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The role of clinicians in
clinical concept modelling
                     Dr Dipak Kalra
  Centre for Health Informatics a...
European health systems:
priorities and challenges
• Growing expectations for equity of access, quality and
  efficiency, ...
A pan-European Health Infostructure


                      Wellness                                                      ...
Goals for EHR semantic
interoperability
• To support patient safety, quality of care, chronic
  disease management, extend...
Electronic Health Record - EHR 2.0

       Clinical trials,
                                                            De...
Contextual building blocks of the EHR


                         Part or all of the electronic health record
  EHR Extract...
ISO EN 13606-1 Reference Model
The EHR landscape that needs modelling




                          Treatment
                   Medication and prescript...
The EHR landscape that needs modelling



Hospital admission
               Treatment
                     Medication and ...
What is a clinical archetype?


  • a clinical archetype is an agreed, formal and
    interoperable specification
  • for ...
What value do archetypes add?

• A user friendly means to capture and collate professional
  consensus on how clinical dat...
openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/
openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/
openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/
openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/
openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/
openEHR CKM archetypes

•   Gold standard (best practice) definitions
•   Leveraging the available published evidence
•   ...
Royal College of Physicians: Clinical
headings
• A standard and defined set of headings for
   • acute medical admission
 ...
RCP Archetype approach

•   Selection of a focussed domain
•   Single profession, for now
•   Start top down, with clinica...
North Central London Integrated Care



     Whittington Hospital
     and its collaborating
           Hospitals



Colla...
Commonly used fragments


Generic                   Medical summary


                          Medication, prescriptions
...
Commonly used fragments


Generic                   Medical summary


                          Medication, prescriptions
...
planning
                               Indication for anticoagulation - {mandatory, ordinal, 15 specified
               ...
planning

                  monitoring   Present health situation
                               Treatment controller
    ...
De facto archetype approach

• Focus on the specific support of clinical shared care
• Work with multiple professionals fr...
Best practice:
               published evidence, guidelines,
                  international consensus,
              foc...
Key challenges for successful
clinical modelling
• Semantic interoperability needs to be underpinned by
  shared clinical ...
Getting clinical engagement right


 •   Involve a wide range of working clinicians
 •   Develop archetypes with multi-pro...
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
The Role of Clinicians in Clinical Concept Modelling
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The Role of Clinicians in Clinical Concept Modelling

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The Role of Clinicians in Clinical Concept Modelling. Kalra D. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

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Transcript of "The Role of Clinicians in Clinical Concept Modelling"

