1. GP2GP Clinical Semantics Leo Fogarty Russell Hotel 12/12/03

2. Nature of health records Collection of information about the health of a person Contains entries made –On one or more occasions –By one or more authors A person may have many health records –A combination of health records for the same person is a health record –A copy of all or part of a health record is a health record

3. Purposes of health records Care of the patient –Informing and reminding care providers –Organising thinking and decision making –Communicating with other care providers Care of the population –Clinical, social and therapeutic research –Epidemiology and strategic planning Support for providers –Professional education and training –Financial, contractual and legal Support for provider organisations –Financial, contractual and legal –Planning services

4. Content & structure of health records Notes –Free form narrative (and cryptic abbreviations) –Documents with agreed conventions –Completed forms Reports –Letters and text reports –Structured numeric reports –Pictures, graphs and tracings Structures –Problem lists and alerts –Episode summaries –Coding for classification and grouping Supporting information –Dates, times, people, places and signatures –Demographics

5. Records, Readers, Authors Introversion, Extroversion and Idleness Obsessives and Creatives Bible Scholars and Cynics Navigators and Head Bangers Informatic Ignorance and Wisdom Solomons and Grundies

6. Electronic health records Health records in electronic form –CPR, EPR, EHCR, EHR, EMR, PMR, … Purposes –As for health records –“Electronic” adds or subtracts value Contents –As for health record –“Electronic” reuse may reduce duplication Structure –Document, message and data –Narrative, code terminologies and templates

7. Elements of Clinical Information The Record of Patient Information as Text:- which is human-readable and easily communicable The inclusion of codes: XE2uV Ischaemic Heart Disease Which may be qualified as: X793b Mild X78th First Episode Which sit in a context which might include: A Heading: “Past History” or Modifying Information: Q= “Possible” Which all sits in a document: “Referral Letter” Which was constructed during an event: Surgery Consultation Relating to an ongoing Problem: Chest Pain

8. A Construction DISCHARGE NOTE Kettering General Hospital Rothwell Road, Kettering Northants NN16 8UZ Tel: 01536 492000 Dear Dr: Prunesquallor A Date: 04/02/2000 Surname: BEAUHARNAIS Unit No: 123451 First name: JOSEPHINE DoB: 01/01/22 NHS: 1234567895 Address: 5 Whitehall KETTERING NORTHANTS NN00 1OO Ward: Deene B Admitted On: 07/01/2000 Discharged On: 02/02/2000 Consultant: Zhivago Y Primary Diagnosis:Pelvic malignancy Secondary Diagnoses:Anaemia unspecifiedD21z. Haematuria K197. Complications: Operations & Procedures Urethral Catheterisation Urethral irrigation of bladder Other blood transfusion NOS Diagnostic Cytoscopy (Rigid) & Bladder Biopsy M478a M471 X339 M451c Date of Op/Proc 07/01/00 08/01/00 09/01/00 10/01/00 Additional Information \ Instructions For palliative care. OPD Follow Up Weeks Signed:Maggie Bell Print Name:Maggie Bell Designation:Clinical Practitioner

9. Positional Syntax Approach Required

10. Positional Syntax Approach

11. One Representation on Receipt DISCHARGE LETTER04/02/2000 BEAUHARNAISJOSEPHINE01/01/22 ZY Urethral Catheterisation Urethral irrigation of bladderOther blood transfusion NOS Diagnostic Cytoscopy (Rigid) & Bladder Biopsy (M478a) (M471)(X339) (M451c) (D21z.)Pelvic malignancyAnaemia unspecified Haematuria(K197.) For palliative care. Patient Details Date of EventEvent Type History Examination Investigations Healthcare Professional Procedures Comment Date of Birth

12. What was Lost? Hospital Address Unit Number The Ward The dates of admission/discharge/operations/procedures Clinical Heading Context –Significant loss of clinical meaning Healthcare Professional Names Healthcare Professional Roles Attestation Identification of Management Plan/Intention In short: - CONTENT and CONTEXT

13. Semantic Interoperability Needs Clinical Coding Schemes –Clinical Concepts –Drugs People, Places and Roles Aggregations –Templates/Archetypes/Clusters Dates Architectural Containment and “Glue”

14. Merriam Webster Definition:Merriam Webster Definition: a unifying or coherent form or structure; a method or style of building Architecture ?

15. GEHR (North) Simplified EHCR EHCR Extract Transactions List of Transaction Types Content CategoryObservation ItemItem Collection List of Item Types

17. ENV 13606 message structure types of 1 contains 1.. * types of 1.. * EHCR extract original component complex record component link item data item folder composition headed section 1 EHCR message cluster

18. ENV13606 message data items record component data item type of Plain/HTML text structured coded quantifiable observation medication physical entity reference external data reference event person identifier person name language address telecom patient related party related location community defined types of

19. GEHR (South)

20. CDA at RIM level

21. Information model – EHR Containers

22. Information model – Clinical statements

23. GP2GP Language Coding Schemes –Read –EMIS –Multilex –Local Consultation Categories (Headings)

24. GP2GP Language Architecture Names Level Codes Composition Names Document Names Compound Names Link Names

25. GP2GP Language Qualifiers Problem Status Epidocity Medication Mood Secondary Status Terms

26. GP2GP Language Major Modifiers Certainty/Negation Action Status Significance Subject of Information Sensitivity Validity

27. GP2GP Project Outcome NHSIA Project 1/6/01-31/5/03 V3 Messaging successful Four (Now five) suppliers implemented in test bed circumstances One supplier implemented same system transfer “for real” Further piloting happening Quo Vadis?