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medexter ®
HL7-Standards zur klinischen Entscheidungsunterstützung
Klaus-Peter Adlassnig
Institut für Medizinische Experten- und Wissensbasierte Systeme Zentrum für Medizinische Statistik, Informatik und Intelligente Systeme Medizinische Universität Wien Spitalgasse 23 A-1090 Wien
und
Medexter Healthcare GmbH Borschkegasse 7/5 A-1090 Wien
HL7-Anwendergruppe Österreich, Jahrestagung, 21. März 2012, Wien
Knowledge packages for integration in:
- HIS
- Outpatient IS
- PDMS
- LIS
- Lab analyzer
- Physician’s office
- Telemedicine
applications
- Health portal
Clinical decision support systems
Stand-alone solutions:
- Infection control
systems
- Lab decision
support systems
- Internal medicine
decision support
systems
- Diagnostic &
therapeutic
reminder systems
Rule engines:
- Arden Syntax Compiler
& Engine & IDE &
Server & host
interface
- Fuzzy Arden Syntax
Compiler & Engine &
IDE & Server &
host interfaces
Services:
- Rule engine
integration
- SOAP & REST & XML &
HL7 interoperability
- Medical
documentation &
ontology services
- Fuzzy-based medical
text formalization
Medical Content
Medical knowledge packages
Inference systemsMedical consulting
services
Technical Frameworks Medical Services
Medexter Healthcare
Teleiatros services:
- Browser-based or
direct server access
to decision support
systems
- Writing and tele-
operating customer-
specific Arden Syntax
& Fuzzy Arden
Syntax MLMs
Telemedicaldecision support
services
medexter ®
Computers in clinical medicine—steps of natural progression
• step 1: patient administration
– admission, transfer, discharge, and billing of medical services
• step 2: documentation and access of patients’ structured medical data
– electronic health record: distributed, life-long
• step 3: patient data retrieval and analysis
– data warehouse, research databases, study support systems, quality assurance and reporting
… for a group of patients
• step 4: software systems for clinical decision support
– safety net, quality assurance and improvement
… for the individual patient
symptoms signs
test results clinical findings
biosignals images
diagnoses therapies
nursing data
• • •
standardization telecommunication
chip cards
anatomy biochemistry physiology
pathophysiology pathology nosology
therapeutic knowledge disease management
• • •
subjective experience intuition
knowledge-based systems
patient’s medical data physician’s medical knowledge
medical statistics clustering & classification data & knowledge mining
machine learning
clinical decision support medical expert systems
many patients
single patient
diagnosis therapy
prognosis management
general knowledge
general knowledge
telemedicine telemedicine integration
Medical information and knowledge-based systems
information systems
induction
deduction
medexter ®
Clinical decision support systems
patients’ structured medical data
patient management guidelines
guideline-based reminders
computerized clinical guidelines, protocols, SOPs
high-level patient and hospital analytics
prognostic prediction
illness severity scores, prediction rules
trend detection and visualization
therapy advice
drug alerts, reminders, calculations
– indication, contraindications, redundant medications, substitutions
– adverse drug events, interactions, dosage calculations, consequent orders
management of antibiotics therapy
(open-loop) control systems
diagnostic support
clinical alerts, reminders, calculations
data interpretation, (tele)monitoring
differential diagnostic consultation
– rare diseases, rare syndromes
– further or redundant investigations
– pathological signs accounted for
consensus-criteria-based evaluation
– definitions
– classification criteria
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Arden Syntax—medical knowledge representation and
processing
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Arden Syntax and Health Level Seven (HL7)
• A standard language for writing situation-action rules that can trigger alerts based on abnormal clinical events detected by a clinical information system.
van Bemmel, J.H., Musen, M.A. (eds.) (1997) Handbook of Medical Informatics, Springer-Verlag, Heidelberg, Glossary, p. 559.
• Each module, referred to as a Medical Logic Module (MLM), contains sufficient knowledge to make a single decision.
extended by packages of MLMs for complex clinical decision support
• Contraindication alerts, management suggestions, data interpretations, treatment protocols, and diagnosis scores are examples of the health knowledge that can be represented using MLMs.
extended by single and differential diagnostic support, temporal monitoring, control systems, computerized processing of clinical pathways and management guidelines
• The first version of the Arden Syntax (draft prepared at the Arden Homestead, New York, in 1989) was administered and issued by the American Society for Testing and Materials ASTM (1992, version 1.0; today 2.8, towards 2.9). Ownership was transferred to HL7 and the American National Standards Institute (ANSI) in 1999 with the approval of version 2.0.
