HINF 335

" the ability for two or more system or components to exchange information and to use the information that has been exchanged"

Technical Interoperability- Moving data from system A to system B

Semantic Interoperability - System A & B understand data in the same way - use, interpret data without ambiguity

Process Interoperability -Coordinates work processes so organizations that house system A and system B can work together.

• Translation
• - Computers store data in different ways
• -Need to translate into a native format
• -Use of intermediate interchange language

• Bit-perfect
• -Need for perfection
• -Specifications must be stringent

• Users
• -Users don't know what they really want
• -Won't commit to requirements
• -Do not understand software development process

• Developers
• -Lack domain knowledge
• -Fail to understand each other
• -Managers wish to re-use existing software

"a document, established by concsensus and approved by a recognized body, that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context"

• Consensus - general agreement
• Recognized Body - an internationally recognized stardards development organization such as ISO, CEN, BSI, ANSI, HL7

• -Complex
• -Changes frequently
• -Can easily become a fog of acronyms

• International Standardization Organization (ISO)
• -established to provide a focal point for all international standards
• -membership organization with a membner in each country (ie. ANSI is the USA member)
• European Standards Organization (CEN)
• -Created when the european union was established

• Health Level Seven (HL7)
• -Has affiliates in 31 countries
• -Produces the world's most widely used standards for healthcare interoperability
• -Creates standards for the exchange, management and integration of electronic healthcare information
• -Voluntary standards organization

• International Health Terminology Standards Development Organization (IHTSDO)
• - Non for profit organization
• - IHTSDO's vision is to enhance the health of humankind by facilitating better health information management; to contribue to improved delivery of care by clinical and social care professions and to facilitate accurate sharing of clinical related health information

• Integrating the Healthcare Enterprise (IHE)
• -Aims to help improve the way healthcare computer systems share information (intially in the imaging domain)
• -Interoperability between equipment in clinical departments with hospital information systems

• Continua Alliance
• -nonprofit open industry coalition of healthcare and technology companies working to establish a system of interoperable personal health solutions
• -tele-health solutions in the home
• -ecosystem of connected technologies, devices, services that will enable the more efficient exchange of fitness, health and wellness information

• OpenEHR
• -develops technology independent architecture, (including reference model, architypes, and templates)

• Open Health Tools (OHT)
• -Produces machine processable artifacts, spanning through all stages of the message design cycle along with a framework for publishing documentation about the artifacts generated by the process

• The name HL7 is derived from the seventh level of the ISO's Open Systems Interconnect Model:
• -The application layer, which provides a framework for communication between disparate computer systems

They offer individual and organizational memberships.

THE OSI model has seven layers; the top three layers are concerned with applicatoins (interworking); the lower four layers are concerned with the transmission of data (interconnection)

• Layer 7 - Application
• Layer 6 - Presentation
• Layer 5 - Session
• Layer 4 - Transport
• Layer 3 - Network
• Layer 2 - Data-link
• Layer 1 - Physical

• - The most widely adopted application of HL7 V3.
• -It takes the document methaphor seriously
• -uses XML

• Databases
• - Organized for rapid search and retrieval
• -updated by transactions - by various people
• -Information can be viewd by different views - restrictions

• Documents
• -Are organized as stand-alone artifacts that mainly convey human understanding. Each document has a clearly identified set of meta-data stating who created it, for whom, when, where, and about what subject

CDA LEVEL 1- Has a header and a human-readable body. It contains basic meta-data, primarily intended to enable information retrieval

CDA LEVEL 2 - Allows the body to be either an unstructured blob, or one or more structured sections

CDA LEVEL 3- Allows each section to include machine-processed entries at almost any level of granularity

• CDA Header is common to all three levels of CDA. It provides unambiguous, structured meta-data about the document itself. This includes:
• What: - Identification of the document itself
• Times: - The time of generation of the CDA document
• Participants: - At least three participents; RecordTarget (the medical record this document belongs to), Author (person responsible for the content of the document) and Custodian (who keeps the record)
• Relationships- Relationships with other documents
• CDA Body- nonXMLBody or StructuredBody
• Section- Each section contains a human-readable narrative block.

- Has been developed by ASTM to provide a common XML format for a patient health record summary of clinical, administrative and demographic patient data to be sent to the next healthcare provider whena patient is referred or transferred to another hospital, clinic or other care provider. It can reference one or more healthcare encounters.