  1. 1. The role of clinicians in clinical concept modelling Dr Dipak Kalra Centre for Health Informatics and Multiprofessional Education (CHIME) University College London d.kalra@chime.ucl.ac.uk
  2. 2. European health systems: priorities and challenges • Growing expectations for equity of access, quality and efficiency, patient empowerment and engagement • Rising incidence of chronic diseases and increased complexity of their treatment • age related: dementia, cancer • lifestyle related: diabetes, asthma, obesity, ischaemic heart disease • Growing expectations and concerns about patient safety • Need for better integration across wellness, health care, public health, occupational health and social care • Demographic change: ageing population • Societal pressure for demonstrable protection of privacy EU National ICT Research Directors Forum, November 9th, 2009
  3. 3. A pan-European Health Infostructure Wellness Social care Fitness Citizen in the Occupational Complementary community health health School health rapid bench to bed translation real-time knowledge directed care Point of care delivery Teaching explicit consent Research Clinical trials Continuing care (within the institution) Education de-identified implied consent Public health Research Health care Epidemiology +/- consent management Data mining Clinical audit Long-term shared care (regional national, global)
  4. 4. Goals for EHR semantic interoperability • To support patient safety, quality of care, chronic disease management, extended home-care, patient empowerment • enable the safe, meaningful sharing and combining of health record data between heterogeneous systems and actors / care providers • enable the integration and safe use of computerised protocols, alerts and care pathways by EHR systems • link EHR data to explanatory and educational materials to support patient and family engagement and professional development • ensure the necessary data quality and consistency to enable meaningful and reliable use of longitudinal and heterogeneous data for public health, research, health service management
  5. 5. Electronic Health Record - EHR 2.0 Clinical trials, Decision support, functional genomics, EHR repositories knowledge management public health databases and analysis components Integrating information Centring services Whittington Hospital on Healthcare Record citizens Personnel registers, Creating and John Smith DoB: 12.5.46 security services using knowledge Mobile devices Clinical Clinical devices, applications instruments Social computing: forums, wikis and blogs
  6. 6. Contextual building blocks of the EHR Part or all of the electronic health record EHR Extract for one person, being communicated High-level organisation of the EHR Folders e.g. per episode, per clinical speciality Set of entries comprising a clinical care Compositions session or document e.g. test result, letter Headings reflecting the flow of information Sections gathering, or organising data for readability Clinical “statements” about Observations, Entries Evaluations, and Instructions Multipart entries, tables,time series, Clusters e.g. test batteries, blood pressure, blood count Element entries: leaf nodes with values Elements e.g. reason for encounter, body weight Date types for instance values Data values e.g. coded terms, measurements with units
  7. 7. ISO EN 13606-1 Reference Model
  8. 8. The EHR landscape that needs modelling Treatment Medication and prescriptions Hypotheses, Advice and education Symptoms health issues Self management and history (problemsChronic and home monitoring and summary Prevention and Conventional medical diseaseWell-being and fitness, screening, diagnoses),rehabilitation after illness manageme Body physical risks population nt examination findings Tests and investigations health Care planning measures Social welfare, culture, religion, attitudes, expectations, hopes, fears Procedures and operations Protocols, guidelines, care pathways Communication, team-based collaboration Consent, permissions, disclosures, complaints
  9. 9. The EHR landscape that needs modelling Hospital admission Treatment Medication and prescriptions Hypotheses, Advice and education Symptoms health issues Self management and history (problemsChronic and home monitoring Mental health and summary Prevention and Conventional medical diseaseWell-being and fitness, screening, diagnoses),rehabilitation after illness manageme Body physical risks population nt examination findings Tests and investigations health Care planning measures Social welfare, culture, religion, attitudes, expectations, hopes, fears Procedures and operations Protocols, guidelines, care Cardiovascular medicine pathways Communication, team-based collaboration Consent, permissions, disclosures, complaints
  10. 10. What is a clinical archetype? • a clinical archetype is an agreed, formal and interoperable specification • for representing a given clinical entity such as a clinical observation, a finding, a plan or a treatment • within an electronic health record • invented and maintained by openEHR • ratified by CEN: EN 13606 Part 2 • ratified by ISO: ISO 13606 Part 2 • to be quality labelled and licensed by EuroRec
  11. 11. What value do archetypes add? • A user friendly means to capture and collate professional consensus on how clinical data should be represented • A formal model of clinical domain concepts • e.g. “blood pressure”, “discharge summary”, “fundoscopy” • Can provide a focussed context for selection of relevant terms • Can be published and shared within a clinical community, or globally • Can be imported by vendors into EHR system data dictionaries • Defines a systematic EHR target for queries and for decision support
  12. 12. openEHR Clinical Knowledge Manager http://www.openehr.org/knowledge/
  13. 13. openEHR Clinical Knowledge Manager http://www.openehr.org/knowledge/
  14. 14. openEHR Clinical Knowledge Manager http://www.openehr.org/knowledge/
  15. 15. openEHR Clinical Knowledge Manager http://www.openehr.org/knowledge/
