Mayo Foundation: Clinical Perspective on Comparable Data

© Copyright Mayo Foundation for Medical Education and Research 2004

Mayo Foundation: Clinical Perspective on Comparable Data

By Peter L. Elkin, MD

Director, Laboratory of Biomedical Informatics

Department of Internal Medicine

Mayo Clinic


Document ManagementThe Tip of the Iceberg

• Millions of Documents are Generated by Healthcare Organizations each Year

• All are lost with respect to retrieval purposes (Except by MR#)– Lost Opportunity to Learn about your practice– Lost Opportunity to Manage your practice


Document ManagementThe Tip of the Iceberg

• Other Applications– Linking Images to Patient Records– Linking the Literature to Patient Records– Aggregate Retrievals for Research– Cost Justification by Better Documentation (links

to Clinical Guidelines, Definitions, etc.)– Linking Documents to Web pages Dynamically

• Challenge is that this Linkage must be robust enough to characterize today’s practice of medicine


Clear Return on Investment

• Automated Vocabulary Management

• Better Asset Management

• Automated evaluation of records to see if they meet the E&M coding guidelines?

• Expert System to Maximize DRG reimbursement…..

• Decision Support (Patient Safety)


Granular Encoding

G u ide lin es E xp ert S yte m sC lin ica l R e m in d e rs

Practice

A g g reg a te R e trie va l P ro toco l E n ro lem e nt

R esearch

C D S S(e .g . D X p la in )

A d h oc T e ach in g F ilesIm ag ing

Education

G ranular Encoding of Patient P roblem s Vocabulary Serve r


Mayo Technology

• Concept Based Indexing– SNOMED-CT– ACE– ACD– Vocabulary Server– Comparable Data



System ArchitectureEnterprise Java Beans


Dell 2650 for File Server (Optional)o 2GBs of Main Memoryo Two (2) - 2.8GHz Processorso 5x73 GB diskso Additional disk expansion available (up to 1.5tb optional)

Sun Fire V210 forDatabase Engineo 2 - GHZ UltraSparc IIIio 4GB Main Memoryo 2- 36GB drives for OS and Sybase Installationo 12 - 73GB drives for DB and online DB backups

SAVS Hardware Architecture

Terminology DB (Static)Document Index DBIndex File Storage

indexed File Server(Optional)

Web/App Server RMIServer

Optional

Optional

Web Client

Dell 2650 for RMI engineo 6GBs of Main Memoryo Two (2) - 2.8GHz Processorso 5x73 GB diskso Additional disk expansion available (up to 1.5tb optional)

RMIServer(Optional)

Dell 2650 Web Servero 4GBs of Main Memoryo Two (2) - 2.8GHz Processorso 3x73 GB disks for OS & applications Optional

Optional

EMR


EMRRepository

TerminologyServer

Record EntryProcess

Record RetrievalProcess

Web ServerEnterprise

Java Bean Container

Map Text To Terminology

Handle Query andExplode Matches

Map Text To Terminology and

Store

Query

Query to Processorand Return

Intelligent Queryto Database

Transcribed Record

Record to Processorand Return

Processed Recordto Storage

EMRRepository

TerminologyServer

Record EntryProcess

Record RetrievalProcess

Web ServerEnterprise

Java Bean Container

Map Text To Terminology

Handle Query andExplode Matches

Map Text To Terminology and

Store

Query

Query to Processorand Return

Intelligent Queryto Database

Transcribed Record

Record to Processorand Return

Processed Recordto Storage


Terminology in Healthcare:

“The nomenclature is of as much importance in this department of inquiry, as weights and measures in the physical sciences, and should be settled without delay.” William Farr, 1839; Regarding the Cullenian system of 1785First Annual Report of the Registrar-Generalof Births,Deaths, and Marriages in England. London: 1839 p. 99.


“In attempting to arrive at the truth, I have applied everywhere

for information, but in scarcely an instance have I been able to obtain

hospital records fit for any purpose of comparison.”

