Progress on Virtual Medical Record

1. Progress on Virtual Medical Record HL7 Salt Lake City

2. Requirements • Medical record communication • From existing EHR to DSS • From DSS to EHR • E.g. decisions, goals, inferred observations • Computer understandable record • Semantic interoperability • Same problems as EHR system to EHR system communication

3. Guideline system  EHR : queries Guideline system EHR : query results Guideline system  Clinical system : act requests Guideline system  EHR : data recording Guideline system  EHR : decision recording Guideline system  EHR : assessment recording Guideline system  EHR : goal recording EHR  DSS communication

4. virtual Medical Record (vMR) • Required to represent standardised view of EHR for • a – standard names in expressions, result sets • b – writing new records to the EHR 1a EHR User Interface Guideline Interpreter 1b

5. What is it? • Simplification of medical record • only has distinctions important to DSS • Aim is to find the minimal set of record types & attributes required to achieve semantic interoperability • Expression language has to be able to write criteria using these

6. Five Basic Classes • Observation • Intervention • Goal • Plan • Commitment • + Patient, Guideline, Agent (Care Provider, DSS)

7. Attributes: All Classes • Patient (instance of Patient) • Care providers • Coded concept • Recording agent • Recording time • Where • (n.b. no encounter class)

8. Observation kinds • Quantitative Observation • e.g. Height 1.56m • Qualitative Observation • e.g. ‘nocturnal cough’ • Assessment • e.g. ‘diagnosis Gestational Diabetes’ • Extra attributes • Duration of observation

9. Qualitative Observation • Subjective • ‘Primary’ observations, not inferred • e.g. symptoms, signs

10. Quantitative Observations • Objective measurements • Additional attribute ‘observed quantity’ • Has quantity and units of measure • e.g. height, weight, hemoglobin

11. Observation questions • Inferred flag • e.g. BMI calculated from weight and height • Use instead of Assessment? e.g. a diagnosis is an observation inferred by clinician • ‘Consequence of’ relationship • To tie observations to the intervention which generated them. Is this necessary for DSS? • e.g. potassium level as result of Chem 7 • !!! Implies Causality – should we represent this? • Do we need observation subtypes?

12. Intervention • Uncertain list of types • Extra attributes • ???Reason – obs that cause this intervention • Valid time • These are ‘done’ interventions • Medication Authorisation • Dose/admin/quantity & ingred/product/pack CMETS • Investigation | • Procedure | • Education • … Schedule appointment + others • is this a useful distinction?

13. Goal, Plan, Commitment • Important for guideline execution and history of guideline use • Extra attribute: context • Context = the guideline they came from • Expression language has to be able to write criteria using these.

14. Goal • A (future) observation you wish to achieve, maintain, avoid. • e.g. ‘keep blood pressure < 130/85’ • Need to be able to cope with these: • e.g. ‘miminise side effects’ • Extra • Observation ‘BP 130/85’ or set{side effects} • Type symbols ‘maintain, less than’ , ‘avoid, any of’

15. Plan • Planned Intervention set • Planned intervention will be converted into Act with mood code

16. Commitment • Decisions made • Choice between alternatives • e.g. ‘start beta blocker’

17. EHR SIG • Initial proposed R-MIM provides most of these classes • Commitment? • EHR SIG have VMR as their second use case • Widen their current R-MIM to do VMR

18. Questions • Workflow – any extensions? • Profiles/templates • Deliberately avoided • Events from EHR • Can these be standardised? • Need to name them in expressions • e.g. • Patient has encounter with care provider • Add/delete/change to record – subtypes?

19. Next steps • Clarify any extensions/changes • Clarify medication info CMETS • Work with HER SIG to extend R-MIM • Aim for candidate R-MIM January 2002