  16. 16. openEHR Clinical Knowledge Manager http://www.openehr.org/knowledge/
  17. 17. openEHR CKM archetypes • Gold standard (best practice) definitions • Leveraging the available published evidence • Referring to as many guidelines as can be found • Inclusive of as many variants on the requirements as possible (maximal) • Openly developed in a social community environment • Wide, international multi-stakeholder contributions • Dependent upon level of interest, and on high quality inputs (like Wikipedia) • Final decisions based on consensus
  18. 18. Royal College of Physicians: Clinical headings • A standard and defined set of headings for • acute medical admission • hospital handover • discharge summary • Method: • literature reviews • evaluating proformas used by different NHS Trusts • clinician workshops • a questionnaire based on the headings and definitions • > 3000 people responded and 80% agreed on 30 of the 36 suggested headings • Feedback and subsequent endorsement from several other Royal Colleges
  19. 19. RCP Archetype approach • Selection of a focussed domain • Single profession, for now • Start top down, with clinical headings • Define content per heading • Involve clinicians and other stakeholders through workshops • Get them to propose content • Focus on what every good doctor should record • Not necessarily maximal • Consider most items to be optional • Use a paper record template to provide a visual cue to the content being proposed
  20. 20. North Central London Integrated Care Whittington Hospital and its collaborating Hospitals Collaborative GP Practices development Consultant-led and of EHR Community Clinical Pharmacies systems Services CHIME (UCL)
  21. 21. Commonly used fragments Generic Medical summary Medication, prescriptions planning Anticoagulation monitoring Cardiovascular cardiac Heart failure respiratory Disease management scales & scores Assessment self-care Dementia prescriptions Treatment effectiveness Consents, carers Shared care management Clinical letters and reports Notifications and alerts Audit and governance
  22. 22. Commonly used fragments Generic Medical summary Medication, prescriptions planning Anticoagulation monitoring Cardiovascular cardiac Heart failure respiratory Disease management scales & scores Assessment self-care Dementia prescriptions Treatment effectiveness Consents, carers Shared care management Clinical letters and reports Notifications and alerts Audit and governance
  23. 23. planning Indication for anticoagulation - {mandatory, ordinal, 15 specified conditions} Other indication - {optional, free text} Anticoagulant drug name - {mandatory, ordinal, 3 specified drugs} Target INR - {mandatory, quantity, range 0-5} Target INR range Upper - {mandatory, quantity} Lower - {mandatory, quantity} Intended end date - {optional, calendar date} ------------- one must If life-long treatment intended - {optional, Boolean} ------------- be provided Actual end date - {optional, calendar date} Precautions to be taken - {optional, free text} Anticoagulation monitoring
  24. 24. planning monitoring Present health situation Treatment controller Current INR Decision support recommended warfarin dose If recommended dose accepted Actual warfarin dosage Decision support recommended monitoring interval If recommended interval accepted Actual appointment date Clinic name Advice given Medical comments Anticoagulation
  25. 25. De facto archetype approach • Focus on the specific support of clinical shared care • Work with multiple professionals from the start • Develop archetypes with a view to what is feasible to record and useful to share • Archetypes mirror the data structures in real use • Build on existing paper and electronic systems if they are useful and used • Developed with rapid reflection back via clinical application screens and practice data entry • Diversity still needs to exist - clinical best practice might not always be at a consensus - yet!
  26. 26. Best practice: published evidence, guidelines, international consensus, focus onand prescriptions completeness Medication maximal Treatment Advice and education Hypotheses, Symptoms Self management and health issues Chronic and history Prevention and home monitoring (problems disease and Conventional medical summary screening, diagnoses), Well-being and fitness, managemen population rehabilitation after illness Body physical risks t health examination findings Tests and investigations measures Care planning Social welfare, culture, religion, attitudes, De facto: expectations, hopes, fears existing operations Procedures and practice, existing systems, Protocols, guidelines, care pathways local consensus, Communication, team-based collaboration focus on supporting shared care Consent, permissions, disclosures, complaints
  27. 27. Key challenges for successful clinical modelling • Semantic interoperability needs to be underpinned by shared clinical data structures: archetypes • Large scale, professionally-driven, archetype library development is now needed • Professionals will need better (ontology-driven) visuals to understand their archetype landscape • Rapid testing of models via clinical applications is vital • The quality labelling and publication of archetypes must be centrally co-ordinated within Europe • More research is needed on how SNOMED CT can help with semantic consistency across multiple archetypes
  28. 28. Getting clinical engagement right • Involve a wide range of working clinicians • Develop archetypes with multi-professional input • Combine available evidence and consensus practice • Solve real clinical information gaps • join up virtual teams to improve safety and shared care • define the benefits right at the start • No need to structure everything • start by codifying the data that will improve care • remember narrative is good for human to human communication • Quality assure archetypes before they are used • Pilot in real settings before wide roll out
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