HL7 Decision Support Activities

1. HL7 Decision Support Activities Rev 1 Draft Feb 23

2. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

3. HL7 Decision Support Activities Arden Syntax Version 2.5 Allow knowledge sharing within and between institutions Make medical knowledge and logic explicit Standardize the way medical knowledge is integrated into hospital information systems

4. HL7 Decision Support Activities Arden Syntax Version 2.5 • Has been used to encode guidelines (as hierarchy of MLMs) • Consensus: Not ideally suited for guidelines • Entry points and eligibility criteria (not triggers) • Flow of steps (not procedures) • Ongoing work • Arden as a separate standard for simple alerts • Examine other models for guidelines

5. HL7 Decision Support Activities Arden Syntax Version 2.5 Finalized “dot notation” and object references Added operators: Object declaration, object creation, object references, reading into an object Deferred decisions Primary time of objects Passing objects by reference or by value Change the granularity of the PRIORITY slot Allow the WHILE statement with assignment in the ACTION slot

6. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

7. HL7 Decision Support Activities GELLO A Guideline Expression Language • Purposes • Query data (READ) • Logically manipulate data (IF-THEN, etc) • Current work: GELLO (BWH) = Guideline Expression Language

8. HL7 Decision Support Activities GELLO • Original goal (InterMed): Procedural component for high-level guideline format (GLIF) • Subsequent goal: Provide similar functionality for current HL7 KR standard (Arden Syntax) • Emphasis: Shareability of queries and expressions • Mechanism: Reference data in OO fashion

9. HL7 Decision Support Activities GELLO Provides basic data types Allows reference to underlying standard data model (vMR) Based on the Object Constraint Language (UML) Current goal: Ballot as a separate HL7 standard during the coming 12 months

10. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

11. HL7 Decision Support Activities vMR • Problem with RIM: Too abstract • Potential solution: Tailored version of RIM specifically for decision support • Current work: Virtual Medical Record • Establish distinct objects that in RIM might be high-level classes (with mood and other attributes) • Key classes: patient, plan, procedure, medication, appointment, referral, goal and assessment

12. HL7 Decision Support Activities vMR SAGE vMR 13 classes Most classes directly from the RIM Most attributes have direct RIM mappings Classes & attributes refined iteratively with each new guideline

13. HL7 Decision Support Activities vMR SAGE vMR 13 classes Most classes directly from the RIM Most attributes have direct RIM mappings Classes & attributes refined iteratively with each new guideline

14. HL7 Decision Support Activities vMR SAGE vMR

15. HL7 Decision Support Activities vMR SAGE vMR Classes • Observation • Procedure • Problem • Order • Medication Order • Substance Administration • Encounter • Referral • Appointment • Goal • Adverse Reaction • Alert • Agent

16. HL7 Decision Support Activities vMR - Challenges • Need standard vocabularies • Agreement is difficult • Solution: Format for referring to a standard vocabulary in data references • Examples: SNOMED-CT, ICD-9, LOINC, CPT, etc • Implementation: One-time mapping between local and standard vocabularies • Facilitation: Free licensing of SNOMED in USA as part of UMLS

17. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

18. Rationale for Guidelines: Knowledge dissemination HL7: Role of the SDO in knowledge representation Shareable components of computable guidelines Guideline models Convergence & the future HL7 Decision Support Activities Guidelines

19. Use in context of systems for providing patient care CPOE EMR Use at the time decisions are being made Ample success for limited alerts/reminders Medication prescribing practices Preventive care: screening tests, immunizations Less demonstrated success for complex guidelines HL7 Decision Support Activities Guidelines - Objectives

20. Avoid duplication of effort when using common guidelines in many institutions Rapid dissemination of modifications Encourage development of tools for retrieving and using guideline information Encourage future guideline authors to be more rigorous (decreased ambiguity) HL7 Decision Support Activities Guidelines - Benefits

21. Many models: GEODE-CM, GLIF, Arden Syntax, EON, DILEMMA, PROforma, Asbru, GEM, GUIDE, PRODIGY, … Many stakeholders: government, vendors, academics, professional organizations, etc Many types of guidelines Many types of (paper) guideline formats: narrative text, tables, flowcharts, graphs, maps, lists, critical pathways, if-then statements, etc. HL7 Decision Support Activities Guidelines - Challenges

22. Availability of data Identification of data: structured, controlled vocabularies Clinical data repositories: Data model Shareable knowledge representation HL7 Decision Support Activities Guidelines - Challenges

23. Opposing view: A single formalism may not be possible or desirable Complexity of guidelines and their purposes Result: A small number of “niche” formalisms Arden for simple alerts/reminders Others for complex guidelines A small group of formalisms would share common components (data model, vocabulary, expression language) HL7 Decision Support Activities Guidelines – An approach?

24. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

25. Infobutton is a point-of-care application that retrieves context-specific information from content providers using patient data extracted from the electronic medical record Can be implemented as an HTTP request Query parameters embedded in the URL HL7 Decision Support Activities Infobutton Definition

27. Resource selection Answer retrieval What are the clinical manifestations of highserum potassium? i Resource 1 ? Resource 2 Answer Resource 3 Question formulation 65 years old female physician lab results

28. Non-standard APIs

29. Standard APIs HL7

30. Username & password Context Patient: age and gender User: patient, physician, nurse App context: Problems, Medications, Labs, etc. Concept: Concept ^ String ^ Terminology Query modifier HL7 Decision Support Activities Infobutton Proposed Parameters

31. http://www.knowledgesourcewebsite.com/search.cgi?applicationContext=problems&conceptOfInterest=D018410&SearchString=Bacterial Pneumonia&terminology=MeSH&contentTarget=physicianhttp://www.knowledgesourcewebsite.com/search.cgi?applicationContext=problems&conceptOfInterest=D018410&SearchString=Bacterial Pneumonia&terminology=MeSH&contentTarget=physician Runs a search for D018410 (MeSH), on the problems section of the knowledge source, and with focus on content for physicians HL7 Decision Support Activities Infobutton Proposed Example

32. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

33. “Order sets allow a care provider to choose common orders for a particular disease state or circumstance according to best practice or other criteria for assembling the order set without having to generate each order individually. The EHR may recommend order sets in certain conditions or as the result of other clinical information being entered into the EHR. Or the order sets may simply be available for use by the ordering care provider “ HL7 Decision Support Activities Order Set Functional Description (EHR DSTU Draft)

34. Support a sequencing of orders for logical and useful presentation to the ordering provider Support explanatory (non-actionable) sequenced elements for ease of use and informational content Order sets may be nested within order sets in order to support editorial efficiency and to avoid clinical and administrative update anomalies Order sets have a unique identification key which supports identification and use in multiple order sets Support identification of an author and brief editorial history in the header Support menu features which include “AND”, “XOR” at the level of order selection HL7 Decision Support Activities Order Set Requirements

35. Each order has a clear text description Support mapping to enterprise order master. Provide a readable version of the orders and the order set. HL7 Decision Support Activities Order Set Requirements

37. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook

38. HL7 Decision Support Activities Implementer’s Workbook http://www.himss.org/asp/cds_workbook.asp

39. HL7 Decision Support Activities Summary Issues • Data capture/display/storage • EMR • central data repository • Controlled, structured vocabulary • Knowledge representation • Knowledge acquisition • Clinical event monitor: integrate the pieces for many different uses (clinical, research, administrative)

40. HL7 Decision Support Activities Summary Issues How to represent (executable) guidelines? How to validate algorithm? How to validate implementation? Who does the validation?

41. HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementer’s Workbook