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Chapter 15

GROUPED KNOWLEDGE ELEMENTS. Chapter 15. 15.1 INTRODUCTION. Data the most fundamental part of CDS well-structured and unambiguous Data type units for quantifiable data types categorical values for dictionary/directory-based data types User-computer communication

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Chapter 15

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  1. GROUPED KNOWLEDGE ELEMENTS Chapter 15

  2. 15.1 INTRODUCTION • Data • the most fundamental part of CDS • well-structured and unambiguous • Data type • units for quantifiable data types • categorical values for dictionary/directory-based data types • User-computer communication • by means of documentation systems

  3. The purpose of documents • to obtain data from or to present data to a user • The specification of the document's structure is a form of knowledge • Two important aspects of documentation systems in CDS • the organization or grouping of data items in documents • the management of a collection of documentation specifications (KM)

  4. DocumentationKnowledge Element (DKE) • unit of a document not divided further • Knowledge Element Group (KEG) • grouping of DKEs

  5. 15.2 CLINICAL DOCUMENTATION • Data Capture • Although there are clear benefits of capturing data at the point of care, there have always been and continue to be significant challenges • Forms • Forms consist of individual elements • A sequence between one form screen and a subsequent one is governed by decision logic based on the data that have been entered

  6. The potential for acting as a CDS mechanism is greatly increased • Electronic forms are capable of • analyzing user input • interacting with other electronic sources of data • reacting in real time by adapting themselves accordingly • forms promote the capture of data in structured fashion • a conditional organization of form sequences

  7. A template • defined as "a pattern used to create documents.“ • In the paper world, if a form is created by stamping a rubber stamp onto a piece of paper, that rubber stamp is the template • In the digital world, a form rendered on a screen of a computer is an instance of a template used to create it • Any dynamic behavior in a system based on such templates must come from the individual elements themselves • static in nature, in that they represent a fixed collection of individual elements

  8. Elements • Each documentation element is a representation of a concept • a system needs to capture the value and value units • Taken together, the underlying concept plus all the associated piece of data, each conforming to its data type, form a documentation element • An information model must govern the internal structure of documentation elements • the mechanism for nesting elements within elements • the relationships between elements • data type definitions must also be standardized

  9. 15.3 CURRENT APPROACHES TO CLINICAL DOCUMENTATION • HL7 Templates • OpenEHR Archetypes and Templates

  10. FIGURE 15-1 HL7 Templates Cascade RIM-Reference Information Model; all other HL7 models are derived from the RIM. Typically in illustrations of this type, the RIM appears on the top of the diagram. Placing it at the bottom affords a view that highlights the similarities between HL7 modeling efforts and those of the European community. Note the downward arrows from Model Fragments to Other Models and eventually to the RIM-if HL7 were to institute a process whereby, if preexisting model fragments do not exist, required changes can be incorporated back into the RIM, it would ease the process of creating individual building blocks for HL7 templates

  11. FIGURE 15-2 A simplified archetype for blood pressure

  12. FIGURE 15-3 Concepts, archetypes, templates, and structured documents

  13. FIGURE 15-4 Archetypes and Templates Stack Controlled medical terminologies (MTs), along with appropriate information models, ontologies, and data type definitions (not shown), provide the foundation necessary for achieving interoperability, reusability, and ease of maintenance of knowledge encoded in archetypes. Archetypes are essentially the same as documentation elements-they are the building blocks for construction of templates. Templates are instantiated to create various types of documents, such as notes, forms, or flow sheets.

  14. 15.4 GROUPED KNOWLEDGE ELEMENTS (KEGs) • KEGs are groups of elements that share common features • personal data : person's name, age, and gender • a collection, for a particular purpose, of elements that share some kind of common association either relevant to • A specific clinical setting • A type of encounter • An intention

  15. KEGs • provide the basis for reusability • critical for the construction of consistent content that can be retrieved, tracked, and assembled as part of a unified content strategy • templates and documents built upon KEGs are transportable across systems and applications • The separation of content from format is at the core of the KEGs approach: same content, different uses

  16. FIGURE 15-8 Schema for medication order

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