- Florence Nightingale, 1893


Electronic Health Record

• Comparable Data– Granularity C/W the Practice

• Outcomes Research• Utilization Review• Managing the Financial Side of the Practice

– Controlled Medical Vocabulary• Maintenance• Coverage• Formal Definitions• Unambiguous (Within a Context)• Non-Redundant

– Ease of Data Acquisition


Current Large Vocabulary Efforts

• SNOMED-RT– SNOMED-DICOM Microglossary

• Clinical Terms v3 (Read Codes)

• SNOMED-CT

• UMLS

• NIC, NOC, NANDA

• NDF-RT


TOMMY G. THOMPSON, SECRETARY OF HEALTH AND

HUMAN SERVICES July 1, 2003

• I am very excited about the tremendous potential for information systems to improve the quality of health care, and I have been pushing everyone in the Department very hard to move forward as rapidly as possible.

• My first charge ……… is to develop incentives for all parts of the health care community to use SNOMED, the electronic medical records, and other standards as they are adopted. We want to see the integration of health information systems through to its logical conclusion.

• I challenge you to adopt and use interoperable electronic health records.


Placing a Stake in the Groundby Don Berwick, MD

Clinicians and Researchers need a comparable mechanism for accessing Medical Record Data.Let’s place that stake in the ground where we think it Really Ought To Be!!!


Interoperability

• Data Exchange Between and Among Computers and Computer Systems– Reliable– Complete– Accurate

• Interoperability Standards– HL7– ASTM– ISO


Statement:

• In Medicine, we will never be able to create a vocabulary, with all the terms that a clinician will want to record, having been pre-coordinated in the vocabulary.

• E.g. Cellulitis, Left foot, with Osteomyelitis of the 3rd Metatarsal.


Answer: Compositionality

• Unambiguous– The Composite Term and its formalism should be

specified in such a way as not to allow two or more interpretations of the term’s meaning.

• Non-Redundant– Normalization of Pre-Coordinated Terms– Normalization of Post-Coordinated Terms


Glossary:

• Atomic Concept:

• Example: Colon has a unique concept

identifier in SNOMED-CT and cannot be

represented by combining two or more other

codes from within the terminology.


Glossary:

• Pre-coordinated Concept:

• Example: Colon Cancer is non-atomic, however

it has a single unique identifier in SNOMED-CT,

which means to the SNOMED that it represents a

“single” concept.


Glossary:

• Post-coordinated Concepts:

• Example: The concept “Status-Post CABG” is

not a unique concept within the SNOMED-CT

Reference Terminology.


Glossary:

• Qualifier: A string which when added to a term changes the meaning of the term in a Temporal or Administrative sense. For example, “History of” or “Recurrent”.

• Modifier: A string which when added to a term changes the meaning of the term in a Clinical sense. For example, clinical stage or severity of illness.

• Ontology: An organization of concepts for which one can make a rational argument. Colloquially this term is used to describe a hierarchy constructed for a specific purpose. For example a hierarchy of Qualifiers would be a Qualifier Ontology.

• Canonical Term: A preferred atomic or pre-coordinated term for a particular medical concept.


Glossary:

• Content Normalization - When all the Pre-coordinated terms in the Vocabulary are mapped to the combinations of Atomic terms in the same Vocabulary, which can be said to be equivalent in meaning.


If We Build It, They Will ComeField of Dreams (Early 90’s)

• Standards– Vocabulary Structure

– Semantic Representation

– Formalism for Content Representation

– Formalism for Composition

– Formalism for Medical Knowledge Representation

– Reliable Set of Views

– Vocabulary Messaging (HL7 CDA and Templates Conformant)


Usability Laboratory Experience

• Compositionality is Essential for a robust and clinically useful Document Retrieval Tool

• Modifiers and Qualifiers provided the greatest Utility• The Interface Design is integral to the acceptance of

the Search Engine• Designers must work to minimize Cognitive Overhead

and potential sources of Disorientation.


