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

GP2GP Clinical Semantics

Leo Fogarty

Russell Hotel 12/12/03

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

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

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

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

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

Elements of Clinical Information

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

Which sit in a context which might include:

A Heading:“Past History”

orModifying Information:Modifying Information:Q= “Possible”Q= “Possible”

Which all sits in a document:

““Referral Letter”Referral Letter”

Which was constructed during an event:

Surgery ConsultationSurgery Consultation

Relating to an ongoing Problem:

Chest PainChest Pain

A ConstructionDISCHARGE NOTE Kettering General Hospital

Rothwell Road, KetteringNorthants NN16 8UZ

Tel: 01536 492000Dear Dr: Prunesquallor A

Date: 04/02/2000 Surname:

BEAUHARNAISUnit No: 123451

First name: JOSEPHINE

DoB: 01/01/22

NHS: 1234567895

Address: 5 WhitehallKETTERINGNORTHANTSNN00 1OO

Ward: Deene B

Admitted On: 07/01/2000

Discharged On: 02/02/2000

Consultant: Zhivago Y

Primary Diagnosis: Pelvic malignancy

Secondary Diagnoses: Anaemia unspecified D21z.

Haematuria K197.

Complications:

Operations & Procedures

Urethral Catheterisation

Urethral Catheterisation

Urethral irrigation of bladder

Other blood transfusion NOS

Diagnostic Cytoscopy (Rigid) & Bladder Biopsy

M478a

M478a

M471

X339

M451c

Date of Op/Proc

07/01/00

08/01/00

08/01/00

09/01/00

10/01/00

Additional Information \ Instructions

For palliative care.

OPD Follow Up Weeks

Signed: Maggie Bell

Print Name: Maggie Bell

Designation: Clinical Practitioner

Positional Syntax ApproachADT ADT Message Chapter

MSH Message Header 2

EVN Event Type 3

PID Patient Identification 3

[PD1] Additional Demographics 3

[ { NK1 } ]Next of Kin / Associated Parties

3

PV1 Patient Visit 3

[ PV2 ] Patient Visit - Additional Info. 3

[ { OBX } ]Observation/Result 7

[ { AL1 } ] Allergy Information 3

[ { DG1 } ]Diagnosis Information 6

[ { DRG } ]DRG Information 6

[ { PR1 } ]Procedures 6

[ { GT1 } ]Guarantor Information 6

[

{ IN1 Insurance Information 6

[ IN2 ] Insurance Information - Addit. Info.

6

[ IN3 ] Insurance Information - Cert. 6

}

]

[ ACC ] Accident Information 6

[ UB1 ] Universal Bill Information 6

[ UB2 ] Universal Bill 92 Information 6

Required

ADT ADT Message Chapter


EVN Event Type 3


PV1 Patient Visit 3




Positional Syntax ApproachADT ADT Message Chapter


EVN Event Type 3


PV1 Patient Visit 3




SEQ LEN DT R/O RP/# TBL# ITEM # ELEMENT NAME

1 1 ST R 1 Field Separator

2 4 ST R 2 Encoding

Characters

9 7 CM R 76 9 Message Type

10 20 ST R 10 Message Control

ID

11 1 ID R 103 11 Processing ID

12 8 ID R 104 12 Version ID

1 3 ID R 3 99 Event Type Code

2 26 TS R 100 Date/Time of Event

5 60 CN O 188 103 Operator ID

2 16 CK 105 Patient ID (External

ID)

3 20 CX R Y 106 Patient ID (Internal

ID)

5 48 XPN R 108 Patient Name

7 26 TS 110 Date of Birth

11 106 XAD Y 114 Patient Address

2 1 ID R 4 132 Patient Class

3 12 CM O 133 Assigned Patient

Location

7 60 XCN O 10 137 Attending Doctor

8 60 XCN O 10 138 Referring Doctor

44 26 TS O 174 Admit Date/Time

45 26 TS O 175 Discharge

Date/Time

2 2 ID R 125 570 Value Type

3 590 CE R 571 Observation

Identifier

14 200 TS O 582 Date/Time of the

Observation

1 4 SI R 391 Set ID - Procedure

2 2 ID R 89 392 Procedure Coding

Method

3 80 CE R 88 393 Procedure Code

4 40 ST O 394 Procedure

Description

5 26 TS R 395 Procedure

Date/Time

6 2 ID R 230 396 Procedure

Functional Type

One Representation on Receipt

DISCHARGE LETTER04/02/2000

BEAUHARNAISJOSEPHINE 01/01/22

ZY

Urethral Catheterisation Urethral Catheterisation

Urethral irrigation of bladder Other blood transfusion NOS

Diagnostic Cytoscopy (Rigid) & Bladder Biopsy

(M478a) (M478a)

(M471) (X339)

(M451c)

(D21z.)Pelvic malignancy Anaemia unspecified Haematuria (K197.)

For palliative care.

Patient Details

Date of Event Event Type

History

Examination

Investigations

Healthcare Professional

Procedures

Comment

Date of Birth

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

Semantic Interoperability Needs

• Clinical Coding Schemes– Clinical Concepts– Drugs

• People, Places and Roles• Aggregations

– Templates/Archetypes/Clusters

• Dates• Architectural Containment and “Glue”

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

Architecture ?Architecture ?

GEHR (North) Simplified

EHCR

EHCR Extract

Transactions

List of Transaction

Types

Content

Category Observation

Item Item Collection

List of Item Types

ENV 13606 message structure

types of

1contains

1..*

types of

1..*

EHCR extract

original compone

nt complex

record component

link item

data item

folder

composition

headed section

1

EHCR message

cluster

ENV13606 message data items

record component data item

type of

Plain/HTML text

structured codedquantifiable observationmedication

physical entity reference

external data reference

event

person identifier

person name

language

address

telecom

patient related party

related location

community defined

types of

GEHR (South)

CDA at RIM level

Information model – EHR Containers

Information model – Clinical statements

GP2GP Language

• Coding Schemes– Read– EMIS– Multilex– Local

• Consultation Categories (Headings)

GP2GP Language Architecture Names

• Level Codes

• Composition Names

• Document Names

• Compound Names

• Link Names

GP2GP Language Qualifiers

• Problem Status

• Epidocity

• Medication Mood

• Secondary Status Terms

GP2GP Language Major Modifiers

• Certainty/Negation

• Action Status

• Significance

• Subject of Information

• Sensitivity

• Validity

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?