1. SNOMED Bound to (Information) Model Putting terminology to work… Koray Atalag MD, PhD, FACHI k.atalag@auckland.ac.nz Senior Research Fellow (NIHI & ABI) openEHR Management Board Member Vice Chair HL7 New Zealand Member HISO / SAG HL7 NZ Workshop, 24 Jul 2015

2. Information Models Definitely NOT reference information models; – as in HL7 v3 RIM, openEHR/ISO13606 or FHIR resource ontology! Define how to capture/represent health information, not the actual concepts (that’s epistemology/ontology!) – e.g. FHIR Patient resource is concerned with how to capture patient information, not define what patient means per se! Use terminology to define clinical meaning or bind valuesets They may employ a number of formats and methods; inc. – Spreadsheets, data dictionaries, mindmaps, UML, XSD, Archetypes, v3 & FHIR and even programming languages Examples: FHIR (HL7), Archetypes (openEHR), Detailed Clinical Models (DCM), Clinical Element Models (CEM-Intermountain)

3. Dealing with forms, Access databases

4. From 2001!!! http://pathos-web.sf.net Using ASTM healthcare DTDs… No CDA, no archetype! First class IM

5. Where in the interop stack? Technical/Format Network & Data Standards Syntax/Semantics Terminology Standards Process/Integration Exchange Standards Structure/Advanced semantics Content Standards SNOMED, ICD, ICPC LOINC, NZMT/NZULM ATC / GMDN UN/EDIFACT HL7 v2, v3, FHIR openEHR/13606 Extract HL7 FHIR, CDA, ASTM CCR openEHR/13606/CIMI DICOM SR TCP/IP, HTTP HTML, XML RDF, JSON, DDL

6. Structure with terminology: SNOMED Inconsistencies due to different post-coordination of concepts In a vasculitis physical examination: “Vascular exams: Carotid Right/Tender” 247348008 | tenderness (finding) | : 363698007 | finding site | = 69105007 | Carotid artery structure (body structure) | : 24028007 | Right (qualifier value) | _____________________________________________________________________________ 301390006 | tenderness of cardiovascular structure | : 363698007 | finding site | = 69105007 | Carotid artery structure (body structure) |: 272741003 | laterality | = 24028007 | Right (qualifier value) | _______________________________________________________________________________ 309655006 | On examination-artery (finding) | : 69105007 | Carotid artery structure (body structure) | : 24028007 | Right (qualifier) |: 247348008 | tenderness | _______________________________________________________________________________ 401050002 | Carotid artery finding (finding) | : 363698007 | finding site | = 69105007 | Carotid artery structure (body structure) | : 272741003 | laterality | = 24028007 | Right (qualifier value) | : 247348008 | tenderness |

7. The Sensible Way to tackle structure from the point of implementers

11.  Open specs, tools and content for representing health records & building EHR Systems – 20+ years of international experience (Good European Health Record - GEHR) – Origin and superset of ISO/CEN 13606 Standard – An MDA/MDD Software Engineering Paradigm (e.g. “Inside Systems” vs HIE) – Learning curve for implementers BUT easy on clinicians / modellers  Governed by openEHR Foundation (not-for-profit)  I’m one of 4 elected Management Board members (end of 2014)  What’s different?  Modelling method: separation of clinical and technical worlds  Mature tooling, scientific research & reference implementations in almost all programming languages Once in Gartner Hype Cycle! – Steady international community, maturing now – Underpins many national EHR programs (most Nordic, Brazil, Slovenia)

12. The Sensible Way cont.

18. IM & Terminology Terminology: Labels/codes attached to atomic concepts (mostly without clinical context) – Diabetes Mellitus, ear ache, left hip, CT scan etc. Some have hierarchy (ICD) & relationships (SNOMED) Boundary Problem (overlap)  Terminology binding Information Model: structure and semantics of concrete clinical concepts with clinical context/provenance – Health condition, lab test result, discharge summary, adverse reaction, prescription etc.

19. Terminology Binding ‘A formally expressible connection between information model representation and terminology representation of clinical statements recorded in the EHR’  Examples define a terminology subset ^ 1111000000132 |allergy event|: 246075003 |causative agent| = < 373873005 |pharmaceutical / biologic product| OR < 105590001 |substance| Two different types of terminology bindings: 1)linking a data item to external terminology/ontology for the purpose of defining its real-world meaning 2)Linking data element values to external terminology (e.g. a RefSet or terminology query)

20. Blood Pressure Measurement mindmap representation of openEHR Archetype 1) Linking items to SNOMED to define clinical meaning

21. NZ Cardiac Registry: Medication 2) Linking data element values to external terminology (NZULM)

22. Clinical Information Modeling Initiative Led by Stan Huff to address profiling needs Develop a single curated repository of models Using a single modelling formalism – Selected Archetypes as starting point – Will harmonise with UML > Archetype Modeling Language (OMG is on it!)

23. & FHIR resources and Archetypes are closely related – should avoid reinvention at all costs! – Also FHIR extensions/profiles <> openEHR Templates Archetype  FHIR resource conversion is expected to be seamless – Archetypes are usually more detailed; as opposed to FHIR resources include most commonly used items (80/20 rule) with an option to extend as needed An opportunity exists for FHIR to leverage openEHR content, tooling and expertise – FHIRman says base resources are not enough! Oh did I just forget SNOMED? – Not really, both FHIR and openEHR allow for terminology bindings (for data items which make sense to encode)

24. Conclusions Information Models key for putting SNOMED to work – Package structure, syntax and semantics in one go – Easy to transform and consume for implementers There’s no point coding every data element! – But SNOMED (and other terminology) play key role in: Advanced decision support (using ontology-like features/inferencing) Analytics, research and reporting It requires effort, tools and training Good news is (for implementers) – They don’t have to be concerned (terminologists and modellers’ job!) – FHIR (inc. SNOMED bindings) sufficient for HIE

25. Questions? k.atalag@auckland.ac.nz www.taniwha.org.nz