GP 2 GP Clinical Semantics Leo Fogarty Russell

GP 2 GP Clinical Semantics Leo Fogarty Russell Hotel 12/12/03

Nature of health records • Collection of information about the health of a person • Contains entries made – On one or more occasions – By one or more authors • A person may have many health records – A combination of health records for the same person is a health record – A copy of all or part of a health record is a health record

Purposes of health records • Care of the patient – Informing and reminding care providers – Organising thinking and decision making – Communicating with other care providers • Care of the population – Clinical, social and therapeutic research – Epidemiology and strategic planning • Support for providers – Professional education and training – Financial, contractual and legal • Support for provider organisations – Financial, contractual and legal – Planning services

Content & structure of health records • Notes – Free form narrative (and cryptic abbreviations) – Documents with agreed conventions – Completed forms • Reports – Letters and text reports – Structured numeric reports – Pictures, graphs and tracings • Structures – Problem lists and alerts – Episode summaries – Coding for classification and grouping • Supporting information – Dates, times, people, places and signatures – Demographics

Records, Readers, Authors • • • Introversion, Extroversion and Idleness Obsessives and Creatives Bible Scholars and Cynics Navigators and Head Bangers Informatic Ignorance and Wisdom Solomons and Grundies

Electronic health records • Health records in electronic form – CPR, EHCR, EHR, EMR, PMR, … • Purposes – As for health records – “Electronic” adds or subtracts value • Contents – As for health record – “Electronic” reuse may reduce duplication • Structure – Document, message and data – Narrative, code terminologies and templates

Elements of Clinical Information Which sit in a context which might include: Relating to an ongoing Problem: Chest Pain Which was constructed during an event: Surgery Consultation A Heading: “Past History” or Which all sits in a document: “Referral Letter” Modifying Information: Q= “Possible” The Record of Patient Information as Text: which is human-readable and easily communicable The inclusion of codes: XE 2 u. V Ischaemic Heart Disease Which may be qualified as: X 793 b Mild X 78 th First Episode

A Construction Date: 04/02/2000 Dear Dr: Prunesquallor A DISCHARGE NOTE Surname: BEAUHARNAIS First name: JOSEPHINE Primary Diagnosis: Secondary Diagnoses: Unit No: 123451 Do. B: 01/01/22 NHS: 1234567895 Pelvic malignancy Anaemia unspecified D 21 z. Haematuria K 197. Discharged On: 02/02/2000 Additional Information Instructions OPD Follow Up Signed: Date of Op/Proc Urethral Catheterisation Urethral irrigation of bladder Other blood transfusion NOS Diagnostic Cytoscopy (Rigid) & Bladder Biopsy M 478 a M 471 X 339 M 451 c 07/01/00 08/01/00 09/01/00 10/01/00 For palliative care. Weeks Maggie Bell Print Name: Maggie Bell Designation: Ward: Deene B Admitted On: 07/01/2000 Complications: Operations & Procedures Address: 5 Whitehall KETTERING NORTHANTS NN 00 1 OO Kettering General Hospital Rothwell Road, Kettering Northants NN 16 8 UZ Tel: 01536 492000 Clinical Practitioner Consultant: Zhivago Y

Positional Syntax Approach Required

Positional Syntax Approach

One Representation on Receipt Patient Details Date of Event History JOSEPHINE BEAUHARNAIS Date of Birth Event Type 04/02/2000 Pelvic malignancy 01/01/22 Anaemia unspecified (D 21 z. ) DISCHARGE LETTER Haematuria (K 197. ) Examination Investigations Procedures Urethral Catheterisation (M 478 a) Urethral irrigation of bladder (M 471) Other blood transfusion NOS (X 339) Diagnostic Cytoscopy (Rigid) & Bladder Biopsy (M 451 c) Comment For palliative care. Healthcare Professional ZY

What was Lost? • • • Hospital Address Unit Number The Ward The dates of admission/discharge/operations/procedures Clinical Heading Context – Significant loss of clinical meaning • • • Healthcare Professional Names Healthcare Professional Roles Attestation Identification of Management Plan/Intention In short: - CONTENT and CONTEXT

Semantic Interoperability Needs • Clinical Coding Schemes – Clinical Concepts – Drugs • People, Places and Roles • Aggregations – Templates/Archetypes/Clusters • Dates • Architectural Containment and “Glue”

Architecture ? • Merriam Webster Definition: a unifying or coherent form or structure; a method or style of building

GEHR (North) Simplified EHCR Transactions EHCR Extract List of Transaction Types List of Item Types Content Category Observation Item Collection

ENV 13606 message structure EHCR message 1 EHCR extract types of contains 1. . * 1 original component complex 1. . * folder composition headed section cluster record component types of link item data item

ENV 13606 message data items Plain/HTML text structured coded quantifiable observation medication type of record component physical entity reference external data reference data item event types of person identifier person name language address telecom patient related party related location community defined

GEHR (South)

CDA at RIM level

Information model – EHR Containers

Information model – Clinical statements

GP 2 GP Language • Coding Schemes – Read – EMIS – Multilex – Local • Consultation Categories (Headings)

GP 2 GP Language Architecture Names • • • Level Codes Composition Names Document Names Compound Names Link Names

GP 2 GP Language Qualifiers • • Problem Status Epidocity Medication Mood Secondary Status Terms

GP 2 GP Language Major Modifiers • • • Certainty/Negation Action Status Significance Subject of Information Sensitivity Validity

GP 2 GP Project Outcome • NHSIA Project 1/6/01 -31/5/03 • V 3 Messaging successful • Four (Now five) suppliers implemented in test bed circumstances • One supplier implemented same system transfer “for real” • Further piloting happening • Quo Vadis?