Download CLINICAL FINDING - Medical informatics at Mayo Clinic

Modelling Patterns
Review & Suggestions
Dr Linda Bird
16th August 2012
Modelling Layers
CLUSTER
ENTRY
SECTION
COMPOSITION
Add
Implementation
Purpose Context
Dispensed
Medications GUI
Neonatal Blood
Pressure in EHR
Current Medication
List in EHR
Discharge Summary
Doc or Message
Add Care Setting
Context
G.P. Dispensed
Medication Item
Home Blood
Pressure
Outpatient Clinic
Current Medication
List
Inpatient Discharge
Summary
Add Specialty
Context
Paediatric
Medication Item
Neonatal Blood
Pressure
Nephrologist
Medication List
Cardiology Discharge
Summary
Add Use Case
Context
Dispensed
Medication Item
Standing Blood
Pressure
Current Medication
List
Medication
Reconciliation Report
Clinical Models
Medication Item
Blood Pressure
Medication List
Discharge Summary
Modelling Patterns
Schedule,
Address,
Material
Observation,
Action
Clinical List
Event Summary,
Assessment
Reference Model
Modelling Patterns Review
•
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•
•
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•
•
•
openEHR
NHS LRA
SNOMED CT
results4Care DCMs
IMH CEMs
MOHH LIM
VA’s Discernables
EN13606 Association
HL7 v3 RIM
Modelling Patterns Types
1. Clinical Statement Types
2. Isosemantic model structure
– key concept, qualifiers, modifiers
3.
4.
5.
6.
7.
Clinical processes events links
History of Events
Order state machine and care flow mapping
Composition/Document
Clinical Model Patterns
– Reference Range Set, Schedule, Material (Device,
Medication), Score/Assessment Scale
NHS LRA Care Components Reference
Model
class extract package constrained classes
EXTRACT_CRITERIA
RECORD_COMPONENT
AUDIT_INFO
{leaf}
-
{leaf}
all_versions: BL [0..1]
archetype_ids: II [0..*]
max_sensitivity : CS [0..1]
multimedia_included : BL [0..1]
other_constraints: ED [0..1]
time_period : IVL [0..1]
-
constraints
{all_versionsDefault}
{all_versionsDefined}
{other_constraintsDefined}
-criteria
committer: II.Uuid.Ref
ehr_system: II
previous_version: II [0..1]
reason_for_revision: CD.CV [0..1]
time_committed: T S
version_set_id: II [0..1]
version_status: CS [0..1]
-feeder_audit
0..1
0..1
constraints
{version status LRA vocab}
{reason for revision LRA vocab}
0..*
-committal
-
LINK
archetype_id: ST [0..1]
meaning: CD.CV [0..1]
name: ST
orig_parent_ref: II [0..1]
policy_ids: II [0..*]
rc_id: II.Uuid
sensitivity: CS [0..1]
synthesised: BL
-links
0..*
follow_link: BL
nature: CS
target: II.Uuid.Ref
constraints
{follow_link default value false}
{links allowed only one target in LRA}
{target exists}
{nature LRA vocab}
constraints
{synthesised defaults to false}
{sensitivity LRA vocab}
1..1
0..1
-content
EHR_EXTRACT
{leaf}
-
0..* -
0..*
-
contribution_id: II [0..1]
session_time: IVL_T S
territory: CS [0..1]
0..1
obs_time: IVL_T S [0..1]
-members
constraints
-parts {item category undefined in LRA}
{emphasis
undefined
in LRA}
0..*
0..*
constraints
{name value}
{composer is of type FUNCT IONAL_ROLE}
{there exists one and only one
other_participations instance representing the
record target (i.e. subject of care)}
0..1
constraints
{rm_id is 13606}
ITEM
0..*
{leaf}
-all_compositions
authorising_party: II [0..1]
ehr_id: II
ehr_system: II
rm_id: ST
subject_of_care: II
time_created: T S
-items
CONTENT
COMPOSITION
SECTION
ELEMENT
CLUSTER
{leaf}
demographics
-demographic_extract
0..*
-composer
0..1
0..1
-
-attestations
1..*
healthcare_facility: II.Uuid.Ref [0..1]
mode: CS [0..1]
-other_participations
performer: II.Uuid.Ref
ATTESTATION_INFO
constraints
{sections may only contain (by
value) other sections}
structure_type: CS
constraints
{name value}
{cluster structure type LRA vocab}