-The key motivation was to allow data from multiple sources to be brought together ina single format, to enable portable PHR

-Google Health has adopted a pragmatic profile of the CCR for the Google Health PHR

- Maps the CCR functionality into HL7 V3 CDA format by setting out a set of constraints on CDA and using templates.

-Set of templates (all parts are optional - and it is practical to mix and match the ones you need)

-CCD is the semantic equivalent of a CCR. Both are XML, both adhere to ANSI based specifications

Trigger Events-Explicit set of stated conditions, which can be recognized by a computer system that initiates an interaction.

• Application Roles - A collection of communication responsibilities intended to be implemented as a group. ( Interactions that the system is able to send and receive.)
• -From the application role definitions, the reader can identify the purpose of information flow between two health care applications and the roles they play in that exchange

Interactions - the smallest unit of communication that can stan don its own. One way transfer of information that ties together HL7's static models of payload content and the dynamic model of information flow and system behavior.

Message Types - the most precise specification of a message, which explicit constraints about what data elements are sent and what values each data element may have


Interaction Sequence- Te precise flow of messages may be represented using a UML sequence diagram, which shows the application roles and the flow of message types between them in sequential order

• Message Wrappers - Whenever domain content (as a payload) is transmitted in the form of messages they may use message wrappers - analogous to a letter's envelope.
• Query - Used to interrogate databases, such as to retrieve patient identification details from a patient master index.

Acknowledgements- Most HL7 transactions involve two or more messages: an originating message and an acknowledgement - in one of two modes: original or enhanced. This tells the sender that the receiver received (and processed) the message.

IHE XDS allows helathcare documents to be shared over a wide area network, between hospitals, primary care providers, and social services.

The idea is to build virtual patient records on the fly from a variety of clinical documents created by different healthcare organizations.

XDS enables users to retrieve different types of documents (letters, results, images), contained in one or more repositories in a quick and consistent way.

-To maintain security, the XDS registry has no access to the content of any document but relies entirely on standardized metadata provided by the source to retrieve relevant items.

The Model fo Use describes how the system, such as an EHR is actually used and the way that data is captured and displayed.

Data capture (the model of use) needs to be tuned to make individual work processes as quick and easy as possible.

One method of data capture is what we call ad hoc data entry, in which the user simply types in the first few letters of the term in mind and the system responds with a list of matching terms.

Structured data entry- removes the requirement to type - the user simply points and picks with a mouse or on a touch screen

• Typical views are:
• -Chronological
• -Summary views
• -Problem oriented
• -Reminders/alerts for drug sensitives
• -Clinican view
• -Notes
• -Detailed flow charts/graphs

Model of Meaning - a representation for reporting an danalysis purposes, and represents our understanding of the world, so that we can reason about it in general and individual patients in particular.

- This is the rational for developing reference models such as the HL7 RIM.

-How to bind HL7 V3 with SNOMED CT??

-For storage and analysis, we need information to be in a form that allows it to be reused in a very wide range of different ways. The best way to do this is to store the data in a form that reflects hte model of meaning. The storage system needs to keep information safe and secure.

HL7 RIM and clinical terminologies (ie. SNOMED CT) are examples of structural models.

The basic idea of a structural model is to provide a common framework that represents clinical information in a consistent standardized way, and relates each entry to common meta-data such as its subject, author, date/time and location.

The process of establishing links between elements of a terminology such as SNOMED CT and an information model. Terminology binding is principally concerned with what can be said (concepts) - not how it is said (terms).

Sometimes, there are several possible ways to express the same meaning (generally due to overlap between HL7 and SNOMED).

• Problems with terminology binding:
• -Enables the re-use of information
• -Different ways of using hte same coding system with the same information model from an obstacle to semantic interoperability

Version three uses an object oriented development methodology and a reference information model (RIM) to create messages. The RIM is an essential part of the HL7 Version 3 development methodology as it provides an explicit representation of the semantic and lexical connections that exist between the information carriend int he fields of HL7 messages.

The RIM was conceived as a universal reference model for healthcare interoperability, covering hte enttire healthcare domain.

HL7 V3 is a lingua franca used by healthcare computers to talk to other computers, to help provide information when and wehre needed. Healthcare communication is complex and the language needs to accomodate this complexity and also handle future needs.

the HIM specifies the grammer of V3 messages, and the basic building blocks of the language (nouns, verbs, etc), their permitted relationships and datatypes.

V3 RIM is based on a simple backbone structure, involving three classes: Act, Role and Entity.

Each class has a number of other classes linked to it. The most important act specializations are Observation, Procedure Substance, Administration, Supply and PatientEncounter

Constraining or refining a general model, for the specific use case being considered, by limiting optionality.

