Virtual Medical Record (vMR): A Simplified RIM-Based Data Model for CDS

1. Virtual Medical Record (vMR): A Simplified RIM-Based Data Model for CDS HL7 Work Group Meeting, San Diego, CA September 2011 Kensaku Kawamoto, MD, PhD Director, Knowledge Management and Mobilization Assistant Professor, Department of Biomedical Informatics University of Utah kensaku.kawamoto@utah.edu

2. 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 is a major barrier to sharing knowledge and scaling CDS Known as the “curly braces” problem in Arden Syntax

3. Example Challenge without VMR Observation Blood Pressure Code = 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

4. vMR Goal • Provide common information model upon which interoperable clinical decision support resources (e.g., rules) can be developed • Desired attributes: • VMR instances can be derived from HL7 V3 artifacts, in particular CCD and Pedigree instances • VMR instances can be populated from HL7 V2 messages, in particular for laboratory data • Leverage Detailed Clinical Models • Capable of being easily understood and used by clinicians/analysts without significant V3 training

5. Project History • Analysis of data required by 20 CDS systems from 4 countries • Analysis of HL7 CCD, Pedigree, Clinical Statement, and other relevant models • Use of greenCDA/greenCCD as an example approach to simplification • Trial implementation of vMR via OpenCDS • Under ballot for September 2011 Work Group cycle • Domain Analysis Model • GELLO implementation guide

6. Simplified ISO 21090 Data Types

7. CDS Inputs

8. CDS Outputs

9. vMR Payload

10. Example Clinical Statement

11. vMR Ballot Reconciliation – Overview Domain Analysis Model 47 affirmative, 2 negative GELLO implementation guide 34 affirmative, 0 negative

12. vMR – Future Directions • Additional implementation guides • Existing/underway: GELLO, v2 implementation guides • XML, Drools, other implementation guides (e.g., Arden?) • Template specifications • For standard data models (e.g., CCD, Pedigree, Care Plan) • For common types of CDS (e.g., drug-drug interactions, vaccine forecasting, family history risk analysis) • Transformations to/from standard models • Alignment with relevant ongoing HL7 work (e.g., CSP, RFH, detailed clinical models) • Version 1.1 based on implementation experience (e.g., via OpenCDS)

13. OpenCDS • Standards-based, open-source clinical decision support (CDS) Web service • Uses HL7 Decision Support Service (DSS) interface • Uses standard data payloads (e.g., CCD, VMR) • Uses standard internal data model (VMR)

14. OpenCDS – Architectural Overview Patient data, knowledge modules to use Patient Data Sources Patient Data Sources Conclusions about patient Institution B Queries for required pt data Queries for required pt data Client Decision Support Apps Client Decision Support Apps Knowledge Modules Standard Interface: HL7/OMG Decision Support Service Standard (http://hssp-dss.wikispaces.com) Standard Data Models: HL7 Virtual Medical Record (vMR) Standard [ http://wiki.hl7.org/index.php?title= Virtual_Medical_Record_(vMR) ] Institution A Trigger Decision Support Service

15. CDS Services – Example Patient Data Sources Eval. Result VMR CCD Pt data Decision Support Service EHR System

16. Current OpenCDS Collaborators • University of Utah • HLN Consulting, LLC • Apelon, Inc. • Intermountain Healthcare • Veterans Health Administration • Wolters Kluwer Health • EBSCO • Univ. of NC at Chapel Hill • Main Line Health • Stanford University • KeonaHealth • Mass. General Hospital • Hospital Universitario Virgen del Rocío, Spain • MaRSInnovation, Canada • SmartCare, Africa • Emetra AS, Norway • Visumpoint, LLC • Genesys, LLC • df8health • Religent, Inc. • IsoDynamic, Inc. • Calcudos.com, Inc. • CogniTechCorporation

17. Key Components of OpenCDS • Standard interfaces and data models • Reference implementation of HL7/OMG DSS interface • vMR data model • Data mappers (e.g., for CCD  vMR) • Reference DSS knowledge management framework • JBoss Drools and associated authoring/knowledge management tools • Full-featured terminology support • A “domain specific language” for intuitive knowledge authoring • Knowledge repository and knowledge sharing service • DSS “wrappers” for other CDS engines

18. NQF Measure 31 for Meaningful Use

19. OpenCDS Implementation – Denom.

20. OpenCDS Implement. – Underlying Details

21. OpenCDS Implementation – Decision Table

22. www.opencds.org

23. Backup Slides

24. Key Benefits of Approach Builds on robust open-source community and resources Provides standard architectural framework for integrating various CDS knowledge resources Supports full life cycle of knowledge authoring, testing, maintenance, and execution Provides an open-source framework for collaboration and innovation in CDS Freely available under Apache 2.0 license

25. DSS Invocation - Wrapper NQF knowledge module vMR payload

26. DSS Invocation - Payload Age & gender Past encounters Past mammographies

27. DSS Response - Wrapper NQF evaluation result NQF evaluation result payload using vMR

28. DSS Response - Payload Denominator criteria met Numerator criteria met