Comparable Data

• SNOMED-CT– Description Logic-Based Terminology– Compositional System– ~340,000 Concepts– ~800,000 Terms– LBI version adds 400,000 Terms– Over 30,000,000 Indices to the SNOMED-CT

Terminology


Compositional Systems


• Acute myocardial infarction of the anterolateral wall• Heart attack, Anterolateral cardiac wall, Acute• AMI, Anterolateral Wall• Acute MI of the Anterolateral Wall

Compositional Systems

• - Myocardial infarction (disorder) [22298006]– - [has Finding Site] . Entire myocardium of

anterolateral region (body structure) [190762001] – - [is Modified By] .

Acute (qualifier value) [53737009]


An Evaluation of the Content Coverage of SNOMED-CT for Clinical Problem Lists

ByPeter L. Elkin, MD1, Steven H. Brown, MD2, Casey Husser, MD1, Brent A. Bauer, MD1, Dietlind Wahner-Roedler, MD1, S. Trent Rosenbloom, MD2, Ted Speroff, PhD2

1. Mayo Foundation for Medical Education and Research2. Vanderbilt University


Methods

• 4,996 Most Common Unique Mastersheet Index Entries were Mapped to SNOMED-CT

• Two expert reviewers (Consultants) independently graded the mappings (using the automated mappings plus a SNOMED-CT browser)

• Disagreements were adjudicated by a third reviewer

# engine

SNOMED-CT

Misspelling

Match Type

Concept Mapping

Decomposition

16 TPFPTNFN

TPFPTNFN

CID abdominal hernia Hernia of abdominal cavity (disorder) [52515009] [K]

17 TPFPTNFN

TPFPTNFN

CID abdominal mass Abdominal mass (finding) [271860004] [K]


Results

SNOMED-CT Results

383 FN

9 FP

36 TN

4568 TP

SmartAccess Vocabulary Server

Results

256 FN

9 FP

419 TN

4312 TP

Results SNOMED-CT SmartAccess Vocabulary Server

SAVS with Synonyms

Sensitivity 92.3% 94.4% 99.7%

Specificity 80.0% 97.9% 97.9%

Positive Likelihood Ratio

4.62 45.0 47.5

Positive Predictive Value

99.8% 99.8% 99.8%

Negative Predictive Value

8.6% 62.1% 97.0%


Results

• The sensitivity of SNOMED-CT without the use of composition was only 51.4%. Using the McNemar Chi-Square Test there was a significant difference between the sensitivity of SNOMED-CT with and without using composition (51.4% vs. 92.3%; p<0.001).


Conclusions Regarding Medical Knowledge Representation using SNOMED-CT

• SNOMED-CT has good coverage of the terms used commonly in medical problem lists.

• Improvements to synonymy and the addition of missing modifiers would lead to the greatest return on investment toward improved coverage of common problem statements.

• Compositional expressions are required to exactly represent a significant portion of common problem statements (p<0.001).


Representational Complexity


Variable Complexity


Avoid the Compositional Tower of Babel


Ambiguous Representation

• “Hepatoma Metastatic to the Lungs”– Malignant neoplastic

disease (disorder) [363346000]

– Entire liver (body structure) [181268008]

– Entire lung (body structure) [181216001]

– Secondary malignant neoplastic disease (disorder) [128462008]

• “Liver Cancer” “Lung” or• “Lung Cancer” “Liver”


Inter-Semantic Relationships

• Dx = (defconcept Hepatoma Metastatic to the Lung

• (and disease

• (and (some Assoc-Morphology “Metastatic Neoplasm”)

• (some Assoc-Topography “Lung”))

• (and (some Assoc-Etiology “Malignant Neoplasm”)

• (some Assoc-Topography “Liver”))))


