clinical observation modeling · goals of clinical observation modeling create conceptual-level...
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Clinical Observation Modeling
Walter Sujansky
January 31, 2013
VA Informatics Architecture SOLOR Meeting
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Goals of Clinical Observation Modeling
Create conceptual-level models of the discrete statements about patients that can be stored in, processed by, and retrieved from an information system
• A.k.a. “Archetypes”, “Clinical Models”, “Clinical Event Models”
• E.g., blood pressure, lab result, exam finding, symptom
Standardize the capture, retrieval, and exchange of clinical observations within and between information systems
• Different software modules use the same clinical obs. models
De-couple the creation and maintenance of clinical domain-specific objects from their technical implementation in software code and database structures
• Domain objects => Diverse, complex, frequently changing
• Technical implemenation => Brittle, costly to update
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Clinical Observation Modeling – Example
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Clinical Observation Models for Interoperability
Core Database Implementation
Data Capture (Data-Entry Forms,
EDI Messages, XML Documents)
Data Query (UI Displays, CDS Rules,
Quality Measures) Data Exchange (APIs,
EDI Messages, XML Documents)
DB Schema & Code (invariant)
Meta-Data Models (flexible, extensible)
“Model-Driven Development”
(MDD)
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OpenEHR: Example MDD Framework
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OpenEHR Reference Model
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OpenEHR Reference Model
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OpenEHR Reference Model
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OpenEHR Reference Model: Entry Classes
Result of a clinical evaluation or test – includes previous results and current observations
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OpenEHR Reference Model: Observation Class
… … …
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OpenEHR: Archetypes
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OpenEHR Example Archetype
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OpenEHR Example Archetype
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OpenEHR Example Archetype - Documentation
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Clinical Observation Models for Interoperability
Core Database Implementation
Data Capture (Data-Entry Forms,
EDI Messages, XML Documents)
Data Query (UI Displays, CDS Rules,
Quality Measures) Data Exchange (APIs,
EDI Messages, XML Documents)
Reference Model
Clinical Models
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OpenEHR Example Archetype
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OpenEHR: Templates
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OpenEHR Example Template
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OpenEHR Example Template: Use of Archetypes
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OpenEHR Example Template
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OpenEHR Example Template: Use of Archetypes
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OpenEHR Example Archetype
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OpenEHR Example Template – Form View
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OpenEHR Architecture
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Clinical Observation Model (OpenEHR)
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Clinical Observation Model (OpenCEM)
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Clinical Observation Model (CIMI)
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Clinical Observations – Design Patterns
Observation = “A Discrete Patient Descriptor”
• E.g., – Diagnosis, LDL level, Systolic BP, Apgar Score, Reported Symptom,
Father’s Diagnoses
Facets of a patient descriptor
1. What Aspect of the patient is being described? – Explicitly (“Patient’s systolic BP is 130 mmHg” : aspect = Systolic BP) or
– Implicitly (“Patient has asthma” : aspect = Diagnosis)
2. What is the Value/Magnitude of the descriptor? – “Fatigue”, “185, with units = mg/dL”, “Asthma, with type= intrinsic”
3. “Context” – When did the descriptor apply to the patient? Who reported it? Was
patient sitting or standing at the time? What technique was used?
– (Sometimes fuzzy distinction between Context and Aspect)
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Multiple Valid Representations of Same Observation
“Patient has fasting LDL cholesterol of 185”
1. Aspect = Serum LDL cholesterol measurement Value = (185, with units-of-measure = mg/dL) Context = Fasting
2. Aspect = Lab Test Result Value = (Test type = Fasting Serum LDL cholesterol, mg/dL Test result = 185)
“Patient’s Father had Heart Failure”
1. Aspect = Diagnosis Value = Heart Failure Context = (Family History, with Relation = Father)
2. Aspect = Family History Value = (Heart Failure, with Relation = Father)
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Clinical Observations – Patterns in Question
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Clinical Observations – Patterns in Question
“Assertion” Pattern
• Aspect = NULL Value = (Asthma, with type=intrinsic, severity = mild, …) Context = (Time of observation, person responsible, …)
“Evaluation” Pattern
• Aspect = Serum LDL cholesterol (“the question”) Value = (185, with units-of-measure=mg/dL, …) (“the answer”) Context = Fasting
“Belief” Pattern (??)
• Aspect = Diagnosis Value = (Asthma, with type=intrinsic, severity = mild, …)
• Aspect = LDL cholesterol, with Fasting-State = true Value = (185, with units-of-measure=mg/dL)
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Clinical Observation Patterns: Why does it matter?
Desiderata for terminologies and concept models
• Understandable – Definitions should be understandable by average clinicians [and others
who use the definitions], given brief explanations
• Reproducible – Retrieval and representation of the same concept should not vary
according to the nature of the interface, user preferences, or the time of entry
• Usable – We should ignore concepts or distinctions for which there is no current
use in healthcare
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Clinical Observation Models for Interoperability
Core Database Implementation
Data Capture (Data-Entry Forms,
EDI Messages, XML Documents)
Data Query (UI Displays, CDS Rules,
Quality Measures) Data Exchange (APIs,
EDI Messages, XML Documents)
Reference Model
Clinical Models
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Clinical Observation Patterns: Why does it matter?
Desiderata for terminologies and concept models
• Understandable – Definitions should be understandable by average clinicians [and others
who use the definitions], given brief explanations
• Reproducible – Retrieval and representation of the same concept should not vary
according to the nature of the interface, user preferences, or the time of entry
• Usable – We should ignore concepts or distinctions for which there is no current
use in healthcare
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Reproducible Clinical Observation Models
Avoid arbitrary variation
1. Aspect = NULL Value = Regular pulse vs.
2. Aspect = Skin Turgor Value = Normal vs.
3. Aspect = Physical Exam Finding Value = Brisk Knee Reflex
Explicitly represent clinically relevant distinctions
1. Aspect = Patient-Reported Symptom Value = Weakness in Right Arm vs.
2. Aspect = Physical Exam Finding Value = Weakness in Right Arm
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Possible Perspectives
1. Standardize on a single pattern for observations
• Easier for data analysts and software developers to remember the pattern for all clinical models and use them in applications, CDS rules, clinical measures, etc.
• Most general pattern is “Belief” pattern – Aspect = <the relationship to the patient, possibly with modifiers>
Value = <value of the relationship, possible with modifiers>
2. Allow multiple patterns, specific to individual types of observations, or even to specific observations
• Clinical models, themselves, will be quite complex and extensive, so the basic “pattern” of the model will comprise the least of the variations among models
• Hence, doesn’t matter if there is one pattern or multiple patterns, as long as they are clearly documented
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OpenEHR Example Archetype
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OpenEHR Example Archetype
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BAD – violates “Reproducible” criterion
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Thank you
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OpenEHR Example Template
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OpenEHR Example Template: Use of Archetypes
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OpenEHR Example Template – Form View