2009-apr-07 UMCG RIMBAA and DCM HL7 UK

RIMBAA Experiences
HL7 UK AGM and TC WGM, April 7th 2009
University Medical Center Groningen, Netherlands

Michael van der Zel
HIT-Architect

Who Am I?
Michael van der Zel
●

michael.vanderzel@skype @linkedin @facebook @gmail
●

m.van.der.zel AT ict.umcg.nl
●

36 yrs – 2 kids (aged 7 and 4)
●

Personality (MBTI) – INFJ
●

Idealist, Perfectionist, Chaotic
●

“INFJs prefer the future and the pathway along which
●

they aspire for profundity.”

Michael van der Zel april 7th, 2009

What Did I Do?
University Hospital Amsterdam
●

BSc Final Project: virtual EHR (Poliplus) 1997
–

0 ~1998 Dipak Kalra
–

Lead Developer & Architect
–

University Hospital Groningen
●

Architect; Healthcare Service Bus
–

Ernst de Bel (Nijmegen); got me hooked on HL7 v3
–

String-of-Pearls Dutch Biobank – Information Arch 2008
–

Co-Chair RIMBAA-NL since 2007
–

Member of RIMBAA Int'l
–

CDA Certified Specialist
–


I Work Here


My Office


Inside the Office
Clinical
Statement SQL

Clinical
Document CMET

Clinical
Statement CMET


UMCG – Some Numbers
1 of 8 UMC’s, 1 of 120 hospitals in the Netherlands
900 trauma helicopter flights
9.756 employees
1.339 beds (including cradles)
11.823 day care treatments psychiatry (2006)
20.758 day care treatments (excl. Psychiatry)
32.831 admissions
326.400 nursing days
460.297 visits to outpatient clinics
Source: annual report 31-12-2007

Agenda

1 2
3 4

“ Everything should be made as simple as

”
possible, but not simpler.
–– Albert Einstein

“ ”
Technology is something that doesnot yet work.
–– Douglas Adams

“ ”
I've seen things you people will not believe...
–– BladeRunner


“ If language is not correct,
then what is said is not what is meant.
If what is said is not what is meant,

”
then what ought to be done remains undone.

–– Confucius


Chaos

Duplicate Functionality
3 HISses, custom build, etc.
●

3 archives; DOCMA &
●

Multiple registration of for the same patient
but different specialty.
E.g. allergies or patient history.

Piles of Paper Forms
“Newest
form!”


Vision

!
Why?

?
Data Data


What?

+ +
Reference Clinical
Terminology
Information Models
Model


= Computable
Semantic
Interoperability


!
Result

!
Clinical
Clinical
Info
Info


How?

+ + HL7 v3 Templates,
SNOMED CT,
HL7 v3 RIM, Detailed Clinical
ISO Datatypes LOINC Models, CCD

= 
Computable
Semantic
Interoperability


CSI
HL7 SAEAF – Computable
●

Semantic Interoperability
●

Report jan 2009
– Semantic InterOperability (SIOp)
Semantic SOA
●


Gartner CPR Generations

D:My documentsInternationaal, Nationaal, RegioGartner2007 CPR Generation Criteria Update - Clinical Display.pdf

UMCG vEHR Roadmap

5. Desicion Support

4. Regional
(RHIO)

3. Process Driven
Functionality

2. Semantic SOA

1. Operational Chaos

2008 2009 2012 2015
2010
Availability


Semantic SOA
Classical Model

Tomorrows Model

Source: http://www.openhealthtools.org/Reports/Apr08/OHTStandardsVisionV2.pdf

Ideal Model
Tomorrows Model

&
RIMBAA T
DC
SNOME
Ideal Model inside

Service Provider Service Provider
Message

End-To-End HL7 v3, SNOMED CT, RIMBAA, From UI to DB


Architecture Overview v0.8 | mrt 2009 | Michael van der Zel
created: dec 2006
(Clinical) Portal
> Clinical Documents (CDA)
Portlet eForm > HL7 v3 Templates
> Detailed Clinical Models
> Widgets

DigiD
UZI
BSN ...

