Kaiser Permanente Standards Summit September 7-8 , 2011 Stanley M. Huff, MD

1. A Brief Review of CIMI Plans and Goals Phoenix CIMI Meetings January 18, 2013 Stanley M Huff, MD Chief Medical Informatics Officer Kaiser Permanente Standards Summit September 7-8 , 2011 Stanley M. Huff, MD

2. The Ultimate Value Proposition of CIMI • Sharing of: • Data • Information • Applications • Decision logic • Reports • Knowledge

3. Clinical System Approach Intermountain can only provide the highest quality, lowest cost health care with the use of advanced clinical decision support systems integrated into frontline workflow

4. Decision Support Modules • Antibiotic Assistant • Ventilator weaning • ARDS protocols • Nosocomial infection monitoring • MRSA monitoring and control • Prevention of Deep Venous Thrombosis • Infectious disease reporting to public health • Diabetic care • Pre-op antibiotics • ICU glucose protocols • Ventilator disconnect • Infusion pump errors • Lab alerts • Blood ordering • Order sets • Patient worksheets • Post MI discharge meds

5. Strategic Goal • Be able to share applications, reports, alerts, protocols, and decision support with anyone in the WORLD

6. Order Entry API (adapted from Harold Solbrig) . . . Application COS Interface Service Data

7. From Ben Adida and Josh Mandel

8. Standard set of detailed clinical data models coupled with… Standard coded terminology Standard API’s (Application Programmer Interfaces) for healthcare related services Open sharing of models, coded terms, and API’s Sharing of decision logic and applications What Is Needed to Create a New Paradigm?

9. Clinical modeling activities • Netherlands/ISO Standard • CEN 13606 • United Kingdom – NHS • Singapore • Sweden • Australia • openEHR Foundation • Canada • US Veterans Administration • US Department of Defense • Intermountain Healthcare • Mayo Clinic • HL7 • Version 3 RIM, message templates • TermInfo • CDA plus Templates • Detailed Clinical Models • greenCDA • Tolven • NIH/NCI – Common Data Elements, CaBIG • CDISC SHARE • Korea • Brazil

10. Clinical Information Modeling Initiative Mission Improve the interoperability of healthcare systems through shared implementable clinical information models.

11. Clinical Information Modeling Initiative Goals • Shared repository of detailed clinical information models • Using a single formalism • Based on a common set of base data types • With formal bindings of the models to standard coded terminologies • Repository is open and models are free for use at no cost

12. Goal: Models that support multiple contexts • Message payload • Service payload • Decision logic (queries of EHR data) • EHR data storage • Clinical trials data (clinical research) • Normalization of data for secondary use • Creation of data entry screens • Natural Language Processing

13. Information Model Ideas V2 “|” CEM Standard Terminologies LRA V2 XML HTML CEMs V3 XML V3 Next DCMs Repository of Shared Models in a Single Formalism Realm Specific Specializations UML Realm Specific Specializations CDA Templates Realm Specific Specializations Translators Realm Specific Specializations Translators Realm Specific Specializations Translators ADL openEHR Archetypes CDA OWL CEN Archetypes SOA Payload LRA Models CDISC SHARE CMETs, HMDs RMIMs CEN Archetype Initial Loading of Repository

14. Roadmap (some parallel activities) • Choose a single formalism • Choose the initial set of agreed data types • Define strategy for the core reference model and our modeling style and approach • Development of “style” will continue as we begin creating content

15. Roadmap (continued) • Create an open shared repository of models • Requirements • Find a place to host the repository • Select or develop the model repository software • Create model content in the repository • Start with existing content that participants can contribute • Must engage clinical experts for validation of the models

16. Roadmap (continued) • Create a process (editorial board?) for curation and management of model content • Resolve and specify IP policies for open sharing of models • Find a way of funding and supporting the repository and modeling activities • Create tools/compilers/transformers to other formalisms • Must support at least ADL, UML/OCL, Semantic Web, HL7 • Create tools/compilers/transformers to create what software developers need • Examples: XML schema, Java classes, CDA templates, greenCDA, RFH, SMART RDF, etc.

17. Selected Decisions

18. Decisions (London, Dec 1, 2011) • We agree to create and use a single logical representation (the CIMI core reference model) comprising one or more models as the basis for interoperability across formalisms. • We approve ADL 1.5 as the initial formalism in the repository using OpenEHR Constraint Model noting that modifications are required. • The corresponding Archetype Object Model will be included and adapted as the CIMI UML profile • The CIMI UML profile will be developed concurrently as a set of UML stereotypes, XMI specification and transformations

19. Definition of “Logical Model” • Models show the structural relationship of the model elements (containment) • Coded elements have explicit binding to allowed coded values • Models are independent of a specific programming language or type of database • Support explicit, unambiguous query statements against data instances

20. Definition of “Logical Model” (cont) • Models shall specify a single unit of measure (unit normalization) • Models can support inclusion of processing knowledge • Models can support recommend defaults • Models can specify assumed values of attributes (meaning of absence of the item) • Examples can be created for the model

21. Isosemantic Models Precoordinated Model (CIMI deprecated Model) HematocritManual (LOINC 4545-0) HematocritManualModel 37 % data Post coordinated Model (CIMI preferred Model) Hematocrit (LOINC 20570-8) HematocritModel 37 % data quals Hematocrit Method HematocritMethodModel Manual data

22. Isosemantic Models • CIMI is committed to isosemantic clinical models in terms of both: • The ability to transform CIMI models into iso-semantic representations in other languages/standards (e.g. OWL, UML, HL7); • The ability to transform CIMI models between iso-semantic representations that use a different split between terminology pre-coordination versus structure.

23. Isosemantic Models (cont) • CIMI will select one model within each isosemantic family that will be the preferred model for interoperability • (Profiles of exact models for specific uses will be created by the users: professional societies, regulatory agencies, public health, quality measures, etc.)

24. Terminology • SNOMED CT will be the primary reference terminology • LOINC was also approved as a reference terminology • In the event of overlap, SNOMED CT will be the preferred source • CIMI will propose extensions to the reference terminologies when needed concepts do not exist • CIMI will maintain the extensions until they are accepted by the RT organization

25. Terminology (cont) • The primary version of models will only contain references (pointers) to value sets • We will create tools that read the terminology tables and create versions of the models that contain enumerated value sets

26. Some Principles • CIMI DOES care about implementation. There must be at least one way to implement the models in a popular technology stack that is in use today. The models should be as easy to implement as possible. • Only use will determine if we are producing anything of value • Approve “Good Enough” RM and DTs • Get practical use ASAP • Change RM and DTs based on use

27. Pleasanton May 10-12, 2012 • Resolution: The reference model presented by the Reference Model Task Force is endorsed as a starting point and establishes the direction that CIMI wishes to take. We expect that this model will be tested and modified as modeling work continues.

28. Pleasanton May 10-12, 2012 • Reference model and associated data types were approved • We expect that this model will be tested and modified as modeling work continues. • Agreed that there must be a computable semantic relationship between elements in a model

29. Goals for Rockville Meeting • Continue modeling work • Approve a proposal for creating an Editorial Board • Decide on what tools to use to make models • Create a team to do an end-to-end proof of concept • Possible targets: FIHR, SMArt, CDA template, HL7 V2, others? • Updates and information sharing: OMG AML RFI, CDL to ADL conversion, finding a parent organization, FIHR, member survey

30. Conflicts of Interest