Generic Rule

• Dx = (defconcept Dxxxxxx • (and disease

• (and (some Assoc-Morphology x)

• (some Assoc-Topography (at least 1 Topography {or t1, t2 ,t3, … tm (m1)}))

• (and (some Assoc-Etiology y)

• (some Assoc-Topography (at least 0 Topography {or t1, t2, t3, … tn (n1))))))


Conceptual Relativity

• Level 1 - Diseases • | Distance 1.0• Level 2 - Cardiovascular Diseases (2000 Siblings)• | Distance = (((256/2000) * (5-2)) * 1.0) = 0.384• Level 3 - Congestive Heart Failure (250 Siblings)• | Distance = (((6/250) * (5-3) * .384) = 0.0399• Level – 4 LV Systolic Dysfunction (5 Siblings)• | Distance = (((1/5) * (5-4) * 0.0399) = 0.008• Level 5 - LV Systolic Dysfunction, Class III HF (1

Sibling)

• Generalization:• ((Sc((ScTT/Sp * (Level/Sp * (LevelTT-Levelp)) * DistLevel –1)-Levelp)) * DistLevel –1)


Semantic Distance from Feature Set Recognition

• Myocardial Infarction• HasMorphology Infarct• HasFindingSite Myocarium• And • Heart Attack• HasMorphology Infarct• HasFindingSite Myocarium

Acute Myocardial InfarctionHasMorphology InfarctHasFindingSite MyocariumHasModifier Acute

N N N

Z = ∑i=1 ai(1-Ncsc(m)/Nc) + ∑i=1 bi(1-Ncs(m)/Nc) – ∑i=1 di(1-Ncsc(nm)/Nc) Formula 1: Feature Set Similarity Metric


Level One Ontology

Champus_coverage

handicapped_program_cd : CEnon_avail_cert_on_file_ind : BLretirement_dttm : TSstation_id : II

Referral

authorized_visits_qty : REALdesc : EDreason_txt : ED

Healthcare_finances

Message_control

Acts (Services)

Appointments & scheduling

Roles

HEALTH LEVEL 7 REFERENCE INFORMATION MODEL RIM_0100

released January 2001 reflects RIM changes through Harmonization on 11/17/2000

Observation

value : ANYderivation_expr : STmethod_cd : SET<CV>body_site_cd : SET<CD>interpretation_cd : SET<CS>

Medication

form_cd : CDroute_cd : CDdose_qty : PQstrength_qty : PQrate_qty : PQdose_check_qty : PQmethod_cd : SET<CV>body_site_cd : SET<CD>substitution_cd : CV

Procedure

entry_site_cd : SET<CD>method_cd : SET<CV>body_site_cd : SET<CD>

Supply

qty : PQ

Diet

energy_qty : PQcarbohydrate_qty : PQ

Consent

Enitites

Document_service

completion_cd : CVset_id : IIstorage_cd : CVversion_nbr : INTcopy_dttm : TSorigination_dttm : TS

Billboard produced by:Rochester Outdoor Advertising

Healthcare_provider

specialty_cd : CV

Containercapacty_qty : PQheight_qty : PQdiameter_qty : PQbarrier_delta_qty : PQbottom_delta_qty : PQseparator_type_cd : CDcap_type_cd : CD

Access

gauge_qty : PQentry_site_cd : CDbody_site_cd : CD

Devicemanufacturer_model_nm : STlast_calibration_dttm : TSsoftware_nm : STlocal_remote_control_state_cd : CEalert_level_cd : CE

Notary_public

notary_county_cd : CEnotary_state_cd : CE

Employee_Employer

addr : SET<AD>hazard_exposure_txt : EDjob_class_cd : CVjob_title_nm : STtelecom : SET<TEL>protective_equipment_txt : EDsalary_qty : MOsalary_type_cd : CVstatus_cd : CSjob_cd : CE

