Healthcare Informatics Standards An Electronic Health Record Developer’s Perspective The 4th International HyTime Conference Montreal, Canada August 20, 1997 Jason P. Williams Oceania, Incorporated jwilliams@oceania.com Good afternoon. It is a pleasure to be here this afternoon. My name is Jason Williams, and I work with a company called Oceania, a company that develops electronic health record software. The title of my talk is Healthcare Informatics Standards: An Electronic Health REcord Developer's Perspective. What I hope to do today is to give an overview of some of the standards in the healthcare informatics community. Additionally, I hope to shed some light on the new work Oceania is doing with SGML and HyTime Architectural Forms. First began work in SGML at the University of Michigan, where I worked on a large digital library project using the TEI. I also became very interested in medical informatics and information retrieval, went to a couple of standards meetings, and have never looked back!

Today’s Topics changing healthcare informatics models healthcare informatics standards language and vocabulary Health Level Seven (HL7) SGML and healthcare informatics Oceania and SGML Oceania and HyTime architectural forms This what I would like to try to cover this afternoon. We will briefly talk about a major shift in the model for the patient medical record. After that we will dive right in to a discussion of some of the major healthcare informatics standards, including language and vocabulary standards and a major healthcare communications standard, HL7.

Document Model

Why Standards? The Vendor Perspective better patient care concentration on core competencies product interoperability benefits to the client internal benefits

Healthcare Informatics Standards vocabulary and language SNOMED, ICD READ, MESH, others NLM UMLS (meta-thesaurus) information / data representation HL7, DICOM, SGML, XML, RDBMS, others medical conventions

SNOMED ICD-9 many other examples to choose from X-ray examination (PROCEDURE) performed on arm (SITE) makes known a fracture (RESULT-FINDING) ICD-9 fracture of radius and ulna [arm], upper end, closed = 813.00 many other examples to choose from each optimized for different purposes each purpose needs to be addressed by vendors can’t “just pick one!”

Health Level Seven (HL7) “Clinical, financial, and administrative data among healthcare oriented computer systems” messaging standard; “trigger event” HL7 defines message types and “structure” messages structure: header: segments: fields

NK1|JONES^BARBARA^K|WIFE||||||NK^NEXT OF KIN<cr> MSH|^~\&|ADT1|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01|MSG00001|P|2.3|<cr> EVN|A01|198808181123||<cr> PID|||PATID1234^5^M11||JONES^WILLIAM^A^III||19610615|M||C|1200 N ELM STREET^^GREENSBORO^NC^27401-1020|GL|(919)379-1212|(919)271-3434 ||S||PATID12345001^2^M10|123456789|987654^NC|<cr> NK1|JONES^BARBARA^K|WIFE||||||NK^NEXT OF KIN<cr> PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||||ADM|A0|<cr> Patient William A. Jones, III was admitted on July 18, 1988 at 11:23 a.m. by doctor Sidney J. Lebauer (#004777) for surgery (SUR). He has been assigned to room 2012, bed 01 on nursing unit 2000. The message was sent from system ADT1 at the MCM site to system LABADT, also at the MCM site, on the same date as the admission took place, but three minutes after the admit.

HL7: The Positives Allows interaction with other systems appointments and scheduling lab results large areas of clinical content defined Version 3, Reference Information Model large user base

HL7: The Negatives mixture of content with representation standards many non-defined areas: Z segments very customized local implementations make extra-institutional exchange difficult document model not supported (not good with text)

The HL7 SGML SIG charter and design principles sample DTDs Kona Architecture Proposal interoperability between HL7 and SGML SGML to encode HL7 messages? Use of HL7 to contain and transport SGML documents? “best of both” approach

SGML Meeting Healthcare Informatics Needs information exchange information retrieval and reporting system and platform independence long-term access and preservation

Information Exchange mobility of patients; emergency situations changing nature of patient care claims and claims attachments claims /attachments vs. clinical documentation HIPAA (Health Insurance Portability and Accountability Act) and HCFA SGML/XML and the WWW intra-institutional and extra-institutional exchange

Information Retrieval smarter full-text retrieval based on semantics enables implementation of document model preserving multiple views clinician gets documents (context preserved) population view (system / platform independence; longevity)

Oceania EMR: WAVETM allows creation and access of clinical data in documents documents and relational tables -- health summary view access to complete document contents not standardized vocabulary: clinical content knowledge base

Oceania and Structured Data clinicians create structured sentences each word encoded based on its role in the sentence interface terminology optimized for clinicians (charting language…charting terms, browsing interface, data entry) clinicians should not have to know about structure

Oceania and SGML representing WAVE documents internally providing browser interface to vocabulary ancillary data: drug information, clinical practice guidelines benefits to Oceania clients

Early DTD Development direct mapping from WAVE document structure based on CCKB user interface for threading granularity: word, based on sentence role attributes for codes and vocabulary

Oceania DTD: Design Questions granularity retrieval purposes vs. document exchange attributes vs. elements negation and clinical documentation specificity vs. generality

DTD Development to Date an ongoing, iterative process many individuals from different functional areas engineering, clinical informatics, product development more than one DTD

Oceania and Architectural Forms standardizing implementations of SGML should not have to standardize the DTD multiple uses of architectural forms: bridge multiple representations of the Oceania documents intra-institutional exchange extra-institutional exchange (Kona)

Oceania Experience with the Kona Architecture the SOAP format and Oceania documents: the sections architectural mappings at different levels of granularity the Kona “code” and “mention” architectural “collisions”: same element; different contextual semantics

SGML Standards Family and Healthcare Informatics SGML will go forward: positives, momentum HL7 and SGML: future cooperation HyTime and others add to SGML implementation functionality what we need: collaboration with standards organizations, experience

Selected References Health Level Seven Standard. http://www.mcis.duke.edu/standards/HL7/hl7.htm Health Level Seven SGML SIG. http://www.mcis.duke.edu/standards/HL7/committees/sgml/index.html Kona Architecture Proposal to the HL7 SGML SIG. http://www.mcis.duke.edu/standards/HL7/committees/sgml/index.html

Selected References Lincoln, Thomas L, Daniel J Essin, Robert Anderson, Willis H Hare (1994). The Introduction of a New Document Processing Paradigm into Health Care Computing: A CAIT Whitepaper. Santa Monica, California: Rand Corporation. [Available at the HL7 SGML SIG website.] Morris, Jonathan A, Rachael Sokolowski, John E Mattison, David Riley (1997). Standard Generalized Markup Language (SGML) in Healthcare. Accepted for panel discussion at the Healthcare Information Management Systems Society (HIMSS) 1998 Conference in Orlando, Florida.