> XDS
> RFD
> RID

AORTA & Common Information
1 2 3
Parelsnoer Model

& RHIO SSZOG
Wrap
Care Doc
ETS
Plan Repos
(CTS) (XDS)
Application
Packaged

HL7 v3
Terminology
XML XML
CDR
SNOMED CT
HL7 v3 MPI

Healthcare Software Toolkit!
Current apps are developed with 1960 technology
●

Develop your own (parts)
●

We need: Healthcare Software Toolkit
●

Small ISV can start fast, developing Healthcare IT instead
●

of putting IT in Healthcare.
Common User Interface, Models, Standard Components
●

Master Patient Index
–

Clinical Data Repository
–

Template Repository
–


RIMBAA
Experiences

UMCG RIMBAA
Technology Matrix (1/2)
Persistent Object Serialized
Representation Representation Representation
(generic)
Model
RIM
Constrained
Information

SQL JAXB &
Clinical
Model

JPA Web
Server JAX-WS
Statement
RIM

Services
2005 WCF

Mapper
Application
specific
Model

Legacy
non HL7v3

XJC
HL7 XSDs


UMCG RIMBAA
Technology Matrix (2/2)
Processing Object User
Logic Representation Interface

XPath
Binding

InfoPath (MOSS),
Java
ASP.NET (Ajax)
.Net C#
NHS CUI
Delphi, Java
(Applet)

(at a 90 ̊ angle to the matrix on the previous slide)

Interoperability Paradigms
Services
●

More real-time
●
Level
of
Current HL7 v3 are messages wrapped Shared
●

Context
double Sending Identity (WS-Security)
–

double Operation (e.g. Schedule Appointment)
–

Documents
●

Messages (between systems and institutions)
●

Mainframe
●


Code Model Generation
NE2008 XSD's; Clinical Document, Clinical
●

Statement, Patient, Assigned Entity
Java 6 XJC
●

Java 6 WebService Glassfish
●

WSDL > .Net WSDL.exe
●

Convert Arrays to Collections script
●

ObjectFactory and converters, e.g. DateTime > TS
●

Some minor simplifications (see Limitations)
●


CDR Persistance
ORM JPA Toplink / MS-SQL & Derby
●

Datatypes R1, Clinical Statement, Patient,
●

Assigned Entity, Clinical Document
SQL generated from Java (with annotations)
●

Table per concrete base class (Act/Role)
–

Side table for datatypes (Patient_II)
–

Simplified BL (bit) and ST (varchar)
–

Table per Hierarchy for CD, CE, CV, CS
–

ANY as multiple; e.g. CD, ST, PQ
–

TS-like-types as serialized XML
–


JPA Query Example

<named-query name=quot;findOrganizersByTemplateAndPatientIdquot;>
<query>
SELECT o
FROM A_Organizer o
JOIN o.templateId1 tid
JOIN o.recordTarget recordTarget
JOIN recordTarget.patient patient
JOIN patient.id id
WHERE tid.root = :templateRoot
AND tid.extension = :templateExtension
AND id.root = :patientRoot
AND id.extension = :patientExtension
</query>
</named-query>

ISO Datatypes as User Defined Types!
> Demo SQL Server UDT II


Query CDR by Example
<organizer>
<templateId assigningAuthorityName=quot;UMCGquot;
extension=quot;5ae9e3b0-7295-4798-a34a-26229f3e8075quot;
root=quot;2.16.840.1.113883.2.4.3.8.1000.9quot; />
<recordTarget typeCode=quot;RCTquot;>
<patient classCode=quot;PATquot;>
<id assigningAuthorityName=quot;UMCGquot;
extension=quot;1010101quot;
root=quot;2.16.840.1.113883.2.4.3.8.12quot; />
</patient>
</recordTarget>
</organizer>


Current Limitations
Clinical Document CS != Care Provision CS
●

XSD Enumerations for ValueSets > want CTS use
●

fixed / default values
●

XML Validation (Schematron)
●

Current HL7 doesnot have inheretance
●

PatientNL extends PatientLite extends PatientIdentified

ISO Datatypes not native, result is complex coding
●

required (in C#, Java and SQL)
Reuse types e.g. with VSTS Add Web/Service
●

Reference

Results
Cookbooks & Guidances (NL Realm)
●

HL7 v3 Templates
●

Mapper Services
●

Widgets
●

Terminology Services (CTS)
●

Clinical Statement CDR (Templates & Instances)
●

HL7 v3 .Net Framework
●

Excel Template Editor, OID Registry
●


Patient History Widget
HL7 v3
End
Modeller
Users

Other Apps (RO) Template Editor
CUI Widgets
Template Browser
(RW)
HL7 v3
Templates

OID Registry
MOSS List

Clinical Statement
OID
HIS LOB Repository
Master


ENT (KNO) Patient History Widget

CUI
DateInputBox

Relevant?