{meaning is undefined}
{leaf}
-
act_id: II [0..1]
uncertainty_expressed: BL.Null
RELATED_PARTY
0..1
attested_view: ED [0..1]
proof: ED [0..1]
reason_for_attestation: CD.CV
target: II.Uuid.Ref [1..*]
time: T S
constraints
{target must exist within extract}
{attester is of type FUNCT IONAL_ROLE}
{reason for attestation LRA vocab}
-attester
0..1
1..1
-info_provider
extended
PARTICIPATION
value: ANY
ENTRY
{leaf}
-
-
0..*
constraints
{function is undefined in LRA}
{mode LRA vocab}
{service setting is undefined in LRA}
0..*
-
-other_participations
FUNCTIONAL_ROLE
IDENTIFIED_ENTITY
{leaf}
0..1
0..1
constraints
{uncertainty expressed has nullFlavor}
{meaning undefined}
{entry items may only contain elements}
{subject_of_information_category undefined in LRA}
{subject_of_information_category no default in LRA}
{act_status is undefined in LRA}
{no relationship type conflict in LRA}
{name value}
{information_provider is of type FUNCT IONAL_ROLE}
{leaf}
-subject_of_information
0..1 -
party: II.Uuid.Ref [0..1]
relationship: CD.CV.SCT
constraints
{relationship code type LRA vocab}
NHS LRA – ELEMENT patterns
class extract package derived classes
UNBOUND_DATA_ELEMENT
{leaf}
constraints
{name value}
{meaning undefined}
COMPONENT_RELATIONSHIP_ELEMENT
{leaf}
BOUND_DATA_ELEMENT
constraints
{meaning is coded data}
{meaning is defined and is not null}
MATERIAL_ENTITY_ELEMENT
{leaf}
constraints
{meaning is a material}
{name value}
{value is type QTY}
{obs_time is undefined in LRA}
constraints
{name value}
{value defines dependency}
{must have exactly 2 links}
{value is coded data}
{one link to subject}
{one link to object}
{coded meaning from LRA vocab}
{meaning is defined}
RECORD_ARTEFACT_ELEMENT
{leaf}
constraints
{name value}
{meaning is a record artefact}
{value must be null}
{name value}
{meaning is a general activity procedure}
NHS LRA – ELEMENT Domain Models
Finding Observations
• AllergyOrAdverseReactionEvent
• AllergyOrAdverseReactionPropensity
• DiagnosisName
• GenericFindingObservation
• GenericProblemAndIssue
• RisksExpectationsOrGoals
Property Observations
• BloodPressureObservation
• BloodSugarObservation
• BodyHeightObservation
• BodySurfaceAreaObservation
• BodyWeightObservation
• DiastolicPressureObservation
• GenericPropertyObservation
• PulseRateObservation
General Activities
GenericAdmissionEvent
GenericDischargeEvent
GenericProcedure
SpecimenCollection
Material Activities
GenericSpecimen
MeasurementDevice
ProductOrSubstance
Investigation Activities
BloodPressureMeasurement
BodyHeightMeasurement
TemperatureMeasurement
Unbound Data
AdviceForPatient
CourseTiming
FutureEventTime
InterpretationRange
NHS LRA – ENTRY Domain Models
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•
GenericClinicalNarrative
GenericAdmissionEvent
GenericFinding
HealthcareActionPlan
GenericProblemAndIssue
GenericProcedure
GenericProperty
MedicationReviewPlan
ProductOrSubstance
ProductOrSubstanceRelatedActivity
ProvisionOfInformationAndAdvice
RecommendationActivity
AllergyOrAdverseReactionEvent
GenericAdmissionProspect
AllergyOrAdverseReactionPropensity
GenericDischargeEvent
BloodPressure
•
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•
BloodSugar
GenericTransfer
BodyHeight
GenericTransferProspect
BodySurfaceArea
RisksExpectationsAndGoals
BodyWeight
ProvisionOfAdviceAndInformation
Diagnosis
FluidIntakeRate
GenericAssessment
SubjectOfCareObservations
GenericInvestigation
PulseRate
Temperature
TreatmentDevice
NHS LRA – e.g. Temperature ENTRY
omposite structure Temperature
«UNBOUND_DATA_ELEMENT»
Text
«FUNCTIONAL_ROLE_CHOICE»
InformationProviderChoice
HasAnnotation
«OBJECT»
0..*
0..*
-items
«SUBJECT»
0..1
«PROPERTY_OBSERVATION_ELE...
