Virtual Medical Record (vMR): A Simplified RIM-Based Data Model for CDS HL7 Work Group Meeting, San Diego, CA September 2011 Kensaku Kawamoto, MD, PhD Director, Knowledge Management and Mobilization Assistant Professor, Department of Biomedical Informatics University of Utah kensaku.kawamoto@utah.edu

Background A “holy grail” of clinical informatics is scalable, interoperable CDS Key requirement for interoperable CDS and re-use of CDS knowledge resources = use of a common patient data model Referred to as a “Virtual Medical Record” or vMR (Johnson et al., AMIA Annu Symp Proc, 2001) Lack of a common vMR is a major barrier to sharing knowledge and scaling CDS Known as the “curly braces” problem in Arden Syntax SCT 14May

Example Challenge without VMR Observation Blood Pressure Code = BP Systolic = 120 mmHg Value = 120/80 mmHg Diastolic = 80 mmHg Observation Vital Sign Code = BP Type = BP Observation Value = 120/80 Code = SBP Units = mmHg Value = 120 mmHg Observation Code = DBP Value = 80 mmHg SCT 14May

vMR Goal Provide common information model upon which interoperable clinical decision support resources (e.g., rules) can be developed Desired attributes: VMR instances can be derived from HL7 V3 artifacts, in particular CCD and Pedigree instances VMR instances can be populated from HL7 V2 messages, in particular for laboratory data Leverage Detailed Clinical Models Capable of being easily understood and used by clinicians/analysts without significant V3 training

Project History Analysis of data required by 20 CDS systems from 4 countries Analysis of HL7 CCD, Pedigree, Clinical Statement, and other relevant models Use of greenCDA/greenCCD as an example approach to simplification Trial implementation of vMR via OpenCDS Under ballot for September 2011 Work Group cycle Domain Analysis Model GELLO implementation guide

Simplified ISO 21090 Data Types SCT 14May

CDS Inputs SCT 14May

CDS Outputs SCT 14May

vMR Payload SCT 14May

Example Clinical Statement SCT 14May

vMR Ballot Reconciliation – Overview Domain Analysis Model 47 affirmative, 2 negative GELLO implementation guide 34 affirmative, 0 negative SCT 14May

vMR – Future Directions Additional implementation guides Existing/underway: GELLO, v2 implementation guides XML, Drools, other implementation guides (e.g., Arden?) Template specifications For standard data models (e.g., CCD, Pedigree, Care Plan) For common types of CDS (e.g., drug-drug interactions, vaccine forecasting, family history risk analysis) Transformations to/from standard models Alignment with relevant ongoing HL7 work (e.g., CSP, RFH, detailed clinical models) Version 1.1 based on implementation experience (e.g., via OpenCDS)

OpenCDS Standards-based, open-source clinical decision support (CDS) Web service Uses HL7 Decision Support Service (DSS) interface Uses standard data payloads (e.g., CCD, VMR) Uses standard internal data model (VMR)

OpenCDS – Architectural Overview Standard Interface: HL7/OMG Decision Support Service Standard (http://hssp-dss.wikispaces.com) Standard Data Models: HL7 Virtual Medical Record (vMR) Standard [ http://wiki.hl7.org/index.php?title= Virtual_Medical_Record_(vMR) ] Institution A Trigger Queries for required pt data Patient Data Sources Patient data, knowledge modules to use Client Decision Support Apps Conclusions about patient Institution B Client Decision Support Apps Patient Data Sources Queries for required pt data Decision Support Service Knowledge Modules SCT 14May

Decision Support Service CDS Services – Example Eval. Result VMR CCD Pt data Patient Data Sources Decision Support Service EHR System SCT 14May

Current OpenCDS Collaborators University of Utah HLN Consulting, LLC Apelon, Inc. Intermountain Healthcare Veterans Health Administration Wolters Kluwer Health EBSCO Univ. of NC at Chapel Hill Main Line Health Stanford University Keona Health Mass. General Hospital Hospital Universitario Virgen del Rocío, Spain MaRS Innovation, Canada SmartCare, Africa Emetra AS, Norway Visumpoint, LLC Genesys, LLC df8health Religent, Inc. IsoDynamic, Inc. Calcudos.com, Inc. CogniTech Corporation

Key Components of OpenCDS Standard interfaces and data models Reference implementation of HL7/OMG DSS interface vMR data model Data mappers (e.g., for CCD  vMR) Reference DSS knowledge management framework JBoss Drools and associated authoring/knowledge management tools Full-featured terminology support A “domain specific language” for intuitive knowledge authoring Knowledge repository and knowledge sharing service DSS “wrappers” for other CDS engines

NQF Measure 31 for Meaningful Use

OpenCDS Implementation – Denom.

OpenCDS Implement. – Underlying Details

OpenCDS Implementation – Decision Table

www.opencds.org SCT 14May

Backup Slides SCT 14May

Key Benefits of Approach Builds on robust open-source community and resources Provides standard architectural framework for integrating various CDS knowledge resources Supports full life cycle of knowledge authoring, testing, maintenance, and execution Provides an open-source framework for collaboration and innovation in CDS Freely available under Apache 2.0 license SCT 14May

DSS Invocation - Wrapper NQF knowledge module vMR payload

DSS Invocation - Payload Age & gender Past encounters Past mammographies

NQF evaluation result payload using vMR DSS Response - Wrapper NQF evaluation result NQF evaluation result payload using vMR

DSS Response - Payload Denominator criteria met Numerator criteria met