medexter ®
• General MLM Layout
– Maintenance Category – Library Category – Knowledge Category – Resources Category
• Identify an MLM • Data Types • Operators
– Basic Operators – Curly Braces – List Operators – Logical Operators – Comparison Operators – String Operators – Arithmetic Operators – Other Operators
• Control Statements • Call/Write Statements and Trigger
medexter ®
Arden-Syntax-based, service-oriented
clinical decision support
medexter ®
Arden Syntax, Arden Syntax server, and health care information systems
Funktionalität
Integration
KIS, MIS, PDMS, LIS, Praxissoftware, EHR, telemedizinische Anwendungen, Gesundheitsportale, …
Reminder und Alarme, Monitoring, Surveillance, Entscheidungsunterstützung für Diagnostik und Therapiewahl, …
operativ: - Harmonisierung der Inputdaten - Arden-Syntax-MLMs - Erklärungskomponente
erforschend: - Regellernen und -tuning - Daten- und Konzeptmining
* Daten- und Wissensbasen-Zentrum
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• web-services-based Arden Syntax server including
- Arden Syntax engine - MLM manager - XML-protocol-based interfaces, e.g., SOAP, REST, and HL7 - a project-specific data and knowledge services center may be hosted
• Java libraries - Arden Syntax compiler - Arden Syntax engine
Arden Syntax server and software components
Arden Syntax development & test
environment
data & knowledge services center
Arden Syntax rule engine
knowledge
knowledge
results
data
healt
h c
are
in
form
ati
on
syste
m
results
reporting tools
knowledge administration
data
inte
rfaces
2)
Arden Syntax server 1)
1) integrated, local, or remote2) local and web services, web frontend
Arden Syntax development & test
environment
data & knowledge services center
Arden Syntax rule engine
knowledge
knowledge
results
data
healt
h c
are
in
form
ati
on
syste
m
results
reporting tools
knowledge administration
data
inte
rfaces
2)
Arden Syntax server 1)
1) integrated, local, or remote2) local and web services, web frontend
Fuzzy Arden Syntax
• extension to fuzzy sets, operators, statements, and parallel execution
• Arden Syntax integrated development and test environment (IDE) including
- Medical logic module (MLM) editor and authoring tool - Arden Syntax compiler (syntax versions 2.1, 2.5, 2.6, 2.7, and 2.8) - Arden Syntax engine - MLM test environment - MLM export component
• command-line Arden Syntax compiler
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Crisp sets vs. fuzzy sets
yes/no decision
gradual transition
age
1
Y young
0 threshold
U = [0, 120]
Y U with Y = {(µY (x)/ x)x U}
µY: U [0, 1]
1
1 + (0.04 x)2 x U 0 age
1
Y young
threshold 0
U = [0, 120]
Y U with Y = {(Y (x)/ x)x U}
Y: U {0, 1}
Y (x) = x U 0 x > threshold
1 x ≤ threshold
1 x ≤ threshold
x > threshold µY (x) =
0
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Interoperability
Monitoring of
healthcare-associated infections
Interpretation von
Hepatitis-Serologie-Befunden (I)
Interpretation of
hepatitis serology test results (II)
Integration into
i.s.h.med
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GELLO/vMR—Query and expression language / accessing a
virtual medical record data model
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GELLO/vMR and Health Level Seven (HL7)
• An object-oriented (OO) query and expression language for decision support
• Originally developed as a guideline expression language for query statements and decision rules
• Based on the existing object constraint language (OCL) and HL7’s reference information model (RIM)
• The GELLO language can be used to
– Build up queries to extract and manipulate data from medical records
– Construct decision criteria by building up expressions to reason about particular data features/values
• Proposal to use a virtual medical record (vMR) that provides a standard interface to heterogeneous medical record systems
• Includes using of terminologies/ontologies such as SNOMED CT and LOINC
• 2005 adopted as international standard by HL7 and the American National Standards Institute (ANSI)
Innovation project “Standards-based CDS”
of the Veterans Health Administration, USA
Web User
InterfaceArden Syntax
GELLO/vMR
MDWS
VistA_1 VistA_2
(3) Patient DFN
(3) Patient DFN
(3) Patient DFN
(4) return NHN
(2) Patient DFN
(1) Patient Lookup
(2) Patient DFN
(1) Patient Lookup
(3) get NHN
(4) return NHN
(3) get NHN
(4) return NHN
Innovation Initiative # 209 -
Clinical Decision Support
Transaction Diagram
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Clinical decision support with Arden Syntax and GELLO/vMR • CDS platforms
– based on Arden Syntax and Fuzzy Arden Syntax
with data (sometimes) and knowledge services center and extended interoperability (web-services, XML data interfaces, libraries)
• integrated into or interconnected with
– CareVue and ICIP PDMSs (by Philips)
monitoring and reporting of ICU-acquired infections (ICUs and NICUs)
– ICM (by Dräger)
ICU decision support modules (Universitätsklinikum Erlangen)
– i.s.h.med HIS (by Siemens AG)
dosing of immunosuppressive drugs for kidney transplant patients
prediction of metastases in melanoma patients
standard operating procedures for chemotherapy treatment of melanoma patients
– medico//s HIS (by Siemens AG)
laboratory-based clinical reminders
– Soarian HIS (by Siemens AG) and Orbis HIS (by Agfa)
hepatitis serology test interpretation
– VistA HIS (by Department of Veterans Affairs)
service-oriented, standards-based CDS (clinical reminders and patient report cards)
– Monitoring adverse drug events (FFG project with Salzburger Universitätsklinikum)
– Teleiatros, iPhone, iPad
remote CDS, mHealth
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