T Beale, Joey Coyle CIMI meeting Sep 2012 Copyright 2012 Ocean Informatics

 Brief pictorial representation of CEMs  CEM  archetype conversion architecture  Issues to do with transformation ◦ Reference model ◦ Data types ◦ Formalism ◦ ‘style’ issues Copyright 2012 Ocean Informatics

Statement > Data StandardLabObs Quantitative e.g. PQ Statement > Data SodiumSCncPt SerPlasBldQnLabObs PQ; mmol/l; labNullFlavor > Attribution > Attribution > Qualifier > Item Statement > Qualifier > Qualifier > Mod > Attribution StandardLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data

> Attribution > Attribution > Qualifier > Item Statement > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item!

> Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! > Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! > Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! > Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! Na + K+K+ HCO 3 - etc > Attribution > Attribution > Qualifier > Item State ment > Qualifier > Qualifier > Mod > Attribution StandardLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data > Attribution > Attribution > Qualifier > Item > panel > Qualifier > Qualifier > Mod > Attribution StandardLabPanel Subject > Qualifier > Data > Qualifier > Data > Item > Item items AccessionNumber; ReportingPriority; TestStatus; PlacerOrderNumber; ResultCopiesTo SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Card (0..*) ~3,000 of these!

> Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! > Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! > Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! > Attribution > Attribution > Qualifier > Item State ment > Data > Qualifier > Qualifier > Mod > Attribution SodiumSCncPt SerPlasBldQnLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item PQ; mmol/l AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Everything eventually turns into Data & Item! Na + K+K+ HCO 3 - etc > Attribution > Attribution > Qualifier > Item State ment > Qualifier > Qualifier > Mod > Attribution StandardLabObs Subject > Qualifier > Data > Qualifier > Data > Item > Item AccessionNumber; ReportingPriority; ResultStatus; PerformingLaboratory; ResponsibleObserver SpecimenCollected; SpecimenReceivedByLab; Resulted; Verified... > Data > Data Electrolytes archetype Lab archetype Lipids archetype LFT archetype etc e.g. Chem20 panel template Archetypes are governance units Templates are the actual models – data sets

 Issue areas: ◦ Reference model differences, including data types ◦ CDL / ADL formalism differences ◦ Model style: granularity, factoring, element classification, structuring ◦ Terminology approach

CDL  ADL converter Arche type Temp late CEM IHC Terminology direct coding Canonical CEM test library CEM CEM  CEM restyler Restyling to obtain consistency IHC Terminology direct coding IHC Terminology binding

 CEM Reference model ◦ Minimalist, ‘RISC’ approach  Statement / Component / Item; Association / Panel /... ◦ Assumes CEMs will do more of the work  openEHR Reference Model ◦ Larger, ‘CISC’ approach ◦ More higher level classes ◦ Archetypes do less work

 CEMs based on modified/simplified HL7 data types  Data type mapping analysis performed ◦ ~ 1:1 match with openEHR ◦ Particular issues:  Some things don’t exist in openEHR  PQ.originalText  CD.codingRationale, CO.codingRationale

 Generally: similar power to ADL but: ◦ Not block-structured  Uses recursive inclusion only ◦ No languages (not needed) ◦ Binding to multiple terminologies not native in CDL - requires using external terminology server (doesn’t have to be IHC) ◦ No multi-attribute (co-occurrence) constraints. ◦ Context-conduction  probably too difficult for modellers to reason about; complicates software... My (TB) personal view  Joey Coyle: this only occurs from panel to statements. The modeller models the statements first!, optional panels come later… no reasoning when building a panel… if qualifier is common to all children in a panel, then makes sense to this simple farm boy that it could go in the panel. ◦ Does templating as single files allowing anonymous constraint types.  ADL 1.5 has same semantics but uses multiple files; needs to be more like CDL

 The following slides are early analysis on my part (TB) ◦ May contain errors  Partly corrected by Joey Coyle ◦ Not criticisms of CEM model base ◦ Many true of CKM model base ◦ Possible risks for any model base, including CIMI

A. Inconsistent style across model base ◦ E.g. Inheritance used in models such as lab and order CEMs but not in others such as measurements and assertions. B. Legacy structuring due to: ◦ Earlier modelling styles now deemed obsolete ◦ Limitations of ASN.1, CEML and/or previous tooling C. Undesirable structures/patterns due to perceived tooling / CDL limitations D. Style that is consciously or unconsciously due to implementation needs E. Patterns due to Ref Model structure (applies to more hard-wired RMs than Intermountain)

F. Conscious ‘good style’ ◦ There today and intended to be preserved G. Further ‘good style’ ideas ◦ described but not yet implemented on model base H. As yet undescribed limitations, poor or missing patterns

 Probably due to ◦ organic growth of models over time ◦ lack of integrated analysis tools (some exist for ASN.1 model and other CEM representations) ◦ Lack of fully described modelling methodology, and different modellers following different styles. Is avoiding this ever possible? ;-)  Examples: ◦ Inheritance is used in StandardLabObs hierarchy, … but not in clinical measurements. ◦ Unclear how much re-use actually exists i.e. are there leaf models that should be incorporated into parents?  requires analytical tool like slot analysis ◦ Qualifiers classification – objective rules?

 Due to previous incarnations of models  Example: ◦ Address sub-items AddressLine1, AddressLine2, etc are separate models due to in ability of ASN.1 to conveniently do nesting. CEML (generation 2) was created to solve this ◦ Nesting now available in CDL – anonymous inline models, but not always used because models have not been converted ◦  child ‘models’ should be incorporated into parent, e.g. Move addressLine1.. N CEM into Address CEM

 CDL may not provide everything that is needed  Example: ◦ There is no Chem20 or Chem7 panel CEM  Note: they are technically possible, just not there ◦ Don’t add any value in Intermountain because all context items are defined on leaf level atoms anyway, but on other RMs this would not be true

 CDL may not provide everything that is needed – do modellers compensate?  Example: ◦ No way to express co-occurrences, e.g. existence of one field depends on value of others. ◦ Others - TBC

 Examples: ◦ A number of Qualifiers appear on single analyte models that only sensibly apply to whole panel, even in the case where panel contains one item  E.g. PlacerOrderNumber, FillerOrderNumber, AccessionId, ResultStatus ◦ These have the appearance of being repeated on all analytes in a panel.  In fact they are not repeated on all analytes in a panel - analytes are modeled completely free from a panel, and if a panel is then later modelled, then common qualifiers among the analytes are also modeled into the panel (Q: is this actually always done?) ◦ The panel model includes some duplicate items

 Some elements appear to be always the same, and could be included in reference model or ‘reference archetype’ aka ‘base models’ ◦ E.g. An Observation with ‘subject’, ‘info provider’

 Use of inheritance e.g. StandardLabObs, Order, Attribution.

 Possible additions ◦ ‘archetype-CEMs’  Add ‘governance unit’ models like archetypes that group things based on topic  Add actual panel/data-set models that inherit from archetype-CEMs and remove unwanted stuff ◦ Separate out process data points from clinical data points  Typically very local, e.g. Workflow ids, order management elements etc