Specimen

body_site_cd : CE

Living_subjectbirth_dttm : TSdeceased_dttm : TSdeceased_ind : BLadministrative_gender_cd : CEorgan_donor_ind : BLmultiple_birth_ind : BL

Materialform_cd : CVdanger_cd : CEeffective_tmr : IVL<TS>handling_cd : CE

Practitioner_provider

position_cd : CVprimary_care_ind : BL

Practitioner_Certifier

board_certification_type_cd : CVcertification_dttm : TSrecertification_dttm : TSresidency_field_cd : CE

Military_person

military_branch_of_service_cd : CVmilitary_rank_nm : STmilitary_status_cd : CV

Placegps_txt : STposition_txtaddr : ADdirections_txt

Manufactured_materialexpiration_dttm : TSlot_nbr : ST

Health_chart

Health_chart_deficiency

assessment_dttm : TSdesc : EDlevel_cd : CVtype_cd : CV

1

0..*

has_an_assessment_of

1

is_assessed_against

0..*

Inpatient_encounter

length_of_stay_qty : PQ

Non_Person_living_subjecttaxonomic_classification_cd : CEbreed_cd : CEstrain_txt : EDeuthanasia_ind : BLproduction_class_cd : CEgender_status_cd : CE

Diagnostic_related_group_definition

base_rate_qty : MOcapital_reimbursement_qty : MOcost_weight_qty : MOmajor_diagnostic_category_cd : CEoperating_reimbursement_qty : MOreimbursement_qty : MOstandard_day_qty : PQstandard_total_charge_qty : MOtrim_high_day_qty : PQtrim_low_day_qty : PQ

Encounter_drg

approval_ind : BLconfidential_ind : BLcost_outlier_qty : MOdesc : EDgrouper_review_cd : CEgrouper_version_id : IIoutlier_days_nbr : REALoutlier_reimbursement_qty : MOoutlier_type_cd : CV

1

0..*

defines 1

is_defined_by0..*

Billing_information_item

condition_cd : CEoccurrence_cd : CEoccurrence_dttm : TSoccurrence_span_cd : CEoccurrence_span_from_dttm : TSoccurrence_span_thru_dttm : TSquantity_nbr : REALquantity_type_cd : CVvalue_amtvalue_cd : CE

Patient_Provider

Organizationorg_nm : SET<ON>standard_industry_class_cd : CEaddr : SET<AD>

Financial_transaction

extended_qty : MOfee_schedule_cd : CEinsurance_qty : MOposting_dttm : TSqty : MOtransaction_batch_id : IIunit_qty : MOunit_cost_qty : MO

Clinical_document_headeravailability_status_cd : CVchange_reason_cd : CVcompletion_status_cd : CVconfidentiality_status_cd : CVcontent_presentation_cd : CVdocument_creation_dttm : TSfile_nm : STlast_edit_dttm : TSreporting_priority_cd : CEresults_report_dttm : TSstorage_status_cd : CVtranscription_dttm : TSdocument_change_cd : CVversion_nbr : INTversion_dttm : TS

Clinical_document

Patient_billing_account

adjustment_cd : CVcertification_required_ind : BLcurrent_unpaid_balance_qty : MOexpected_insurance_plan_qty : REALexpected_payment_source_cd : CVnotice_of_admission_dttm : TSnotice_of_admission_ind : BLpatient_financial_class_cd : CVprice_schedule_id : IIreport_of_eligibility_dttm : TSretention_ind : BLsignature_on_file_dttm : TSspecial_program_cd : CVstoploss_limit_ind : BLsuspend_charges_ind : BLtotal_adjustment_qty : MOtotal_charge_qty : MOtotal_payment_qty : MOseparate_bill_ind : BLbad_debt_recovery_qty : MObad_debt_transfer_qty : MO

Guarantor_contract

billing_hold_ind : BLbilling_media_cd : CEcharge_adjustment_cd : CEcontract_duration_cd : CEcontract_type_cd : CEeffective_tmr : IVL<TS>interest_rate_nbr : REALperiodic_payment_qty : MOpriority_ranking_cd : CV

