1. Virtual Medical Record (vMR): A Simplified RIM-Based Data Model for CDS
HL7 Work Group Meeting, San Diego, CA
September 2011
Kensaku Kawamoto, MD, PhD
Director, Knowledge Management and Mobilization
Assistant Professor, Department of Biomedical Informatics
University of Utah

2. Background
A “holy grail” of clinical informatics is scalable, interoperable CDS
Key requirement for interoperable CDS and re-use of CDS knowledge resources = use of a common patient data model
Referred to as a “Virtual Medical Record” or vMR (Johnson et al., AMIA Annu Symp Proc, 2001)
Lack of a common vMR is a major barrier to sharing knowledge and scaling CDS
Known as the “curly braces” problem in Arden Syntax
SCT 14May

3. Example Challenge without VMR
Observation Blood Pressure
Code = BP Systolic = 120 mmHg
Value = 120/80 mmHg Diastolic = 80 mmHg
Observation Vital Sign
Code = BP Type = BP
Observation Value = 120/80
Code = SBP Units = mmHg
Value = 120 mmHg
Observation
Code = DBP
Value = 80 mmHg
SCT 14May

4. vMR Goal
Provide common information model upon which interoperable clinical decision support resources (e.g., rules) can be developed
Desired attributes:
VMR instances can be derived from HL7 V3 artifacts, in particular CCD and Pedigree instances
VMR instances can be populated from HL7 V2 messages, in particular for laboratory data
Leverage Detailed Clinical Models
Capable of being easily understood and used by clinicians/analysts without significant V3 training

5. Project History
Analysis of data required by 20 CDS systems from 4 countries
Analysis of HL7 CCD, Pedigree, Clinical Statement, and other relevant models
Use of greenCDA/greenCCD as an example approach to simplification
Trial implementation of vMR via OpenCDS
Under ballot for September 2011 Work Group cycle
Domain Analysis Model
GELLO implementation guide

6. Simplified ISO 21090 Data Types
SCT 14May

7. CDS Inputs
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8. CDS Outputs
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9. vMR Payload
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10. Example Clinical Statement
SCT 14May

11. vMR Ballot Reconciliation – Overview
Domain Analysis Model
47 affirmative, 2 negative
GELLO implementation guide
34 affirmative, 0 negative
SCT 14May

12. vMR – Future Directions
Additional implementation guides
Existing/underway: GELLO, v2 implementation guides
XML, Drools, other implementation guides (e.g., Arden?)
Template specifications
For standard data models (e.g., CCD, Pedigree, Care Plan)
For common types of CDS (e.g., drug-drug interactions, vaccine forecasting, family history risk analysis)
Transformations to/from standard models
Alignment with relevant ongoing HL7 work (e.g., CSP, RFH, detailed clinical models)
Version 1.1 based on implementation experience (e.g., via OpenCDS)

13. OpenCDS
Standards-based, open-source clinical decision support (CDS) Web service
Uses HL7 Decision Support Service (DSS) interface
Uses standard data payloads (e.g., CCD, VMR)
Uses standard internal data model (VMR)

14. OpenCDS – Architectural Overview
Standard Interface:
HL7/OMG Decision Support Service Standard (
Standard Data Models:
HL7 Virtual Medical Record (vMR) Standard
[ Virtual_Medical_Record_(vMR) ]
Institution A
Trigger
Queries for required pt
data
Patient Data Sources
Patient data,
knowledge modules to use
Client Decision Support Apps
Conclusions about patient
Institution B
Client Decision Support Apps
Patient Data Sources
Queries for required pt
data
Decision Support Service
Knowledge Modules
SCT 14May

15. Decision Support Service
CDS Services – Example
Eval. Result
VMR
CCD
Pt data
Patient Data Sources
Decision Support Service
EHR System
SCT 14May

16. Current OpenCDS Collaborators
University of Utah
HLN Consulting, LLC
Apelon, Inc.
Intermountain Healthcare
Veterans Health Administration
Wolters Kluwer Health
EBSCO
Univ. of NC at Chapel Hill
Main Line Health
Stanford University
Keona Health
Mass. General Hospital
Hospital Universitario Virgen del Rocío, Spain
MaRS Innovation, Canada
SmartCare, Africa
Emetra AS, Norway
Visumpoint, LLC
Genesys, LLC
df8health
Religent, Inc.
IsoDynamic, Inc.
Calcudos.com, Inc.
CogniTech Corporation

17. Key Components of OpenCDS
Standard interfaces and data models
Reference implementation of HL7/OMG DSS interface
vMR data model
Data mappers (e.g., for CCD  vMR)
Reference DSS knowledge management framework
JBoss Drools and associated authoring/knowledge management tools
Full-featured terminology support
A “domain specific language” for intuitive knowledge authoring
Knowledge repository and knowledge sharing service
DSS “wrappers” for other CDS engines

18. NQF Measure 31 for Meaningful Use

19. OpenCDS Implementation – Denom.

20. OpenCDS Implement. – Underlying Details

21. OpenCDS Implementation – Decision Table

22.
SCT 14May

23. Backup Slides
SCT 14May

24. Key Benefits of Approach
Builds on robust open-source community and resources
Provides standard architectural framework for integrating various CDS knowledge resources
Supports full life cycle of knowledge authoring, testing, maintenance, and execution
Provides an open-source framework for collaboration and innovation in CDS
Freely available under Apache 2.0 license
SCT 14May

25. DSS Invocation - Wrapper
NQF knowledge module
vMR payload

26. DSS Invocation - Payload
Age & gender
Past encounters
Past mammographies

27. NQF evaluation result payload using vMR
DSS Response - Wrapper
NQF evaluation result
NQF evaluation result payload using vMR

28. DSS Response - Payload
Denominator criteria met
Numerator criteria met