL7 SAIF
● OMG MDA
● Common RM-ODP
● Many others e.g.
TOGAF … not now

15. GCM & RM-ODP

16. RM-ODP & HL7 SAIF

17. Place of DCM in EHR-S FM

18. EHR-S FM
Function
«rootconcept» DC.1.4.1
PropensityToAdv erseReaction
CD
«data,enum eration»
Certainty
1..*
EHR-FM CD
«data,enum era ti...
Reaction
trig gers
(Functions) Causativ eAgent
Criteria #1
CD
«data,enum er...
FM Info Req's CD
Sev erity
« data ,enu m eration»
ReactionType
Computational Criteria #4
Independent Model Criteria #3
HL7 Archetype ... DCM?

19. Model Driven Architecture

20. MDA
,
L, open
r-neu tral, UM odels,
vendo ndent m
-indepe siness
platform arate bu
sep
hnology
from tec

21. Gartner Hype Cycle

22. Were are we today?
De Turk. Bron: http://en.wikipedia.org/wiki/The_Turk copyrights expired

23. MDA Viewpoints
C M
Conceptual
D
C M
Logical
+ reference model D
Physical
concrete or plastic

24. Focus of different DCM Approaches
● logical & physical views
● Clinical Templates Scotland
● Korea CCM – Clinical Content Models
● Archetypes
● HL7v3 Domain Models
● Intermountain Health Clinical Elements
● conceptual & logical views
● Care Information Models (Dutch ZIM's)
● conceptual view
● ISO DCM 13792

25. DCM in the Netherlands
National IT Institute
for Healthcare in the
Netherlands

26. Some Information Model Characteristics:
1. Requirements for Good Models
2. Information vs Terminology
3. Granularity

27. Requirements for Good Models
1. Accurate – corresponds to the real world
2. Unambiguous – only one meaning
3. Understandable – People recognize the real world referent(s)
4. Reproducible – Different modellers would model in the same way
5. Parsimonious and harmonious use of terminology – Semantics of the
model and terminology match
6. Flexible – Evolve gracefully over time
7. Consistent across domains – Specimen Collection and I&O Charting
8. Practical – implementable in real systems
9. Minimally complex – cover only what is needed
10.Common queries are easy
11.Fits with available technology (OO languages)
Source: 2010 Stan Huff, Intermountain Health

28. Information vs Terminology
● Information Model vs Terminology Model
● Where to cut?
Source: David Markwell Masterclass CiC 2010-mrt-25

29. Source: David Markwell Masterclass CiC 2010-mrt-25

30. Where to Cut
● You should split all parts that are important in the
interpretation of the DCM
body part = “Left Ear” body part = “Ear”
1 Data
laterality = “Right”?
Element 2 Data
Elements

31. 3. Granularity

32. Granularity
Medical Condition
(e.g. Diabetes Record)
Questionnaire
Apgar Score
Full BP
Propensity to
Adverse Reaction
Systolic Bp
“I can not tell you how big a clinical model
must be, only guidelines.”
Number of Data Elements →
“There are Clinical Models from small to
big, just because they are.”

33. The Granularity Issue
● Information- vs Terminology Model
● Level of Detail
● direct care
● use for measures (KPI)
● highly detailed for research
● Level of Detail <> Number of Data Elements
● Temporal aspect
● e.g. Apgar Score is measured a number of times, the IM
has a data element for the number

34. Example Counts
➔ 7 forms personal
➔ CCR / CCD 9 entries summary
➔ 15 DCMs summary
➔ String-of-Pearls 75 DCMs research
➔ 89 types / things personal
➔ LRA (R3) 37 entry models summary
241 elements
➔ HCLS 322 DCMs research

35. Example Forms

36. Granularity Summary
● Information- vs Terminology Model
● Level of Detail
● Fit-for-Purpose … and stop there!

37. Propensity to Adverse Reaction
(PtAR) Example Case

38. Propensity to Adverse Reaction
When I talk about PtAR #2 Event / Reaction
I talk about #1
#1 Statement
#3 Test

39. Transforming

40. Transformation Tool Options
● Eclipse M2M as used by the HL7 SMD
● EA Model 2 Model Transformations
● Robert Worden Mapping Tool
● Advanced MDA Tooling
● For now:
● XSLT
● Plain Old Programming
● EA RTF Export

41. Transformation Examples
● Document
● Information Model Narrative
● HL7 v3 CSP
● HL7 v3 CSP XML

42. 1st Informative HL7 v3 Ballot sept 2010
(example Body Height)

43. Information Model Narrative
PropensityToAdverseReaction has CausativeAgent
PropensityToAdverseReaction has Reaction
PropensityToAdverseReaction has Certainty «roo tcon cept»
PropensityToAdv erseReaction
CausativeAgent triggers Reaction CD
«da ta,en um erati on »
Reaction has Severity
Certainty
1..*
CD
Reaction
« data,enum era ti ...
tri gg ers
Reaction has ReactionType
Causativ eAgent
Severity is a coded description DCM IM (Conceptual) CD
«da ta,en um er...
Sev erity
CD
Certainty is a coded description «d ata,e num e ra tio n»
ReactionType
CausativeAgent is a coded description
ReactionType is a coded description