• Types of constrained information models include:
• 1. Domain Message Information Model - a general model of a domain, in HL7 notation, from which a related family of message specifications can be derived
• 2.Refined Message Information Model - The most widely used constrained information model - which is a diagram of a message specification
• 3.Hierarchical Message Description - RMIM can also be expressed in a tabular format, known as a hierarchical message description
• 4.Message Type- a particular specification of a message whihc can be used in data interchange.

• Types of constraint
• 1. Omission and cloning - Classes/attributes with classes are left out
• 2.Cloning - The same RIM class can be used many times in different was
• 3. Multiplicity and Optionality - Constraining multiplicities in terms of repeatability and optionality. Most associations and attributes in the RIM are optional and allow a number of repeats
• 4. Data Types Constraint - constraining data types
• 5. Code Binding - specifying what could value sets shall be used.

A value set is a set of codes that may be used to populate a specific attribute in a message instance, and is usually specified by the message designer.

A vocabulary domain is the set of codes available to the message designer for a specific attribute. For example, the vocabulary domain for the Act.moodCode is the set of all mood code values defined and maintaiend by HL7.

A template- is an expression set of constraints on the RIM, which is used to apply additional constraints to a portion of an instance of data expressed in terms of some other Static Model. Templates are used to further define and refine these existing models within a narrower and more focused scope.

HL7's development methodology is documented in the HL7 Development Framework (HDF). It is written for HL7 memebers who are developing standards within HL7 committees. However, much of what it says is of unversal relevance.

To select for evaluation and piloting SNOMED CT in both English and French as the Canadian standard for the reference terminology of the pan-Canadian Interoperable EHR (iEHR) for 27 priority Clinical Information Groups.

Infoway's goal is to have an interoperable EHR in place and serving 50 percent of the Canadian population by the end of 2009.

SNOMED CT

10th revision of the international classification of diseases and related health problems (ICD-10-CA)

the Canadian Classification of Interventions (CCI)

the INternational Classification of Primary Care Version 2 (ICPC-2)

International Classification for Nursing Practice (ICNP)

In Febuary 2006, the Electronic Health Record (EHR) Standards Steering Committee (SSC) decided to select for evaluation and piloting SNOMED CT in both English and French as the Canadian Standard for the Reference terminology of the pan-Canadian interoperable EHR (iEHR) for 27 priority Clinical Information Groups (CIGs).

• Infoway's goal to have an interoperable
• EHR in place and serving 50 per cent of the Canadian population by the end of
• 2009.

Standards are a key foundational element of the pan-Canadian iEHR. A common terminology standard for the interoperable EHR allows patient data across the clinical spectrum to be encoded with the same system, thus enabling electronic healthcare systems to understand one another's data - facilitating semantic interoperability.

Esentially, the adoption of SNOMED CT is being recommended for the iEHR because it captures clinical information at the level of detail needed by clinicians or the provision of care (the reference terminology level).

SNOMED CT is a controlled medical vocabulary.

Because SNOMED CT was developed to support the recording and retrieval of electronic clinical information, its use does not replace the need for classification systems.

• Successful terminology implementations depend on
• quality software solutions with good user interfaces that speak the language of the user; coding should be transparent to the user and be done in the background by the software.

• 2.Must be interoperable with the pan-Canadian EHR
• 3. Must be financially Viable
• 4. Must have established governance and processes related to all aspects of the
• standards life cycle
• 5. Must meet specific business needs
• 6.Must be technically viable

about patients amongst providers across the healthcare system.

It's a controlled medical vocabulary developed and owned by the College of American Pthologiests. It was created in 1965 by the CAP for the needs of pathologiests, it has evolved to become the most comprehensive structure for supporting an EHR.

They are classifications that complement one another. In Canada, ICD-10-CA and CCI are the standards for classifying diagnosis and interventions respectively for morbidity purposes.

ICD-10-CA is the Canadian revision of the World Health Organization's International Statistical Classification of Diseases and Related Health Problems. WHO is the official publisher of ICD-10. It classifies diseass, injuries and causes of death as well as external causes of injury and poisoning. It is a variable axis classification with alphanumeric codes. It is organized into Chapters according to the body system/anatomy with the execption of some additional chapters for certian condidtions, causes or factors influencing health status.