TemperatureObserv ation
0..1
IsResultantObservationOf
-items
«SUBJECT»
1
«ENTRY»
Temperature
«RELATED_PARTY_CHOICE»
SubjectOfInformationChoice
-items
0..1
-
name: SC {readOnly}
rc_id: II
synthesised: BL
uncertainty_expressed: BL {readOnly}
0..1
0..1
«INVESTIGATION_ACTIVITY_EL...
TemperatureMeasurement
«OBJECT»
«SUBJECT»
0..1
HasClinicalContext
-items
0..*
0..*
«FINDING_OBSERVATION_ELEM...
GenericFindingObserv ation
«OBJECT»
0..*
«SUBJECT»
0..*
«FUNCTIONAL_ROLE_CHOICE»
OtherParticipationsChoice
0..*
-items
0..*
«OBJECT»
«UNBOUND_DATA_ELEMENT»
UnboundGenericFinding
0..*
«OBJECT»
HasClinicalContext
«OBJECT»
0..*
0..*
NHS LRA – e.g. Temperature ENTRY
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•
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•
•
Subject of Information (Participation)
Information Provider (Participation)
OtherParticipation (Participation)
TemperatureObservation (PropertyObservation)
TemperatureMeasurement (InvestigationActivity)
Text (UnboundDataElement)
UnboundGenericFinding (UnboundDataElement)
GenericFindingObservation (FindingObservation)
NHS LRA – e.g. TemperatureObservation
ELEMENT
composite structure TemperatureObserv ation
«INVESTIGATION_ACTIVITY_ELEME...
TemperatureMeasurement
«PROPERTY_OBSERVATION_ELEMEN...
TemperatureObserv ation
-
archetype_id: ST [0]
meaning: CD.CV
name: SC {readOnly}
obs_time: IVL<TS> [0..1]
orig_parent_ref: II [0]
policy_ids: SET<II> [0]
rc_id: II
sensitivity: INT [0]
synthesised: BL
value: PQ
IsResultantObservationOf «OBJECT»
0..1
«SUBJECT»
0..1
-
archetype_id: ST [0]
meaning: CD.CV.SCT
name: SC {readOnly}
obs_time: IVL_TS [0..1]
orig_parent_ref: II [0]
policy_ids: SET<II> [0]
rc_id: II.Uuid
sensitivity: INT [0]
synthesised: BL
value: ANY {readOnly}
«FINDING_OBSERVATION_ELEMENT»
GenericFindingObserv ation
HasClinicalContext
«SUBJECT» 0..*
0..*
«OBJECT»
0..*
«SUBJECT»
0..1
HasAnnotation
-
archetype_id: ST [0]
meaning: CD.CV
name: SC {readOnly}
obs_time: IVL<TS> [0..1]
orig_parent_ref: II [0]
policy_ids: SET<II> [0]
rc_id: II
sensitivity: INT [0]
synthesised: BL
value: ANY {readOnly}
«OBJECT»
«UNBOUND_DATA_ELEMENT»
UnboundGenericFinding
0..*
«OBJECT»
«UNBOUND_DATA_ELEMENT»
Text
-
archetype_id: ST [0]
name: SC {readOnly}
obs_time: IVL<TS> [0]
orig_parent_ref: II [0]
policy_ids: SET<II> [0]
rc_id: II.Uuid
sensitivity: INT [0]
synthesised: BL
value: ED.Text
«SUBJECT»
-
archetype_id: ST [0]
name: SC {readOnly}
obs_time: IVL<TS> [0..1]
orig_parent_ref: II [0]
policy_ids: SET<II> [0]
rc_id: II
sensitivity: INT [0]
synthesised: BL
value: ANY
0..*
«OBJECT»
HasClinicalContext
0..*
0..*
«OBJECT»
NHS LRA – e.g. TemperatureObservation
ELEMENT (mindmap)
openEHR – ENTRY patterns
SNOMED CT
• OBSERVABLE ENTITY
• CLINICAL FINDING
– Finding method: PROCEDURE
– Interprets: PROCEDURE
– Interprets: OBSERVABLE ENTITY
• PROCEDURE
– Has focus: CLINICAL FINDING
SNOMED CT – Observable
(draft)
SNOMED CT – Observable
(draft)
results4Care DCMs
•
•
•
•
Root concept
Data
Qualifier
State
IMH CEMs
• Observed, StandardLabObs, Procedure, Order,
Intolerance, Allergy, Adverse Reaction
Summary, Admit/AdminDiagnosis
• Key, Item, Qualifier, Modifier, Attribution
MOHH LIM
• ENTRY
– Observation Entry (Observable Name/Value)
• Heart Rate/ Blood Pressure / Blood Glucose
– Clinical Finding
• Problem Diagnosis Entry
• Adverse Reaction Entry
• Alert Entry
– Activity
• Pharmacy Activity Entry
– Pharmacy Order Entry
– Pharmacy Dispense Entry
