1. 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
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!

2. 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.

3. Document Model

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

5. 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

6. 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 =
many other examples to choose from
each optimized for different purposes
each purpose needs to be addressed by vendors
can’t “just pick one!”

7. 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

8. NK1|JONES^BARBARA^K|WIFE||||||NK^NEXT OF KIN<cr>
MSH|^~\&|ADT1|MCM|LABADT|MCM| |SECURITY|ADT^A01|MSG00001|P|2.3|<cr>
EVN|A01| ||<cr>
PID|||PATID1234^5^M11||JONES^WILLIAM^A^III|| |M||C|1200 N ELM STREET^^GREENSBORO^NC^ |GL|(919) |(919) ||S||PATID ^2^M10| |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.

9. 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

10. 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)

11. 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

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

13. 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

14. 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)

15. 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

16. 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

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

19. 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

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

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

23. 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)

24. 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

25. 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

26. Selected References
Health Level Seven Standard.
Health Level Seven SGML SIG.
Kona Architecture Proposal to the HL7 SGML SIG.

27. 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.