44. Mapping to HL7 v3 «rootconcept»
PropensityToAdv erseReaction
● Bind DCM to CD
«data,enu m e rati on»
Certainty
HL7 v3 Reference Model
1..*
CD
Reaction
«d ata ,en um erati ...
tri gge rs
Causativ eAgent
Care Statement DCM IM (Conceptual) CD
«data,enu m e r...
Severity
● Add Common Elements «data,enu m e rati on»
ReactionType
CD
«HL 7Role»
Superv isor :AssignedEntity
CMET «Pa rticipation»
id = zo rgverle nerid v erifier :Verifier « Act»
PropensityToAdv erseReaction :Organizer
effectiveT im e = geld ighe idsp eriode overg evoelig heid
cod e = S CT :42 0134 006 P rop ensity to a dverse reacti ons (clinical findin g)
« HL 7Ro le»
«P articipatio n» statusCode = < StatusCo de
Auteur :AssignedEntity
dataEnterer :DataEnterer ava ilabili tyT im e = -
CMET
id = -
id = zo rgverle nerid tim e = registratie datu m te m pla teId = -
« HL7 Role» «P articip ation »
Patiënt :AssignedEntity recordTarget :RecordTarget
CMET
id = patientnum m er
Care Statement (Logical) «Act»
Reaction :Organizer
«Act»
Certainty :Observ ation
cod e = SCT :2 4610 3008 ce rtain ty
val ue < Cau sali ty
«Act»
Causativ eAgent :Observ ation
code = SCT :246 0750 03 causative agen t
value < CausativeAgent
«A ct» «Act»
ReactionType :Observ ation Sev erity :Observ ation
code = SCT :2638 51003 rea ction cod e = S CT :2 46112 005 severi ty
value < Reaction T ype val ue < S everity

45. <REPC_MT000100UV01.Organizer xmlns="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 multicacheschemas/REPC_RM000100UV.xsd"
xsi:type="REPC_MT000100UV01.Organizer"
classCode="CATEGORY" moodCode="EVN">
<templateId root="2.16.840.1.113883.2.4.3.8.1000.9" extension="TODO" />
<id root="2.16.840.1.113883.2.4.3.8.1000.10"
extension="ac13267b-a0a7-4741-9363-2230c3f1da03" />
<code displayName="Propensity to adverse reactions (clinical finding)"
code="420134006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" />
<statusCode code="active" />
<effectiveTime><low value="20090309" /></effectiveTime>
<recordTarget typeCode="RCT">
<patient classCode="PAT">
<id root="2.16.840.1.113883.2.4.3.8.12" extension="6022832"/>
<statusCode code="active"/>
<patientPerson classCode="PSN" determinerCode="INSTANCE"/>
</patient>
</recordTarget>
<dataEnterer typeCode="ENT">
<assignedEntity classCode="ASSIGNED"> Care Record XML (Physical)
<id root="2.16.840.1.113883.2.4.3.8.1000.2" extension="10006773"/>
</assignedEntity>
</dataEnterer>
<component typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code displayName="causative agent" code="246075003"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<value displayName="Non-steroidal anti-inflammatory agent (product)"
code="16403005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" xsi:type="CD" />
</observation>
</component>
<component typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code displayName="certainty" code="246103008"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
<value displayName="possible diagnosis" code="60022001"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
xsi:type="CD" />
</observation>
</component>

46. PtAR Widget

47. DCM Tooling

48. DCM Tool Chain
● Tools for DCM can be considered a set of software
programs that facilitate one or more steps in the
DCM development or use.
● Tools should work together, or allow moving
smoothly from one step to the other, ending with
testing of working systems

49. DCM Tool Chain
Conceptual Logical Physical
Mindmap
+ XSLT
DCM Content
DCM Model SMD !?
Creator
Creator
healthcare professionals healthcare systems developers
software developers

50. DCM Model Creator

51. Why EA & UML
● Why EA?
● Not expensive, but not free
● Use existing tooling
● Widely used (e.g. HL7, CDISC)
● Feature rich, extendible
● Why UML?
● Use existing modelling language
● Don't reinvent the wheel
● Knowledge wide spread, easy to get

52. Lessons Learned
● Conceptual, Logical, Physical separation is very
useful even if not doing full MDA
● Traceability very important and useful
● Use a Generic Pattern and validation to get
consistent Models
● XMI is not so standard, XSLT tedious
● Start by using standards as checklists and answers
to questions, and then standards will be embrased,
slowely

53. Lessons Learned
● There is no one answer to the question of
granularity. Maybe, 42?
● … Oh yes, and of course, use DCM!

54. Working on ...
● Patient History, Advance Directives, Trial, other
Patient Summary
● Patient – Provider Relationships (= Common
Elements, not DCM)
● EHR-S FM Tooling (in EA)
● Integration with CliniClue SNOMED CT (in EA)
● Connect to HL7 Static Model Designer?

55. Hospital IT Europe Magazine

56. Thank you for your attention.
m.van.der.zel AT ict.umcg.nl
© 2010-sep-17 Michael van der Zel @ Bioparco di Roma

57. Results 4 Care B.V. T: +31 6 54 614 458
De Stinse 15 F: +31 33 25 70 169
3823 VM Amersfoort E: info@results4care.nl
The Netherlands
www.results4care.nl