– Pharmacy Administration Entry
• Investigation Activity Entry
– Investigation Order Entry
– Investigation Result Entry
• Procedure Entry (Reference Pattern)
• CLUSTER
– Pharmacy Item / Investigation Test Item
IsoSemantic Models – Example Instances
e.g. “Suspected Lung Cancer”
IsoSemantic Models – Compositional Grammar
Problem Diagnosis = $ProblemDiagnosisName:
246090004|associated_finding|=
(404684003|clinical_finding|:
63698007|finding_site|=($BodySite:
272741003|laterality|=$Laterality),
246112005|severity|=$Severity),
408729009|finding_context|=$FindingContext
EN13606 Association
HL7 v3 RIM
Modelling Patterns Types
1. Clinical Statement Types
2. Isosemantic model structure
– key concept, qualifiers, modifiers
3.
4.
5.
6.
7.
Clinical processes events links
History of Events
Order state machine and care flow mapping
Composition/Document
Clinical Model Patterns
– Reference Range Set, Schedule, Material (Device,
Medication), Score/Assessment Scale
Clinical Statement Types
Reviewed
• openEHR
– Observation, Evaluation, Instruction, Action, Admin Entry
• MOHH
– Observation, Finding, Activity (Medication, Laboratory), Administration
• NHS LRA
– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,
General), Material Entity
– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....
• Intermountain/GE
– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction
Summary, Admit/AdminDiagnosis, ...
• SNOMED CT
– Observable Entity, Clinical Finding, Procedure, ...
• HL7 v3
– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial
Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)
Clinical Statement Types
(Observation)
• openEHR
– Observation, Evaluation, Instruction, Action, Admin Entry
• MOHH
– Observation, Finding, Activity (Medication, Laboratory), Administration
• NHS LRA
– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,
General), Material Entity
– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....
• Intermountain/GE
– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction
Summary, Admit/AdminDiagnosis, ...
• SNOMED CT
– Observable Entity, Clinical Finding, Procedure, ...
• HL7 v3
– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial
Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)
Clinical Statement Types
(Finding)
• openEHR
– Observation, Evaluation, Instruction, Action, Admin Entry
• MOHH
– Observation, Finding, Activity (Medication, Laboratory), Administration
• NHS LRA
– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,
General), Material Entity
– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....
• Intermountain/GE
– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction
Summary, Admit/AdminDiagnosis, ...
• SNOMED CT
– Observable Entity, Clinical Finding, Procedure, ...
• HL7 v3
– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial
Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)
Clinical Statement Types
(Activity)
• openEHR
– Observation, Evaluation, Instruction, Action, Admin Entry
• MOHH
– Observation, Finding, Activity (Medication, Laboratory), Administration
• NHS LRA
– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,
General), Material Entity
– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....
• Intermountain/GE
– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction
Summary, Admit/AdminDiagnosis, ...
• SNOMED CT
– Observable Entity, Clinical Finding, Procedure, ...
