The Role of Clinicians in Clinical Concept Modelling

The role of clinicians in

clinical concept modelling

Dr Dipak Kalra

Centre for Health Informatics and Multiprofessional Education

(CHIME)

University College London

[email protected]

mailto:[email protected]

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

Point of care

delivery

Continuing care (within the institution)

Long-term shared

care (regional

national, global)

Teaching

Research

Clinical trials

explicit consent

Education

Research

Epidemiology

Data mining

de-identified

+/- consent

Public health

Health care

management

Clinical audit

implied consent

A pan-European Health Infostructure

Citizen in the

community

Social care

Occupational

health

School health

Wellness

Fitness

Complementary

health

real-time knowledge directed carerapid bench to bed translation

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

Electronic Health Record - EHR 2.0

Whittington

Hospital

Healthcare Record

John SmithDoB: 12.5.46

Clinical trials,

functional genomics,

public health databasesEHR repositories

Clinical devices,

instruments

Clinical

applications

Decision support,

knowledge management

and analysis components

Mobile devices

Personnel registers,

security services

Social computing:

forums, wikis and blogs

Integrating information

Centring services on citizens

Creating and using knowledge

CompositionsSet of entries comprising a clinical care

session or document e.g. test result, letter

EHR ExtractPart or all of the electronic health record

for one person, being communicated

FoldersHigh-level organisation of the EHR

e.g. per episode, per clinical speciality

SectionsHeadings reflecting the flow of information

gathering, or organising data for readability

ClustersMultipart entries, tables,time series,

e.g. test batteries, blood pressure, blood

count

ElementsElement entries: leaf nodes with values

e.g. reason for encounter, body weight

Data values Date types for instance values

e.g. coded terms, measurements with units

EntriesClinical “statements” about Observations,

Evaluations, and Instructions

Contextual building blocks of the EHR

ISO EN 13606-1 Reference Model

TreatmentMedication and prescriptions

Symptoms

and history

Body physical

examination findings

Procedures and operations

Hypotheses,

health issues

(problems

and

diagnoses),

risks

Conventional medical summary

Care planning

Advice and education

Chronic

disease

manageme

ntTests and investigations

Self management

and home monitoring

Protocols, guidelines, care

pathways

Prevention and

screening,

population

health

measures

Communication, team-based collaboration

Well-being and fitness,

rehabilitation after illness

Consent, permissions, disclosures, complaints

Social welfare, culture,

religion, attitudes,

expectations, hopes, fears

The EHR landscape that needs modelling


Symptoms

and history

Body physical



Hypotheses,

health issues

(problems

and

diagnoses),

risks


Care planning


Chronic

disease

manageme

ntTests and investigations

Self management

and home monitoring


pathways

Prevention and

screening,

population

health

measures








The EHR landscape that needs modelling

Cardiovascular medicine

Mental health

Hospital admission

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

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

openEHR Clinical Knowledge Managerhttp://www.openehr.org/knowledge/





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

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

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

North Central London Integrated Care

Whittington Hospital

and its collaborating

Hospitals

CHIME

(UCL)

Consultant-led

Community Clinical

Services

GP Practices

and

Pharmacies

Collaborative

development

of EHR

systems

Generic

Commonly used fragments

Medical summary

Medication, prescriptions

Disease management

Cardiovascular

Anticoagulation

Heart failurerespiratory

cardiac

planning

monitoring

Dementia

Assessment

Treatmenteffectiveness

prescriptions

scales & scores

self-care

Audit and governance

Shared care management Clinical letters and reports

Notifications and alerts

Consents, carers

Generic

Commonly used fragments

Medical summary

Medication, prescriptions

Disease management

Cardiovascular

Anticoagulation

Heart failurerespiratory

cardiac

planning

monitoring

Dementia

Assessment

Treatmenteffectiveness

prescriptions

scales & scores

self-care

Audit and governance

Shared care management Clinical letters and reports

Notifications and alerts

Consents, carers

Anticoagulation

planning

monitoring

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

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

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!


Symptoms

and history

Body physical



Hypotheses,

health issues

(problems and

diagnoses),

risks


Care planning


Chronic

disease

managemen

t

Tests and investigations

Self management and

home monitoring


pathways

Prevention and

screening,

population

health

measures








Best practice:

published evidence, guidelines,

international consensus,

focus on maximal completeness

De facto:

existing practice, existing systems,

local consensus,

focus on supporting shared care

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

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

Health & Medicine

The Role of Clinicians in Clinical Concept Modelling