Insurance_certification

certification_duration_qty : PQeffective_tmr : IVL<TS>id : IIinsurance_verification_dttm : TSmodification_dttm : TSnon_concur_cd : CEnon_concur_effective_dttm : TSpenalty_qty : MOreport_of_eligibility_dttm : TSreport_of_eligibility_ind : BL

10..*has_coverage_affirmed_by 1

affirms_insurance_coverage_for

0..*

Individual_healthcare_practitioner

fellowship_field_cd : CEgraduate_school_nm : ONgraduation_dttm : TSboard_certified_ind : BL

Role-role relationships

Healthcare_benefit_coverage_item

service_category_cd : CVservice_cd : CEservice_modifier_cd : CEauthorization_ind : BLnetwork_ind : BLassertion_cd : CEcovered_parties_cd : CEqty : REALquantity_qualifier_cd : CEtime_period_qualifier_cd : CErange_low_qty : PQrange_high_qty : PQrange_units_cd : CVeligibility_cd : CEpolicy_source_cd : CEeligibility_source_cd : CEcopay_limit_ind : BL

Healthcare_benefit_product_policy

assignment_of_benefits_ind : BLbenefit_product_desc : EDbenefit_product_nm : STbenefit_product_type_cd : CEbenefits_coordination_ind : BLcob_priority_nbr : REALcombine_baby_bill_ind : BLgroup_benefit_ind : BLmail_claim_party_cd : CErelease_information_cd : CEstatus_cd : CScoverage_type_cd : CEagreement_type_cd : CEpolicy_category_cd : CEaccess_protocol_desc : ED

Financial_act

effective_tmr : IVL<TS>reason_cd : CEstatus_dttm

Unmapped_financial_classes(from RIM_Healthcare_finances)

Language_ability

mode_cd : CVproficiency_level_cd : CV

Persondisability_cd : CEethnic_group_cd : CErace_cd : CEambulatory_status_cd : CVbirth_order_nbr : INTeducation_level_cd : CVliving_arrangement_cd : CVmarital_status_cd : CVreligious_affiliation_cd : CVstudent_cd : CVcredit_rating_cd : CVaddr : SET<AD>special_accommodation_cd : SET<CV>

Person_Language

0..*

1

specifies_ability_in 0..*

is_specified_by1

1

0..*

communicates_in

1

is_communicated_by

0..*

Working_list

ownership_level_cd

Public_health_case

detection_method_cdtransmission_mode_cddisease_imported_cd

Outbreak

tmr

Act_relationship

type_cd : CSinversion_ind : BLsequence_nbr : INTpriority_nbr : INTpause_qty : PQcheckpoint_cd : CSsplit_cd : CSjoin_cd : CSnegation_ind : BLconjunction_cd : CS

Act_context

level_cd

Act

id : SET<II>mood_cd : CStype_cd : CCtxt : EDstatus_cd : CSactivity_time : GTScritical_time : GTSconfidentiality_cd : SET<CV>max_repeat_nmr : IVL<INT>interruptible_ind : BLpriority_cd : SET<CV>orderable_ind : BLavailability_dttm : TS

0..*1

has_target

0..*

is_target_for

1

0..*1

has_source

0..*

is_source_for

1

1..*

0..*

originates_in_context_of1..*

provides_context_for0..*

Role_relationship

type_cd : CCeffective_tmr : IVL<TS>id : SET<II>status_cd : CSresponsibility_cd : SET<CE>position_nbr : LIST<INT>qty : PQcertificate_txt : ED 0..*

0..1

is_part_of

0..*

has_parts

0..1

Participation

type_cd : CStmr : IVL<TS>note_text : EDsignature_cd : CVfunction_cd : CDawareness_cd : CVsignature_txt : EDencounter_accommodation_cd : CVstatus_cd : CS