• HL7 v3
– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial
Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)
Clinical Statement Types
(Administration)
• openEHR
– Observation, Evaluation, Instruction, Action, Admin Entry
• MOHH
– Observation, Finding, Activity (Medication, Laboratory), Administration
• NHS LRA
– ELEMENTs: Property Observation, Finding Observation, Activity (Investigation, Material,
General), Material Entity
– ENTRYs: GenericFinding, GenericProcedure, GenericProblemAndIssue, ....
• Intermountain/GE
– Observed, StandardLabObs, Procedure, Order, Intolerance, Allergy, Adverse Reaction
Summary, Admit/AdminDiagnosis, ...
• SNOMED CT
– Observable Entity, Clinical Finding, Procedure, ...
• HL7 v3
– Act (Observation, Procedure, Exposure, Patient Encounter, Financial Contract, Financial
Transaction, Account, Invoice Element, Context Structure, Device, Task, Supply)
CIMI ENTRY Pattern Suggestions
•
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•
•
Property Observation (property-value pair)
Clinical Finding (name)
Activity (orders, procedures, etc)
Administration (X ?)
Property Observation
(Existing Definitions)
• openEHR
– Observation: the observation of any phenomenon or state of interest to do
with the patient (eg diagnosis, goal, adverse reaction).
• NHS LRA
– Property Observation: Used to represent the results of investigations
undertaken to find out more information about a patient's state of health or
wellbeing and device or procedure related parameter settings. (Meaningvalue pairs)
• SNOMED CT
– Observable Entity: represents a question or procedure which can produce
an answer or a result. Used to code elements on a checklist or any element
where a value
• EN13606 Association
– Observation/Inspection: Used to define all that can be documented about a
specific state of a process in the Patient System at a point in time using the
faculties of seeing, hearing, tasting, touching, smelling, or directly via a
medical device or service.
Property Observation
(Suggested CIMI Definition)
Used to represent the results of observations or
investigations undertaken to find out more information
about a patient’s state of health or wellbeing, and device
or procedure related settings.
Comments:
• E.g. Heart rate, Blood glucose, Glasgow Coma Scale
• Represents the common name-value or question-answer pattern
• Supports isosemantic representation of Observation Names that
may include method, patient_state, device, location and other
related information in pre or post-coordinated form.
Clinical Finding
(Existing Definitions)
• openEHR
– Evaluation: the Opinion category , including problem/diagnosis, risk
assessment, scenario, goal and recommendation
• NHS LRA
– Finding Observation: used to represent both normal and abnormal clinical
states found on examination or deduced from clinical reasoning (e.g. 'clear
sputum', 'diabetes mellitus') and events to which the patient or service user
may have been to subject (e.g. 'physical abuse', 'exposure to mercury').
• SNOMED CT
– Clinical Finding: represent the result of a clinical observation, assessment or
judgement, and include both normal and abnormal clinical states
• EN13606 Association
– Evaluation/Consideration: Used for the documentation about an inferred
process in the patient system using observations, expertise and knowledge,
or about plans with, or risk assessments about, the Patient system
Clinical Finding
(Suggested CIMI Definition)
Used to represent clinical states found on examination or
deduced from clinical reasoning (e.g. ‘diabetes mellitus’,
‘clear sputum’), and events to which the patient may have
been subject (e.g. ‘physical abuse’, ‘exposure to mercury’).
Comments:
• E.g. Diagnosis, Adverse Reaction, Alert
• Supports isosemantic representation of Clinical Finding Names
that may include body location, laterality, causative agent and
other related information in pre or post-coordinated form.
Activity
(Existing Definitions)
• openEHR
– Action: Information recorded due to the execution of an instruction by some
agent
– Instruction: Actions to be performed in the future.
• NHS LRA
– Activity: Used to record treatment procedures, investigation procedures,
administrative procedures and the provision of advice and information to
patients and carers
• SNOMED CT
– Procedure: Activities performed in the provision of health care
• EN13606 Association
– Instruction/Order: used to define all that can be documented about the
intended actions with the aim to change the state or process in the Patient
System
– Action/Intervention: is used to define all that can be documented about
events that changed (or could change) states or processes in the Patient
System
Activity
(Suggested CIMI Definition)
Used to record activities that have been, are being, or are to
be performed, including treatments, investigations,
administrative procedures and the provision of advice or
information.