CUI
DateLabel

http://digizorgo1.umcg.nl/PatientHistory/


Diagnosis HL7 v3 Template
class PatientHistory.Diagnoses

«Pa rticipa tion» «Ro le»
«Act»
:RecordTarget :PatientIdentified CMET
Diagnoses :Organize r
code = RJM

«Participati on» «Role »
« Act» :DataEntere r :AssignedEntityIdentified CMET
Diagnosis :Observ ation id = Zorgve rlenerId
text = Glob ale beschrijvin g van d e diag nose
c od e = DX
«Role »
effe ctiveT im e = di agnose datum «Pa rticipati on»
:AssignedEntityIdentified CMET
valu e < KNO Diag nose :Author
0..*
id = Specia lism eCode of Zorgverlener

HL7 v3 ClinicalStatement Observation value ContentObject / ZIS
{text OR value}
dbc.reg.getAlleZorgtrajectenV
anPatient
id<II>.root “2.16.840.1.113883.2.4.3.8.1000.31”
id<II>.assigningAuthorityName “UMCG”
id<II>.extension 6. zorgtrajectid^INTEGER
moodCode “EVN”
HL
7v

Zo
value<CD>.code “DX”

u
3C

value<CD>.codeSystem “2.16.840.1.113883.1.11.16228”

ga
lin

(
value<CD>.codeSystemName “ObservationDiagnosisTypes”

LO
i ca

B
code<CD>.code
l

Ad
St

code<CD>.originalText 3. diagnose
at

ap
em

te
code<CD>.codeSystem

r)
en

code<CD>.codeSystemName “KNO Diagnosen”
t

effectiveTime<IVL_TS>.min.value 0. begindatum^DATE
effectiveTime<IVL_TS>.max.value 5. einddatum^DATE
author.assignedEntity.id<II>.root “2.16.840.1.113883.2.4.3.8.1000.8”
author.assignedEntity.id<II>.extension 1. specialisme
author.assignedEntity.id<II>.assigningAuthorityName “UMCG”

Sample Output
<organizer classCode=quot;ORGANIZERquot; xmlns=quot;urn:hl7-org:v3quot;>
<templateId root=quot;2.16.840.1.113883.2.4.3.8.1000.9quot;
extension=quot;660d999b-0157-41c2-8f2b-762d101aa279quot; assigningAuthorityName=quot;UMCGquot;/>
<code code=quot;RJM2009021801quot; codeSystem=quot;2.16.840.1.113883.2.4.3.8.1000.21quot;
codeSystemName=quot;UMCG Tijdelijkquot;>
<originalText>Diagnosis</originalText>
</code>
<recordTarget typeCode=quot;RCTquot;>
<patient classCode=quot;PATquot;>
<id root=quot;2.16.840.1.113883.2.4.3.8.12quot; extension=quot;2761703quot; assigningAuthorityName=quot;UMCGquot;/>
</patient>
</recordTarget>
<component typeCode=quot;COMPquot;>
<observation classCode=quot;OBSquot; moodCode=quot;EVNquot;>
<id root=quot;2.16.840.1.113883.2.4.3.8.1000.31quot; extension=quot;491216quot;/>
<code code=quot;DXquot; codeSystem=quot;2.16.840.1.113883.1.11.16228quot;
codeSystemName=quot;ObservationDiagnosisTypesquot;/>
<text/>
<effectiveTime value=quot;20060329quot;/>
<value xsi:type=quot;CDquot; code=quot;474.10quot; codeSystem=quot;2.16.840.1.113883.6.103quot;
codeSystemName=quot;ICD-9-CMquot;>
<originalText>Otitis media / niet gespecificeerd</originalText>
</value>
<author typeCode=quot;AUTquot;>
<assignedEntity classCode=quot;ASSIGNEDquot;>
<id root=quot;2.16.840.1.113883.2.4.3.8.1000.8quot; extension=quot;KNOquot;/>
</assignedEntity>
</author>
</observation>
</component>
<component typeCode=quot;COMPquot;>
<observation classCode=quot;OBSquot; moodCode=quot;EVNquot;>
<id root=quot;2.16.840.1.113883.2.4.3.8.1000.31quot; extension=quot;469403quot;/>
<code code=quot;DXquot; codeSystem=quot;2.16.840.1.113883.1.11.16228quot;
codeSystemName=quot;ObservationDiagnosisTypesquot;/>
<text/>
<effectiveTime value=quot;20060217quot;/>
<value xsi:type=quot;CDquot; code=quot;784.69quot; codeSystem=quot;2.16.840.1.113883.6.103quot;
codeSystemName=quot;ICD-9-CMquot;>