The CCI is a natinoal standard for classifying health care interventions. CCI is the companion classification system to the ICD-10-CA. It has a broad range of interventions such as: Therapeutic interventions, Diagnostic interventions (imaging tests, measurements,), Cognitive interventions... etc

The International Classification of Primary Care Version 2 (ICPC-2) is a classification designed for primary care. It was desigened for the collection and analysis of patient data and clinical activity in the domain sof general/family practice and primary care. This collection and analysis can occur at the level of an individual patient for clinical care, at the practice level for recall, clinical audit and activity analysis at the regional, state and national level for health services research and statistics. It can be used to classify terminologies and other classifications in electrionic health records to faciliate decision support and patient safety systems.

• The Systematized NOmenclature of MEDicine
• Clinical Terms (SNOMED CT) standard
• is a clinical terminology which facilitates the interoperability of
• Electronic Health Records.

• SNOMED CT® provides the core clinical terminology for the interoperable Electronic Health Record (iEHR). Currently it contains more than 357,000 concepts with unique meanings and formal logic-based definitions organized into hierarchies. When implemented in software applications, SNOMED CT® represents clinically relevant information consistently, reliably and comprehensively as an integral part of producing and populating clinical information in interoperable Electronic Health
• Records.

• In October 2005, the Infoway Clinical Terminology Integration (CTI) project recommended SNOMED CT® as the best choice for the reference terminology for priority clinical information groupings (or
• sub-domains) of the core interoperable Electronic Health Record (iEHR). As the pan-Canadian iEHR must serve the Canadian population (providers
• and patients alike), that also necessitates the need for SNOMED CT® to be available in both official languages.

• In February 2006, acting on the recommendations of the Infoway CTI project and the EHR Standards Advisory Committee (SAC), the Infoway EHR Standards Steering Committee (SSC) agreed:
• 1. To select SNOMED CT® for evaluation and piloting in both English and French as the Canadian standard for the reference terminology of the pan-Canadian iEHR; and
• 2.To move to the next phase of the Standards Life Cycle where further
• detailed analysis work will be carried out so that SNOMED CT® is evaluated and tested as rapidly as possible.

• No. The purpose, use and application of a clinical terminology such as SNOMED CT® to express primary clinical information in a real-time mode
• within an EHR differs from that of classifications such as ICD-10-CA or CCI.

• Yes. Infoway recently approved the first phase of translation of SNOMED CT®. The goal of the SNOMED CT® French Translation Project is
• to provide Canadians with a French version of the terminology. The initial objective is to translate the priority sections of SNOMED CT® in
• French, using qualified vendor(s) and a proven software tooling environment capable of supporting such a complex multi-year project. Based on this experience, recommendations will be made for translation of remaining contents. More information on the project and its progress can be found on the Forum.

• The purpose of the National Product Centre (NPC) is to provide a central and single point within Canada to:
• - Interface to the IHTSDO®;
• - Interface to other NPCs;
• - Interface to all entities within Canada that have an interest in the products or business of the IHTSDO®;
• - Manage and control the use of the IHTSDO®'s assets within the member's territory;
• - Interface to the IHTSDO Support Organisation and or to any Division of the CAP but only in accordance with IHTSDO® policies, procedures and regulations.

While some cross-maps were previously created within specific jurisdictions (the United Kingdom and the United States) for constrained purposes, such as the International Classification of Diseases - Clinical Modification ICD-9-CM billing reimbursement maps created specifically for use in the U.S., these are not part of the release material being provided in Canada.

• The World Health Organization (WHO) andIHTSDO have started collaboration on mapping between SNOMED-CT and the WHO Family of
• International Classifications (FIC) which include ICD-10 Second Edition.

• At this time, there are no current Canadian mapping projects underway. No cross maps between SNOMED CT and ICD-10-CA and Canadian
• Classification of Health Interventions (CCI) exist. In order to move forward on a decision to map these terminologies several items need to be addressed such as needs, priorities, feasibility, and requirements.
• Any such determination and undertaking must involve the SDOs and/or maintenance bodies responsible for each standard, including Canada Health Infoway (Infoway) and the Canadian Institute for Health
• Information (CIHI).

Members can be either agencies of national governments or other bodies (such as corporations or regional government agencies) endorsed by an appropriate national government authority within the country they represent.

• The Charter Members are those countries that worked together to form the IHTSDO® organisation and include Australia, Canada, Denmark, Lithuania,
• Sweden, the Netherlands, New Zealand, United Kingdom and United States.

