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HL7 Decision Support Activities
Rev 1 Draft Feb 23
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
HL7 Decision Support ActivitiesArden Syntax Version 2.5
• Allow knowledge sharing within and between institutions
• Make medical knowledge and logic explicit
• Standardize the way medical knowledge is integrated into hospital information systems
•Has been used to encode guidelines (as hierarchy of MLMs)
•Consensus: Not ideally suited for guidelines
•Entry points and eligibility criteria (not triggers)•Flow of steps (not procedures)
•Ongoing work•Arden as a separate standard for simple alerts•Examine other models for guidelines
HL7 Decision Support ActivitiesArden Syntax Version 2.5
Finalized “dot notation” and object references
Added operators: Object declaration, object creation, object references, reading into an object
Deferred decisions
Primary time of objects
Passing objects by reference or by value
Change the granularity of the PRIORITY slot
Allow the WHILE statement with assignment in the ACTION slot
HL7 Decision Support ActivitiesArden Syntax Version 2.5
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
HL7 Decision Support ActivitiesGELLO
A Guideline Expression Language
•Purposes•Query data (READ)•Logically manipulate data (IF-THEN, etc)
•Current work: GELLO (BWH) = Guideline Expression Language
HL7 Decision Support ActivitiesGELLO
•Original goal (InterMed): Procedural component for high-level guideline format (GLIF)
•Subsequent goal: Provide similar functionality for current HL7 KR standard (Arden Syntax)
•Emphasis: Shareability of queries and expressions
•Mechanism: Reference data in OO fashion
HL7 Decision Support ActivitiesGELLO
•Provides basic data types
•Allows reference to underlying standard data model (vMR)
•Based on the Object Constraint Language (UML)
•Current goal: Ballot as a separate HL7 standard during the coming 12 months
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
•Problem with RIM: Too abstract
•Potential solution: Tailored version of RIM specifically for decision support
•Current work: Virtual Medical Record •Establish distinct objects that in RIM might be high-level classes (with mood and other attributes)
•Key classes: patient, plan, procedure, medication, appointment, referral, goal and assessment
HL7 Decision Support ActivitiesvMR
13 classes
Most classes directly from the RIM
Most attributes have direct RIM mappings
Classes & attributes refined iteratively with each new guideline
SAGE vMR
HL7 Decision Support ActivitiesvMR
13 classes
Most classes directly from the RIM
Most attributes have direct RIM mappings
Classes & attributes refined iteratively with each new guideline
SAGE vMR
HL7 Decision Support ActivitiesvMR
SAGE vMR
HL7 Decision Support ActivitiesvMR
SAGE vMR Classes
• Observation• Procedure• Problem• Order• Medication Order• Substance
Administration
• Encounter• Referral• Appointment• Goal• Adverse Reaction• Alert• Agent
HL7 Decision Support ActivitiesvMR
HL7 Decision Support ActivitiesvMR - Challenges
•Need standard vocabularies
•Agreement is difficult•Solution: Format for referring to a standard vocabulary in data references•Examples: SNOMED-CT, ICD-9, LOINC, CPT, etc•Implementation: One-time mapping between local and standard vocabularies
•Facilitation: Free licensing of SNOMED in USA as part of UMLS
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
• Rationale for Guidelines: Knowledge dissemination
• HL7: Role of the SDO in knowledge representation
• Shareable components of computable guidelines
• Guideline models
• Convergence & the future
HL7 Decision Support ActivitiesGuidelines
• Use in context of systems for providing patient care– CPOE– EMR
• Use at the time decisions are being made• Ample success for limited alerts/reminders
– Medication prescribing practices– Preventive care: screening tests,
immunizations
• Less demonstrated success for complex guidelines
HL7 Decision Support ActivitiesGuidelines - Objectives
• Avoid duplication of effort when using common guidelines in many institutions
• Rapid dissemination of modifications
• Encourage development of tools for retrieving and using guideline information
• Encourage future guideline authors to be more rigorous (decreased ambiguity)
HL7 Decision Support ActivitiesGuidelines - Benefits
• Many models: GEODE-CM, GLIF, Arden Syntax, EON, DILEMMA, PROforma, Asbru, GEM, GUIDE, PRODIGY, …
• Many stakeholders: government, vendors, academics, professional organizations, etc
• Many types of guidelines
• Many types of (paper) guideline formats: narrative text, tables, flowcharts, graphs, maps, lists, critical pathways, if-then statements, etc.