Procedure HL7 v3 Template

class PatientHistory.Procedures

« Participation » «Role»
:RecordTarget :PatientIdentified CMET

«Role»
« Participation »
:DataEntere r

{text OR code}
«Act»
«A ct» :Procedure
Procedures :Organize r
e ffectiveT ime = jaa rtal
code = COT G code
text = operatie
i d = Id

0..*

«Role»
« Participation »
:Performe r
id = S pecialism eCode of Zorgverlener


Rudimentary Templates Viewer

http://digizorgo1.umcg.nl/Templates.WebApplication/


OID Registry

https://www.surfgroepen.nl/personal/michael_vanderzel/Lists/OID%20Registry/AllItems.aspx


Document Services
UMCG CDA Implementation Guide
●

Modelled after IHE XDS
●

Virtual to make our archives
●

standards compliant
Move to full IHE XDS
●

compliance


Used Standards
EHR-S-FM
PKI


http://www.zurich.ibm.com/news/07/asme.html

Conclusions 1/2
Querytool Essential
●

Paradigm Shift (Monilite > SOA > Semantic SOA CSI)
●

We need: “Let's make this work!”
●

instead of “Is this the way to go?”
Use standards as jump starts
●


Conclusions 2/2
Tooling constrains developers
●

When .Net or Java would provide a HL7 framework &
guidance they will use it.
Standards give jump start to design and
●

implementation, but current design/developers
don't know how to integrate this into their process.
They want to start from scratch.


http://softwareindustrialization.com/content/binary/design.jpg

DCM's

Content Modeling
HL7 v3 Templates
●

Detailed Clinical Models (ISO)
●

Archetypes
●

HealthVault Things
●

Google Health
●


Building Block
M
C

D

Electronic Health Records

RIMBAA


William Goossen DCM sum up
20 februari 2009
“DCM = clinical concepts (blood pressure, Apgar score,
Glasgow Coma scale and a milion others)
with a slot binding to terminology for code
with a UML representation similar to DAM but
detailed level
with a HL7 v3 (XML) representation to fit the clinical
statement and its use in CDA and Message
with a OpenEHR/ 13606 archetype
with a screen design
with a database table suggestion
with XYZ upon request.”

DCM Content Modeling
DCM is the “glue” between UML and e.g HL7 v3

Physician, Info Analist Info Analist, Physician, Coder V3 Modeller, Developer

Collect Group Model Add HL7 v3 Develop
Information Information (UML) Terminology Template WebService/
Widget

© William Goossen
Clinical Specification Agnostic Different Technical /
Information Model Standards
Implementations


DCM's under Development
Evolution of “Zorginformatiemodellen”
●

NICTIZ – Results4Care / Patient Care
●

BMI, Weight, Length
●

Body Temperature
●

Vital Signs
●

Scores and Scales
●

Allergies
●

UMCG Patient History, TNM
●

String-of-Pearls Dutch Biobank
●


DCM
Patterns, Score, Scale, Finding, Conclusion
●

extends mechanism; KNO Oncology Diagnosis
●

extends Generic Diagnosis
Tool Chain
●

CIM
●

Examples
●

Implicit Rules for transformations
●


Together with William / ISO
XMI Export
●

> RTF Document
> Spreadsheet Mapping Table
> HL7 v3 Template XML


More Info
Email
●

m.van.der.zel AT ict.umcg.nl
●

Wiki
●

RIMBAA-NL http://hl7book.net
●

RIMBAA http://wiki.hl7.org/index.php?title=RIMBAA
●

Blog
●

My Healthcare SOA http://hl42.blogspot.com
●


2009-apr-07 UMCG RIMBAA and DCM HL7 UK

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2009-apr-07 UMCG RIMBAA and DCM HL7 UK