• - Equivalence of post and pre coordinated terms (are they the same??? )
• -Does not yet adequately cope with negation (of clinical status)
• - Usability
• -User training (both in capacity and motivation)
• -SNOMED is very complex, so, is it too complex for everyday practice?
• -A lot of practitioners are "terminologically hostile" and don't want new terminologies to be implemented
• -

• Intervie participants indicated that:
• -The priority of SNOMED CT implementation ranges from low to very high across jurisdictions
• -Subsets would facilitate implementation but they are time consuming to create
• -More knowledge about when to implement local temrs that arte mapped to SNOMED CT in the background vs. when to implement native SNOMED CT concpet descriptions is required
• -Few vendor solutions have the ability to use the fulness of SNOMED CT
• -Implementation challanges are not nessarily due to SNOMED itself
• -Implementation benefits are starting to be realized by those who have adopted SNOMED CT.

• - Designed to be scalable
• -Designed using a formal object-oriented methodology
• -Based on central consistent models
• -More then messages
• -Rigorously defined vocabulary bindings
• -Industry standard technology for implementaion and transport (XML, SOAP/WDSL)

• Context
• -Many mapping issues are context driven.
• -Message structure (different versions capture data differently, and therefore are not interoperable)

• Semantics
• -The attributes/Data type fields in both HL7V2 and HL7V3 are associated with a specific HL7 data type. In both the versions, data types are basic building blocks of information exchanged in the messages. However
• -HL7V2 data types are another level of nesting
• -HL7V3 data types define the semantics of data values that can be assigned to a data element
• -Not all data types that appear in HL7V2 exist in V3

• Time
• - There are some issues with the mapping of datatypes between HL7V2 and HL7V3. The HL7V2 Timing Quantitiy data type with describes when a service should be preformed and how frequently - have potentially 3 datatypes

• RECOMMENDED ACTIONS:
• -Leverage existing mapping resources to gather information regarding activities, timing, known issues, pitfalls, etc.
• -Standardization of HL7V2 to reduce mapping work for each implementation
• -Consider a phsed-mapping approach
• -Establish a general strategy

1.Concept - A unit of thought consittuted through abstraction on th basis of properties common to a set of objects

2.Term- Designation of a defined concept ina special language by linguistic expression

3.Terminology - Set of terms representing the system of concpets of a particular subject field

4.Nomenclature - System of terms that is elaborated according to preestablished naming rules

5.Dictionary - Structured collection of lexical units, with linguistic information about each of them

6. Vocabulary - Dictionary containing the terminology of a subject field

Postcoordination -When the coding is accomplished through the use of multiple codes as needed to describe the data. For example, a case of bacterial pneumonia would be ocdded in ICPC as a combination of the code R81 and the code for the particular test result that identifies the causative agent.

Precoordination - Where every type of pneumonia is assigned its own code

The Diagnostica nd Statistical Manual of Mental Disorders (DSM-IV) provides definitions of psychiatric disorders and includes specific diagnostic criteria. It is coordinated with ICD-10 and contains over 450 terms.

The Read Clinical Codes comprise a set of terms designed specifically for use in coding EHRs. It is able to be cross mapped to ICD.

Galen is developing a reference model for medical concepts using a formalism called Structured Meta Knowledge (SMK). In SMK, terms are defined through relationships to other terms, and grammars are provided to allow combinations of terms into sensible phrases. The reference model is intended to allow representation of patient information in a way that is independent of the language being recorded and of the data model used by an EHR system.

Logical Observation Identifiers Names and Codes (LONIC) creates a naming system for tests and observations.

Nursing Terminologies- Coordinate with SNOMED and LOINC. Terminologies such as North American Nursing Diagnosis Association (NANDA), etc. They are important because nurses have different observations than doctors - and therefore need different terms to accurately record a patients status.

• - Data about data
• -Information about information
• -Structured data that describes, explains, locates, or makes it easier to retrieve, use or manage an information resource.

• Types of Metadata:
• -Descriptive (describes an object)
• -Structural (Indicates how objects go together)
• -Administrative (Provides information to manage a resource)

• Communities that use Metadata
• -Libraries (catalogs)
• -Software Developers (Data dictionaries)
• -Software Programs (Machine understandable info such as HL7)

The describe the speceific interactions a user will have with the system. The steps the user will follow to use the software or carry out the work. Use cases describe the ways the users will ineract with the software.

Purpose - This storyboard illustrates how a system user records a patient discharge/care summary


Story Event -Mable is treated with an atibiotic medication and her urinary tract infection starts to resolve. Dr.Leblanc convinces Mable.... etc

Interaction Diagram:



Flow of Events

• 1. Discharge provider discharges patient from hospital
• 2.Family Medical Resident records discharge/care summary