Comments:
• E.g. Medication Activity (Requested, Dispensed, Administered),
Investigation Activity (Requested, Performed)
• Supports isosemantic representation of Activity Names, which
may include body location, priority, context and other related
information in pre or post-coordinated form.
CIMI Modelling Patterns
(Suggested Definitions)
Property Observation (property-value): Used to represent the results
of observations or investigations undertaken to find out more
information about a patient’s state of health or wellbeing, and
device or procedure related settings.
• E.g. Heart rate, Blood glucose, Glasgow Coma Scale
Clinical Finding (name): Used to represent clinical states found on
examination or deduced from clinical reasoning (e.g. ‘diabetes
mellitus’, ‘clear sputum’), and events to which the patient may
have been subject (e.g. ‘physical abuse’, ‘exposure to mercury’).
• E.g. Diagnosis, Adverse Reaction, Alert
Activity: Used to record activities that have been, are being, or are to
be performed, including treatments, investigations, administrative
procedures and the provision of advice or information.
• E.g. Medication Activity (Requested, Dispensed, Administered),
Investigation Activity (Requested, Performed)
CIMI Call For Clinical Models
•
•
•
•
•
•
•
•
•
Heart Rate - Property Observation
Body Mass Index – Property Observation
Apgar Score – Property Observation
Glucose Tolerance Test Result – Property Observation
Adverse Reaction – Clinical Finding
Medication order - Activity
Problem list – List (Section) of Clinical Finding (+ ?)
Care Giver Reported Nausea – Clinical Finding
Wound Culture Result – Activity + Property Observation?
LINKS between Models
(Suggestions)
• Property Observation to:
– Finding: ‘has interpretation’
– Activity: ‘results in’
• Activity to:
– Activity: ‘has instruction’, ‘depends on’, ‘must occur before’, etc
– Clinical Finding: ‘has focus’, ‘results in’
– Property Observation: ‘results in’
• Clinical Finding to:
– Property Observation: ‘reason for’
– Activity: ‘finding method’, ‘is indication for’
Where to from here?
– Review of Existing Approaches (e.g. NHS, ISO, SNOMED)
– Proposal for CIMI
NHS LRA – Component
Relationship Vocabulary (draft)
EN13606:3 Link Nature
Code
Meaning
LINK-A0
is related to
LINK-B0
is confirmed by
LINK-C0
is related to the same problem or health issue
LINK-D0 is related to the same plan of care, act or episode
LINK-E0
is a related documentation
EN13606:3 Link Role
Code
LINK-A1
LINK-A2
LINK-A2i
LINK-A3
LINK-B1
LINK-B2
LINK-B3
LINK-B3i
LINK-B4
LINK-B5
LINK-B6
LINK-B6i
LINK-C1
LINK-C1i
LINK-C2
LINK-C3
LINK-C3i
LINK-C4
LINK-C4i
LINK-C5
LINK-C5i
LINK-C6
LINK-C6i
Meaning
unspecified link
suggests (tentatively related to)
is suggested by
re-occurrence or repeat of
endorses (agrees with, confirms, verifies)
disagrees with (e.g. another opinion)
permits (sanctions, authorises)
permitted by
assumes responsibility for
declines (refuses, cancels)
consents to
consented by
cause (interpretation)
caused by
revised interpretation
evidence for
justified by
evidence against
countered by
indicated by
indication for
contra-indicated by
contra-indication for
Code
Meaning
LINK-C7
trigger for
LINK-C7i
triggered by
LINK-C8
manifestation of
LINK-C8i
manifested by
LINK-C9
sequel (consequence, progression)
LINK-C10 intended (aim, goal, target, hoped for, desired)
LINK-C11
anticipated (predicted)
LINK-C12 to be avoided (at risk of, fear of, prophylaxis)
LINK-D1
outcome
LINK-D2
has pre-condition
LINK-D3
evaluation (assessment, milestone)
LINK-D4
contributes to or fulfils goal, plan or act
LINK-D5
revised state of the same act
LINK-D6
sub-task of
LINK-E1
documented by (is documented within)
LINK-E1i
documents (describes, reports)
LINK-E2
summarises
LINK-E3
supplements
LINK-E4
excerpts