0..*

1for

0..*

has 1

Role

type_cd : cceffective_tmr : IVL<TS>addr : SET<AD>telecom : SET<TEL>

0..*

1

has_as_target

0..*

is_target_for11

0..*

is_source_of

1

has_as_source

0..*

0..*0..1

has_as_participant

0..*

participates_in

0..1Entity_name

effective_tmr : IVL<TS>nm : ENpurpose_cd : CV

Entityid : SET<II>type_cd : CCdeterminer_cd : CSimportance_status_txt : EDqtytelecom : SET<TEL>descstatus_cd : CS

10..*

plays_a_role

1is_played_by

0..*

0..* 1

is_for

0..*

has

1

Message_interaction

1..*shall_receive1..*1..1sends1..1

0..1

is_communicated_as

0..1

Transportation

Preauthorization

authorized_encounters_qty : REALauthorized_period_begin_tmr : IVL<TS>id : IIissued_dttm : TSrequested_dttm : TSrestriction_desc : EDstatus_cd : CSstatus_change_dttm : TS

Patient_encounter

discharge_disposition_cd : CVacuity_level_cd : CVbirth_encounter_ind : BLstatus_reason_cd : CVclassification_cd : CVencounter_classification_cd : CVpractice_setting_cd : CVvaluables_desc : EDpre_admit_test_ind : BLsource_cd : CVspecial_courtesies_cd : CVvaluables_location_desc : EDeffective_tmr

0..*

1is_utilized_during

0..*utilizes

1

1

0..1

is_authorized_by

1

authorizes

0..1

Healthcare_facilitylicensed_bed_nbr : REALmobile_ind : BL

Encounter_facility_association

effective_tmr : IVL<TS>status_cd : CStransfer_reason_cd : CV

0..*

1

is_used_by

0..*

uses

11

0..*

is_site_for1

is_sited_at

0..*

Schedule

status_cd : CSslot_size_increment_qty

Resource_slot

status_cd : CStime_slot : GTS

1

0..*

manages1

is_managed_by

0..*

Entity

RoleParticipation

ActRelationship

RoleRelationship

Act

Entity

RoleParticipation

ActRelationship

RoleRelationship

Act


Level Two OntologyEHR architecture (Level 2 Ontology: Healthcare Specific)

Core Classes

Patient Clinical State

1 1..*

11..*Episode of Care

1 1..*1 0..*

Documents

Clinical Reminders

1..*

0..*

1 1..*

Reports

1 1..*

Quality Assurance

0..*

0..*Abstraction

*

*

1 1..*

Surveillance

0..*

1

EncounterNon-Encounter Event

Diagnosis

1

0..*

Symptoms

1

0..*

Medications

0..*

1

ProcedureOrderResult

0..*

0..*

1

0..* 1

0..*

Privileged Clinician10..*

0..*

1..*

**

* *

10..*

1

0..*

Prescription

1*

*

1

*

*

*

*

*

*

1

0..*

1..*

0..*

*

1

1..*

0..*

1

0..*

0..*

0..*

1

0..*

1..*

1..*

Best Practice Rules

*

1

1

*

Temporal Model

*

*

-Authenticate-Authorization-Confidentiality-Integrity-Non-reputability

Security management Information Base

Authentication1 1Privileges

1 *

Audit Log

*

*

*

1

-Identity

Clinician

1

1

-Allergic-Non-allergic

Adverse Reactions

* *

1

*

1

*

* 1

1 1

Genomics/Proteomics*

1 11

*

1

1

0..*

Security Policies

*

1

* 1


Level Three Ontology

• Fully Encoded Health Record• Consistent with the Level One and Two

Ontologies for Health• Compositional Expressions are assigned

Automagically• No Human effort is needed so that the practice of

Medicine does not have to be shaped around information systems but instead the Information Systems can unobtrusively improve Patient Care.

• Example…………..


Moving Towards a Harmonious Formalism