HL7 Decision Support ActivitiesGuidelines - Challenges
• Availability of data
• Identification of data: structured, controlled vocabularies
• Clinical data repositories: Data model
• Shareable knowledge representationShareable knowledge representation
HL7 Decision Support ActivitiesGuidelines - Challenges
• Opposing view: A single formalism may not be possible or desirable– Complexity of guidelines and their purposes– Result: A small number of “niche” formalisms
• Arden for simple alerts/reminders• Others for complex guidelines
– A small group of formalisms would share common components (data model, vocabulary, expression language)
HL7 Decision Support ActivitiesGuidelines – An approach?
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
• Infobutton is a point-of-care application that retrieves context-specific information from content providers using patient data extracted from the electronic medical record– Can be implemented as an HTTP request– Query parameters embedded in the URL
HL7 Decision Support ActivitiesInfobutton Definition
i
What are the clinical manifestations of high serum potassium?
•65 years old•female•physician•lab results
Question formulation
Resource 3
Resource 1
Resource 2?
Resource selection
Answer
Answer retrieval
Non-standard APIs
POE system
Lab results review
Outpatient clinical information system
i
i
i
InfobuttonManager 1
InfobuttonManager 2
Resource 1
Resource 2
Resource 3
API
API
API
API
API
Standard APIs
InfobuttonManager 1
InfobuttonManager 2
POE system
Lab results review
Outpatient clinical information system
i
i
i
Resource 1
Resource 2
Resource 3
HL7 HL7
HL7
• Username & password• Context
– Patient: age and gender– User: patient, physician, nurse– App context: Problems, Medications, Labs, etc.
• Concept: Concept ^ String ^ Terminology• Query modifier
HL7 Decision Support ActivitiesInfobutton Proposed Parameters
• http://www.knowledgesourcewebsite.com/search.cgi?applicationContext=problems&conceptOfInterest=D018410&SearchString=Bacterial Pneumonia&terminology=MeSH&contentTarget=physician– Runs a search for D018410 (MeSH), on the
problems section of the knowledge source, and with focus on content for physicians
HL7 Decision Support ActivitiesInfobutton Proposed Example
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
“Order sets allow a care provider to choose common orders for a particular disease state or circumstance according to best practice or other criteria for assembling the order set without having to generate each order individually. The EHR may recommend order sets in certain conditions or as the result of other clinical information being entered into the EHR. Or the order sets may simply be available for use by the ordering care provider “
HL7 Decision Support ActivitiesOrder Set Functional Description (EHR DSTU Draft)
Support a sequencing of orders for logical and useful presentation to the ordering provider
Support explanatory (non-actionable) sequenced elements for ease of use and informational content
Order sets may be nested within order sets in order to support editorial efficiency and to avoid clinical and administrative update anomalies
Order sets have a unique identification key which supports identification and use in multiple order sets
Support identification of an author and brief editorial history in the header
Support menu features which include “AND”, “XOR” at the level of order selection
HL7 Decision Support ActivitiesOrder Set Requirements
• Each order has a clear text description• Support mapping to enterprise order master. • Provide a readable version of the orders and the
order set.
HL7 Decision Support ActivitiesOrder Set Requirements
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook
HL7 Decision Support ActivitiesImplementer’s Workbook
http://www.himss.org/asp/cds_workbook.asp
HL7 Decision Support ActivitiesSummary Issues
•Data capture/display/storage•EMR •central data repository
•Controlled, structured vocabulary•Knowledge representationKnowledge representation•Knowledge acquisition•Clinical event monitor: integrate the pieces for many different uses (clinical, research, administrative)
HL7 Decision Support ActivitiesSummary Issues
•How to represent (executable) guidelines?
•How to validate algorithm?
•How to validate implementation?
•Who does the validation?
HL7 Decision Support ActivitiesHighlights
Arden Syntax
GELLO
vMR
Guidelines
Infobutton
Order Sets
Implementer’s Workbook