LINK-E5
derived from
LINK-E6
has reference ranges
LINK-E7
identified within (study product)
SNOMED CT
• OBSERVABLE ENTITY
• CLINICAL FINDING
– Finding method: PROCEDURE
– Interprets: PROCEDURE
– Interprets: OBSERVABLE ENTITY
• PROCEDURE
– Has focus: CLINICAL FINDING
... And many other ‘Linkage’ concepts
SNOMED CT Concept Model
• Clinical Finding
– Finding site <<442083009|Anatomical or acquired body structure|
– Associated morphology << 4975500|Morphologically abnormal structure|
– Associated with <<404684003|Clinical Finding|, 71388002|Procedure|, 272379006|Event|,
410607006|Organism|, 105590001|Substance|, 260787004|Physical object|, 78621006|Physical
force|, 373873005 |Pharmaceutical / biologic product|
Severity <= 272141005 |Severities|
–
– Clinical course <= 288524001|Courses|
– Episodicity <= 288526004|Episodicities|
– Interprets << 363787002|Observable entity|, 108252007|Laboratory procedure|,
–
–
–
–
–
–
386053000|Evaluation procedure|
Has interpretation << 260245000|Findings values|
Pathological process == 263680009|Autoimmune|, <<441862004|Infectious process|
Has definitional manifestation << 404684003|Clinical finding|
Occurrence < 282032007|Periods of life|
Finding method <= 71388002|Procedure|
Finding informer <<420158005|Performer of method|, 419358007|Subject of record or
other provider of history|
SNOMED CT Concept Model
• Procedure
–
–
–
–
–
–
–
–
–
–
Procedure site << 442083009|Anatomical or acquired body structure|
Procedure morphology <<49755003|Morphologically abnormal structure|
Method <<129264002|Action|
Procedure device <<49062001|Device|
Access <=309795001|Surgical access values|
Direct Substance <<105590001|Substance|, 37387305|Pharmaceutical / biologic product|
Priority <=272125009|Priorities|
Has focus <<404684003|Clinical finding|, 71388002|Procedure|
Has intent <=363675004|Intents (nature of procedure values)|
Recipient category <<125676002|Person|, 35359004|Family|, 133928008|Community|, 105455006|Donor for
medical or surgical procedure|, 389109008|Group|
– Revision status <<261424001|Primary operation|, 255231005|Revision - value|, 257958009|Part of
multistage procedure|
–
–
–
–
Route of administration <<284009009|Route of administration value|
Surgical approach <=103379005|Procedural approach|
Using energy <<78621006|Physical force|
Using substance <<105590001|Substance|
LINKS between Models
(Suggestions)
• Property Observation to:
– Finding: ‘has interpretation’
– Activity: ‘results in’
• Activity to:
– Activity: ‘has instruction’, ‘depends on’, ‘must occur before’, etc
– Clinical Finding: ‘has focus’, ‘results in’
– Property Observation: ‘results in’
• Clinical Finding to:
– Property Observation: ‘reason for’
– Activity: ‘finding method’, ‘is indication for’
Where to from here?
– Review of Existing Approaches (e.g. NHS, ISO, SNOMED)
– Proposal for CIMI
CIMI Modelling Pattern Attributes
(Suggestion)
– All
• Participations: subject, information provider
• Elements: Timing
• Elements: Clinical Status
– Property Observation
•
•
•
•
Participations: observer
Cluster (Isosemantic ): Property (name, descriptors)
Cluster: Result (name, value, details, interpretation, reference range)
Links: observing activity, interpretation, is indication of, other
– Finding
•
•
•
•
Participations: finder
Cluster (Isosemantic ): Finding Item (name, descriptors)
Cluster: Finding Details (details)
Links: finding method, finding procedure, is indication of
– Activity
•
•
•
•
•
Participations: performer
Cluster (Isosemantic): Activity Item (name, descriptors)
Element: Activity Identifier(s)
Cluster: Activity Details (details)
Links: has instruction, depends on, must occur before
Property Observation
Heart Rate Example
Clinical Finding
Activity
Thank You
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