GP2GP Clinical Semantics

1. GP2GP Clinical Semantics Leo Fogarty Russell Hotel 12/12/03

2. 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

3. 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

4. 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

5. 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

6. Electronic health records • Health records in electronic form • CPR, EPR, 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

7. 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 Which all sits in a document: “Referral Letter” A Heading: “Past History” Modifying Information: Q= “Possible” or The Record of Patient Information as Text:- which is human-readable and easily communicable The inclusion of codes: XE2uV Ischaemic Heart Disease Which may be qualified as: X793b Mild X78th First Episode

8. Urethral Catheterisation K197. Haematuria M478a Operations & Procedures Date of Op/Proc Surname: BEAUHARNAIS Unit No: 123451 08/01/00 08/01/00 07/01/00 10/01/00 09/01/00 M478a Urethral Catheterisation Urethral irrigation of bladder M471 First name: JOSEPHINE DoB: 01/01/22 Other blood transfusion NOS X339 Diagnostic Cytoscopy (Rigid) & Bladder Biopsy M451c NHS: 1234567895 Address: 5 Whitehall KETTERING NORTHANTS NN00 1OO A Construction DISCHARGE NOTE Kettering General Hospital Rothwell Road, Kettering Northants NN16 8UZ Tel: 01536 492000 Date: 04/02/2000 Dear Dr: Prunesquallor A Ward: Deene B Admitted On: 07/01/2000 Primary Diagnosis: Pelvic malignancy Secondary Diagnoses: Anaemia unspecified D21z. Discharged On: 02/02/2000 Complications: Consultant: Zhivago Y Additional Information \ Instructions For palliative care. OPD Follow Up Weeks Signed: Maggie Bell Print Name: Maggie Bell Designation: Clinical Practitioner

9. Positional Syntax Approach Required

10. Positional Syntax Approach

11. (K197.) Haematuria BEAUHARNAIS Urethral Catheterisation (M478a) Urethral Catheterisation (M478a) (M471) Urethral irrigation of bladder JOSEPHINE 01/01/22 Other blood transfusion NOS (X339) Pelvic malignancy Anaemia unspecified (D21z.) (M451c) Diagnostic Cytoscopy (Rigid) & Bladder Biopsy One Representation on Receipt Patient Details Date of Birth Date of Event 04/02/2000 Event Type DISCHARGE LETTER History Examination Investigations Procedures Comment For palliative care. Healthcare Professional ZY

12. 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

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

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

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

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

18. Plain/HTML text structured coded quantifiable observation medication physical entity reference record component data item external data reference event person identifier person name language address telecom patient related party related location community defined ENV13606 message data items type of types of

19. GEHR (South)

20. CDA at RIM level

21. Information model – EHR Containers

22. Information model – Clinical statements

23. GP2GP Language • Coding Schemes • Read • EMIS • Multilex • Local • Consultation Categories (Headings)

24. GP2GP Language Architecture Names • Level Codes • Composition Names • Document Names • Compound Names • Link Names

25. GP2GP Language Qualifiers • Problem Status • Epidocity • Medication Mood • Secondary Status Terms

26. GP2GP Language Major Modifiers • Certainty/Negation • Action Status • Significance • Subject of Information • Sensitivity • Validity

27. GP2GP Project Outcome • NHSIA Project 1/6/01-31/5/03 • V3 Messaging successful • Four (Now five) suppliers implemented in test bed circumstances • One supplier implemented same system transfer “for real” • Further piloting happening • Quo Vadis?