HL7 Decision Support Activities Rev 1 Draft Feb 23

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

HL7 Decision Support Activities Arden Syntax Version 2.5 Allow knowledge sharing within and between institutions Make medical knowledge and logic explicit Standardize the way medical knowledge is integrated into hospital information systems

Has been used to encode guidelines (as hierarchy of MLMs) Consensus: Not ideally suited for guidelines Entry points and eligibility criteria (not triggers) Flow of steps (not procedures) Ongoing work Arden as a separate standard for simple alerts Examine other models for guidelines HL7 Decision Support Activities Arden Syntax Version 2.5

Finalized dot notation and object references Added operators: Object declaration, object creation, object references, reading into an object Deferred decisions Primary time of objects Passing objects by reference or by value Change the granularity of the PRIORITY slot Allow the WHILE statement with assignment in the ACTION slot HL7 Decision Support Activities Arden Syntax Version 2.5

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

HL7 Decision Support Activities GELLO A Guideline Expression Language Purposes Query data (READ) Logically manipulate data (IF- THEN, etc) Current work: GELLO (BWH) = Guideline Expression Language

HL7 Decision Support Activities GELLO Original goal (InterMed): Procedural component for high-level guideline format (GLIF) Subsequent goal: Provide similar functionality for current HL7 KR standard (Arden Syntax) Emphasis: Shareability of queries and expressions Mechanism: Reference data in OO fashion

HL7 Decision Support Activities GELLO Provides basic data types Allows reference to underlying standard data model (vMR) Based on the Object Constraint Language (UML) Current goal: Ballot as a separate HL7 standard during the coming 12 months

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

Problem with RIM: Too abstract Potential solution: Tailored version of RIM specifically for decision support Current work: Virtual Medical Record Establish distinct objects that in RIM might be high-level classes (with mood and other attributes) Key classes: patient, plan, procedure, medication, appointment, referral, goal and assessment HL7 Decision Support Activities vMR

13 classes Most classes directly from the RIM Most attributes have direct RIM mappings Classes & attributes refined iteratively with each new guideline SAGE vMR HL7 Decision Support Activities vMR

13 classes Most classes directly from the RIM Most attributes have direct RIM mappings Classes & attributes refined iteratively with each new guideline SAGE vMR HL7 Decision Support Activities vMR

SAGE vMR HL7 Decision Support Activities vMR

SAGE vMR Classes Observation Procedure Problem Order Medication Order Substance Administration Encounter Referral Appointment Goal Adverse Reaction Alert Agent HL7 Decision Support Activities vMR

HL7 Decision Support Activities vMR - Challenges Need standard vocabularies Agreement is difficult Solution: Format for referring to a standard vocabulary in data references Examples: SNOMED-CT, ICD-9, LOINC, CPT, etc Implementation: One-time mapping between local and standard vocabularies Facilitation: Free licensing of SNOMED in USA as part of UMLS

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

Rationale for Guidelines: Knowledge dissemination HL7: Role of the SDO in knowledge representation Shareable components of computable guidelines Guideline models Convergence & the future HL7 Decision Support Activities Guidelines

Use in context of systems for providing patient care –CPOE –EMR Use at the time decisions are being made Ample success for limited alerts/reminders –Medication prescribing practices –Preventive care: screening tests, immunizations Less demonstrated success for complex guidelines HL7 Decision Support Activities Guidelines - Objectives

Avoid duplication of effort when using common guidelines in many institutions Rapid dissemination of modifications Encourage development of tools for retrieving and using guideline information Encourage future guideline authors to be more rigorous (decreased ambiguity) HL7 Decision Support Activities Guidelines - Benefits

Many models: GEODE-CM, GLIF, Arden Syntax, EON, DILEMMA, PROforma, Asbru, GEM, GUIDE, PRODIGY, … Many stakeholders: government, vendors, academics, professional organizations, etc Many types of guidelines Many types of (paper) guideline formats: narrative text, tables, flowcharts, graphs, maps, lists, critical pathways, if-then statements, etc. HL7 Decision Support Activities Guidelines - Challenges

Availability of data Identification of data: structured, controlled vocabularies Clinical data repositories: Data model Shareable knowledge representationShareable knowledge representation HL7 Decision Support Activities Guidelines - Challenges

Opposing view: A single formalism may not be possible or desirable –Complexity of guidelines and their purposes –Result: A small number of niche formalisms Arden for simple alerts/reminders Others for complex guidelines –A small group of formalisms would share common components (data model, vocabulary, expression language) HL7 Decision Support Activities Guidelines – An approach?

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

Infobutton is a point-of-care application that retrieves context-specific information from content providers using patient data extracted from the electronic medical record –Can be implemented as an HTTP request –Query parameters embedded in the URL HL7 Decision Support Activities Infobutton Definition

i What are the clinical manifestations of high serum potassium? 65 years old female physician lab results Question formulation Resource 3 Resource 1 Resource 2 ? Resource selection Answer retrieval

Non-standard APIs

Standard APIs HL7

Username & password Context –Patient: age and gender –User: patient, physician, nurse –App context: Problems, Medications, Labs, etc. Concept: Concept ^ String ^ Terminology Query modifier HL7 Decision Support Activities Infobutton Proposed Parameters

applicationContext=problems &conceptOfInterest=D &SearchString=Bacterial Pneumonia &terminology=MeSH &contentTarget=physicianhttp:// –Runs a search for D (MeSH), on the problems section of the knowledge source, and with focus on content for physicians HL7 Decision Support Activities Infobutton Proposed Example

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

Order sets allow a care provider to choose common orders for a particular disease state or circumstance according to best practice or other criteria for assembling the order set without having to generate each order individually. The EHR may recommend order sets in certain conditions or as the result of other clinical information being entered into the EHR. Or the order sets may simply be available for use by the ordering care provider HL7 Decision Support Activities Order Set Functional Description (EHR DSTU Draft)

Support a sequencing of orders for logical and useful presentation to the ordering provider Support explanatory (non-actionable) sequenced elements for ease of use and informational content Order sets may be nested within order sets in order to support editorial efficiency and to avoid clinical and administrative update anomalies Order sets have a unique identification key which supports identification and use in multiple order sets Support identification of an author and brief editorial history in the header Support menu features which include AND, XOR at the level of order selection HL7 Decision Support Activities Order Set Requirements

Each order has a clear text description Support mapping to enterprise order master. Provide a readable version of the orders and the order set. HL7 Decision Support Activities Order Set Requirements

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook

HL7 Decision Support Activities Implementers Workbook

HL7 Decision Support Activities Summary Issues Data capture/display/storage EMR central data repository Controlled, structured vocabulary Knowledge representationKnowledge representation Knowledge acquisition Clinical event monitor: integrate the pieces for many different uses (clinical, research, administrative)

HL7 Decision Support Activities Summary Issues How to represent (executable) guidelines? How to validate algorithm? How to validate implementation? Who does the validation?

HL7 Decision Support Activities Highlights Arden Syntax GELLO vMR Guidelines Infobutton Order Sets Implementers Workbook