The Role of Clinicians in Clinical Concept Modelling. Kalra D. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. The role of clinicians in
clinical concept modelling
Dr Dipak Kalra
Centre for Health Informatics and Multiprofessional Education
(CHIME)
University College London
d.kalra@chime.ucl.ac.uk

2. European health systems:
priorities and challenges
• Growing expectations for equity of access, quality and
efficiency, patient empowerment and engagement
• Rising incidence of chronic diseases and increased
complexity of their treatment
• age related: dementia, cancer
• lifestyle related: diabetes, asthma, obesity, ischaemic heart
disease
• Growing expectations and concerns about patient safety
• Need for better integration across wellness, health care,
public health, occupational health and social care
• Demographic change: ageing population
• Societal pressure for demonstrable protection of privacy
EU National ICT Research Directors Forum, November 9th, 2009

3. A pan-European Health Infostructure
Wellness Social care
Fitness Citizen in the Occupational
Complementary community health
health School health
rapid bench to bed translation real-time knowledge directed care
Point of care
delivery
Teaching explicit consent
Research
Clinical trials
Continuing care
(within the institution)
Education de-identified implied consent Public health
Research Health care
Epidemiology +/- consent management
Data mining Clinical audit
Long-term shared
care (regional
national, global)

4. Goals for EHR semantic
interoperability
• To support patient safety, quality of care, chronic
disease management, extended home-care, patient
empowerment
• enable the safe, meaningful sharing and combining of health
record data between heterogeneous systems and actors / care
providers
• enable the integration and safe use of computerised protocols,
alerts and care pathways by EHR systems
• link EHR data to explanatory and educational materials to
support patient and family engagement and professional
development
• ensure the necessary data quality and consistency to enable
meaningful and reliable use of longitudinal and heterogeneous
data for public health, research, health service management

5. Electronic Health Record - EHR 2.0
Clinical trials,
Decision support,
functional genomics, EHR repositories knowledge management
public health databases
and analysis components
Integrating
information
Centring services
Whittington
Hospital
on Healthcare Record
citizens
Personnel registers, Creating and
John Smith
DoB: 12.5.46
security services using knowledge
Mobile devices
Clinical
Clinical devices, applications
instruments Social computing:
forums, wikis and blogs

6. Contextual building blocks of the EHR
Part or all of the electronic health record
EHR Extract for one person, being communicated
High-level organisation of the EHR
Folders e.g. per episode, per clinical speciality
Set of entries comprising a clinical care
Compositions session or document e.g. test result, letter
Headings reflecting the flow of information
Sections gathering, or organising data for readability
Clinical “statements” about Observations,
Entries Evaluations, and Instructions
Multipart entries, tables,time series,
Clusters e.g. test batteries, blood pressure, blood
count
Element entries: leaf nodes with values
Elements e.g. reason for encounter, body weight
Date types for instance values
Data values e.g. coded terms, measurements with units

7. ISO EN 13606-1 Reference Model

8. The EHR landscape that needs modelling
Treatment
Medication and prescriptions
Hypotheses,
Advice and education
Symptoms health issues
Self management
and history (problemsChronic
and home monitoring
and summary Prevention and
Conventional medical diseaseWell-being and fitness,
screening,
diagnoses),rehabilitation after illness
manageme
Body physical risks population
nt
examination findings Tests and investigations health
Care planning measures
Social welfare, culture,
religion, attitudes,
expectations, hopes, fears
Procedures and operations
Protocols, guidelines, care
pathways
Communication, team-based collaboration
Consent, permissions, disclosures, complaints

9. The EHR landscape that needs modelling
Hospital admission
Treatment
Medication and prescriptions
Hypotheses,
Advice and education
Symptoms health issues
Self management
and history (problemsChronic
and home monitoring
Mental health
and summary Prevention and
Conventional medical diseaseWell-being and fitness,
screening,
diagnoses),rehabilitation after illness
manageme
Body physical risks population
nt
examination findings Tests and investigations health
Care planning measures
Social welfare, culture,
religion, attitudes,
expectations, hopes, fears
Procedures and operations
Protocols, guidelines, care
Cardiovascular medicine pathways
Communication, team-based collaboration
Consent, permissions, disclosures, complaints

10. What is a clinical archetype?
• a clinical archetype is an agreed, formal and
interoperable specification
• for representing a given clinical entity such as a
clinical observation, a finding, a plan or a treatment
• within an electronic health record
• invented and maintained by openEHR
• ratified by CEN: EN 13606 Part 2
• ratified by ISO: ISO 13606 Part 2
• to be quality labelled and licensed by EuroRec

11. What value do archetypes add?
• A user friendly means to capture and collate professional
consensus on how clinical data should be represented
• A formal model of clinical domain concepts
• e.g. “blood pressure”, “discharge summary”, “fundoscopy”
• Can provide a focussed context for selection of relevant
terms
• Can be published and shared within a clinical community, or
globally
• Can be imported by vendors into EHR system data
dictionaries
• Defines a systematic EHR target for queries and for decision
support

12. openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/

13. openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/

14. openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/

15. openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/

16. openEHR Clinical Knowledge Manager
http://www.openehr.org/knowledge/

17. openEHR CKM archetypes
• Gold standard (best practice) definitions
• Leveraging the available published evidence
• Referring to as many guidelines as can be found
• Inclusive of as many variants on the requirements as
possible (maximal)
• Openly developed in a social community environment
• Wide, international multi-stakeholder contributions
• Dependent upon level of interest, and on high quality
inputs (like Wikipedia)
• Final decisions based on consensus

18. Royal College of Physicians: Clinical
headings
• A standard and defined set of headings for
• acute medical admission
• hospital handover
• discharge summary
• Method:
• literature reviews
• evaluating proformas used by different NHS Trusts
• clinician workshops
• a questionnaire based on the headings and definitions
• > 3000 people responded and 80% agreed on 30 of the 36 suggested
headings
• Feedback and subsequent endorsement from several
other Royal Colleges

25. RCP Archetype approach
• Selection of a focussed domain
• Single profession, for now
• Start top down, with clinical headings
• Define content per heading
• Involve clinicians and other stakeholders through
workshops
• Get them to propose content
• Focus on what every good doctor should record
• Not necessarily maximal
• Consider most items to be optional
• Use a paper record template to provide a visual cue to
the content being proposed

26. North Central London Integrated Care
Whittington Hospital
and its collaborating
Hospitals
Collaborative GP Practices
development Consultant-led and
of EHR Community Clinical Pharmacies
systems Services
CHIME
(UCL)

27. Commonly used fragments
Generic Medical summary
Medication, prescriptions
planning
Anticoagulation
monitoring
Cardiovascular
cardiac
Heart failure
respiratory
Disease management
scales & scores
Assessment
self-care
Dementia
prescriptions
Treatment
effectiveness
Consents, carers
Shared care management Clinical letters and reports
Notifications and alerts
Audit and governance

28. Commonly used fragments
Generic Medical summary
Medication, prescriptions
planning
Anticoagulation
monitoring
Cardiovascular
cardiac
Heart failure
respiratory
Disease management
scales & scores
Assessment
self-care
Dementia
prescriptions
Treatment
effectiveness
Consents, carers
Shared care management Clinical letters and reports
Notifications and alerts
Audit and governance

29. planning
Indication for anticoagulation - {mandatory, ordinal, 15 specified
conditions}
Other indication - {optional, free text}
Anticoagulant drug name - {mandatory, ordinal, 3 specified drugs}
Target INR - {mandatory, quantity, range 0-5}
Target INR range
Upper - {mandatory, quantity}
Lower - {mandatory, quantity}
Intended end date - {optional, calendar date} ------------- one
must
If life-long treatment intended - {optional, Boolean} ------------- be
provided
Actual end date - {optional, calendar date}
Precautions to be taken - {optional, free text}
Anticoagulation
monitoring

30. planning
monitoring Present health situation
Treatment controller
Current INR
Decision support recommended warfarin dose
If recommended dose accepted
Actual warfarin dosage
Decision support recommended monitoring interval
If recommended interval accepted
Actual appointment date
Clinic name
Advice given
Medical comments
Anticoagulation

37. De facto archetype approach
• Focus on the specific support of clinical shared care
• Work with multiple professionals from the start
• Develop archetypes with a view to what is feasible to
record and useful to share
• Archetypes mirror the data structures in real use
• Build on existing paper and electronic systems if they
are useful and used
• Developed with rapid reflection back via clinical
application screens and practice data entry
• Diversity still needs to exist - clinical best practice might
not always be at a consensus - yet!

38. Best practice:
published evidence, guidelines,
international consensus,
focus onand prescriptions completeness
Medication maximal
Treatment
Advice and education
Hypotheses,
Symptoms Self management and
health issues
Chronic
and history Prevention and
home monitoring
(problems disease
and
Conventional medical summary screening,
diagnoses), Well-being and fitness,
managemen
population
rehabilitation after illness
Body physical risks t
health
examination findings Tests and investigations measures
Care planning
Social welfare, culture,
religion, attitudes,
De facto: expectations, hopes, fears
existing operations
Procedures and practice, existing systems,
Protocols, guidelines, care
pathways
local consensus,
Communication, team-based collaboration
focus on supporting shared care
Consent, permissions, disclosures, complaints

39. Key challenges for successful
clinical modelling
• Semantic interoperability needs to be underpinned by
shared clinical data structures: archetypes
• Large scale, professionally-driven, archetype library
development is now needed
• Professionals will need better (ontology-driven) visuals
to understand their archetype landscape
• Rapid testing of models via clinical applications is vital
• The quality labelling and publication of archetypes must
be centrally co-ordinated within Europe
• More research is needed on how SNOMED CT can
help with semantic consistency across multiple
archetypes

40. Getting clinical engagement right
• Involve a wide range of working clinicians
• Develop archetypes with multi-professional input
• Combine available evidence and consensus practice
• Solve real clinical information gaps
• join up virtual teams to improve safety and shared care
• define the benefits right at the start
• No need to structure everything
• start by codifying the data that will improve care
• remember narrative is good for human to human communication
• Quality assure archetypes before they are used
• Pilot in real settings before wide roll out