1. NHS Modelling Efforts – ISO13606 adoption and beyond Dr. Rahil Qamar Siddiqui Health and Social Care Information Centre, NHS, England

2. Background: Information Standards use in UK The Health and Social Care Act 2012 states that the following must have regard to an Information Standard published under the Act: Secretary of State for Health NHS England Public bodies involved with health services or adult social care Anyone providing publicly funded health services or adult social care commissioned by or on behalf of a public body

3. Information Standards development Source: www.hscic.gov.uk

4. Implementing Standards The Information Standards Delivery department provides the building blocks to enable development and implementation of information standards Terminologies Read SNOMED CT dm+d Classifications OPCS-4 ICD-10 NHS Data Dictionary Data Collections Data Sets NHS Data Dictionary for Care ? Data recording/ record keeping Terminology Binding

5. HSCIC.GOV.UK -> Information Standards

6. HSCIC.GOV.UK.. With DD4C

7. The DD4C Process..(1)

8. The DD4C Process..(2) Phase 1 Existing Content SNOMED CT Subsets Data Collections NHS Messaging Specs Royal Colleges Headings Catalogue Define metadata of all content Metadata model based on ISO 13119 Harmonise ISO13606-based logical models for Royal Colleges headings ISO13606-based logical models for clinical record keeping Publish

9. Catalogue Metadata

10. Logical Models for Care..(1) The aim Provide clinically assured, quality assessed, process-driven logical representations of health care records Single reference point for all product-dependent modelling work such as NHS Data Dictionary and NHS Messaging Specifications Provide metadata for our logical models to provide valuable information about the models as well as to allow associations with other content such as SNOMED CT subsets, message templates etc Allow multiple format download of our logical models as a free public resource: ADL, UML, HTML, XML, JSON, Mindmap, Word etc.

11. Logical Models for Care..(2) ISO 13606 Extract Reference Model adopted Revision proposed to ISO 13606 Demographics Model (awaiting adoption) SNOMED CT used as the reference terminology for binding to clinical content Demographic and participant-related vocabulary for other content (to be decided) LinkEHR Editor used for logical modelling (pending approval) Logical Modelling Guideline document to help with consistent modelling and terminology binding (draft status)

12. Logical Models for Care..(3) Two level modelling process High level models (for initial discussion with health informaticians and clinicians) Logical models (technical models for discussion with health informaticians and technical modellers) Transformation process (initially manual but possible automated transformation in future?) NHS Data Dictionary models NHS Messaging Specifications (CDA, FHIR?) Other consumers (NHS as well as external) that require information models

13. Logical Models for Care..(4) ISO13606-based models for Royal College headings ISO13606-based models for record keeping External Reference Resources Discharge Summary Outpatient Referrals Diagnosis Blood Pressure Medications.... CIMI Models SemanticHealthNet patterns CONTSys SNOMED CT International Internal Reference Resources SNOMED CT UK Extensions Logical Record Architecture (LRA)

14. Example: Royal Colleges Headings

15. Level one: High level (discussion) models

16. Level one: High level Examination Finding

17. Level two: Logical models Bottom-up modelling approach..(1) CLINICAL STATEMENT SUB-PARTS: CLUSTER & ELEMENT Where clinical statements have a more complex structure, each of the sub-parts of a clinical statement should be modelled as independent, reusable models using the ITEM classes: CLUSTER and ELEMENT. These clinical statement sub-parts may represent both the core data describing parts of a statement and, optionally, other details the – examination method (technique and/or device used), – the patient’s physical state, – assertion status such as presence/absence, normality/abnormality indicators of the core value. When modelling a clinical statement sub-part it is appropriate to start at the CLUSTER class as the ISO 13606 Reference Model allows for nesting of CLUSTERs within CLUSTERs as well as inclusion of one or more ELEMENTs which hold the actual data

18. CLUSTER: Blood Pressure Measurement

19. CLUSTER: Blood Pressure Measurement State

20. Level two: Logical models Bottom-up modelling approach..(2) CLINICAL STATEMENT: ENTRY Clinical Statements in this document refer to clinical observations, requests, results, actions, plans, instructions, intentions, interpretations, reasoning etc. which may have a simple or a more complex structure. Each of the CLUSTERs represents a single, indivisible, and reusable clinical statement sub-part which are then collectively modelled in an ENTRY, which is used to record information in an EHR as a single, indivisible clinical statement. The ENTRY class also helps to provide the set of context attributes that help to facilitate the safe interpretation of the clinical statement.

21. ENTRY: Blood Pressure

22. Level two: Logical models Bottom-up modelling approach..(3) COLLECTIONS: SECTION The term Collections is used to refer to a group of clinical statements which might be viewed together under a common heading for human consumption. These collections are modelled using the CONTENT class: SECTION. Within DD4C, the SECTION class should be used only when implementation-specific requirements warrant the need for headings such as is the case with the Royal Colleges headings. NOTE: Else the CLUSTER and ENTRY models should be used to logically model the clinical content irrespective of how it is desired to be viewed by specific user communities.

23. SECTION: Vital Signs

24. SECTION: Examination Findings

25. Level two: Logical models Bottom-up modelling approach..(4) ORGANISERS: COMPOSITIONs and FOLDERs Collections of clinical statements could be included in high- level organiser groups to which authoring, attesting, and auditing information can be associated. These organisers help in human readability, storage, and communication rather than machine computability and semantics. COMPOSITIONs are typically used to communicate extracts of records both internally within an organisation such as Admission and Handover records, as well as records that might be communicated externally such as Discharge, Outpatients, and Referral records. Each instance of a COMPOSITION is about a single subject of care.

26. COMPOSITION: Outpatients

27. Logical Models for Care.. (5) The project started mid-November 2013 First batch of logical models to be produced by end of April 2014 – Royal College Headings 2-3 detailed headings e.g. Vital Signs, Diagnosis, Procedures – Medications (which includes Dose Syntax) Dose Syntax, LRA models, other NHS work, Reviewing Scottish work on Medications (using openEHR archetypes) Terminology Binding strategies underway. All ‘clinical’ logical models to be bound to SNOMED CT appropriately. ‘Demographic’ logical models along with participant information to be included as per requirements.

28. Logical Models for Care..(6) Future Aspirations! NICE - National Institute for Health and Clinical Excellence Large, open library of logical models for primary consumption within NHS and its providers Provide implementable NICE Guidelines : supported by logical models Provide a valuable resource to Standardisation Committee for Care Information (SCCI) (old ISB) to harmonise the content within the standards approved by them to have a better view of data and information flow across existing SCCI standards Provide rules for applying a combination of logical models along with the implementable NICE Guidelines and (potentially) SCCI standards mandated to arrive at decision support logic.

29. Thank you Questions? rahil.siddiqui@hscic.gov.uk