Logical Model Collaboration Scope, proposal, and next steps

The Need A logical model With a strong community behind it That is clinically viable That is expressive That is structured and computable That supports reasoning That informs FHIR profiles That supports “closing the quality feedback cycle” That is implementable

The Problem (I) Often conflated with a physical model such as FHIR Often implied and not explicit vMR + QDM  QUICK  QI Core  QUICK’ DAF SDC Too many variants out there RIM QDM vMR QUICK/QIDAM/QUICK’ CEM CIMI FHIM SNOMED/LOINC/RxNORM …

The Problem (II) Unclear boundary between terminology and model Unclear boundary between expression language and model Often inconsistent Patient has diabetes (Condition) Presence implied Patient does not have diabetes (Observation) Absence explicit Pre-coordinated/conflated semantics Incomplete or just ‘too hard’ Scope hard to define. Need some boundaries.

Exploration Areas for LM Collaboration What is a Logical Model? How does it differ from a physical model like FHIR? How does it differ from a reference model like CIMI Core? How does it align with clinical terminologies/ontologies such as SNOMED CT? How far does it align with clinical terminologies/ontologies such as SNOMED CT? Bindings only? At model level too? How can it be implemented? How can it be leveraged for Quality Improvement Can we better align (or eliminate) variants and how?

Time Frame First set of meeting to last 8 weeks Begin exploration of model/terminology alignment Focus: Alignment of CIMI ‘Observation Result’ with SNOMED Observable Model Use Case: Systolic BP Goal: Implement simple prototype illustrating alignment of approaches Last meeting of series on 10/13 Group to decide how to proceed after 10/13 Question: Should group disband and regroup under the CIMI Modeling Task Force? Should group remain as an exploratory task force looking at longer term questions?

Discussion to Date CIMI/SNOMED Observable Reconciliation Slides from Keith Campbell

Assumptions: Terminology Taken from: SNOMED CT is the primary reference terminology LOINC is also approved as a reference terminology SNOMED relationship concepts will be used to define the parent-child relationships in the models

Assumption: Models Taken from: CIMI models shall, by design, include SNOMED CT content Goal: Enable use of the SNOMED CT concept model to support translation of data from pre coordinated to post coordinated representations

Proposal: Naming Overlapping naming has led to confusion about the collaborative and/or competitive nature of CIMI and SNOMED The SNOMED/LOINC Observable Model has a significant development history, and has specific, documented meaning An alternative yet intuitive name for a complementary CIMI effort can reduce confusion and perceived competition Possibilities CIMI Observation Result Model CIMI Assertion Model

Proposal: Separation of Concerns Clearly and reproducibly delineate a separation of the semantics of the terminology from the semantics of the higher- order models Use a simple nested structure to differentiate observable model attributes surfaced by CIMI All surfaced attributes are defined with respect to the SNOMED/LOINC observable model, although CIMI may define “friendly” preferred names for use within the CIMI model Simpler to understand and implement while “using the SNOMED CT concept model to support translation of data from pre coordinated to post coordinated representations”

Example: Simple nested Structure Subject of information Code Reason Method Result observation Subject of information Observable* Reason Method* Result assertion Subject of information Reason Result assertion Code/Expression Method Other surfaced attributes observable Separate the terminology model attributes from higher-level model attributes Existing model Renamed model Separated model 11

Alternative Names Subject of information Reason Result observation result Code/Expression Method Other surfaced attributes discernable Intuitive names that do not overlap can reduce confusion and perceived competition assertion/observable observation result/observable observation result/discernable 11 Subject of information Reason Result assertion Code/Expression Method Other surfaced attributes observable 11 Subject of information Reason Result observation result Code/Expression Method Other surfaced attributes observable 11 Subject of information Reason Result assertion Code/Expression Method Other surfaced attributes discernable assertion/discernable 11

Defining CIMI Surfaced Attributes Provide algorithmic support for translation between pre- and post-coordinated forms. SNOMED Templates are one possibility XSL, Xquery, and other options are possible

Moving forward How do we turn these ideas into reality? Naming Separation of concerns Define surfaced attributes and pre/post coordination transformation specification Add any necessary concepts to a CIMI extension CIMI has obtained a SNOMED CT extension identifier CIMI is committed to create a Terminology Authority to review and submit concepts to IHTSDO as appropriate

Validating the Proposal Systolic Blood Pressure Use Case

Selected Initial Use Case Representing a “systolic blood pressure taken from the right brachial artery using a blood pressure cuff while the patient is supine and at rest”

|Systolic blood pressure (observable entity)|: |Property type (attribute)| = |Pressure (property) (qualifier value)|, |Inheres in (attribute)| = |Lumen of artery (body structure)|, |Direct site (attribute)| = ( |Structure of brachial artery (body structure): |Laterality (attribute)| = |Right (qualifier value)|), |Technique (attribute)| = |Auscultation (procedure)|, |Using device (attribute)| = |Blood pressure cuff, device (physical object)|, |Precondition (attribute)| = ( |Supine body position (finding)|, |Precondition (attribute)| = ( |Resting state (finding)|) SNOMED Post Coordinated Expression

Prototype Next Steps CIMI Team working on development of a CIMI ADL representation of CEM Systolic Blood Pressure model CIMI systolic BP model to be represented using AML VA Team to build SNOMED CT ‘template’ Group to determine how to map the two models in ADL/AML VA Team to explore and develop transformation between iso-semantic representations Group to review approach

Next Steps for Collaborative Work Towards Better Convergence

Convergence Centralize logical model efforts and profile development under CIMI umbrella? Will CIMI be an HL7 Working Group? Need central governance to prevent fragmentation Derive FHIR profiles from CIMI logical model DCM profiles Foundational profile Bottom up/top down approach Multi-layered logical model DCM (Serum Creatinine) Mid-level logical model(s) (QuantitativeLabResult  Observation Result) Moving beyond assertion models E.g., procedures and procedure requests E.g., Composite orderables …

Cross Collaboration HL7/FHIM participation in CIMI logical model effort CIMI/HL7 participation in terminology efforts (SNOMED, LOINC, RxNORM). Eg., Extension of SNOMED CT Development of observable model Development of procedure model Development of orderable catalog

Validation & Adoption Encouraging use of CIMI profiles (not just plain FHIR resources) in HSPC and SMART-on-FHIR projects Validate logical model use cases for clinical quality improvement in HSPC and SMART-on-FHIR projects Who else needs to be targeted for implementation and validation Argonaut Epic, Allscripts, Cerner, VA Others Does HSPC reach a broad enough community?