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
Example Challenge without VMR
Observation
Code = BP
Value = 120/80 mmHg
Blood Pressure
Systolic = 120 mmHg
Diastolic = 80 mmHg
Observation
Code = BP
Observation
Code = SBP
Value = 120 mmHg
Observation
Code = DBP
Value = 80 mmHg
Vital Sign
Type = BP
Value = 120/80
Units = mmHg
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
class dataTypes
iso-21090-datatypes-simplified-vmr::
ANY
iso-21090-datatypes-simplified-v mr::IVL_INT
+
+
+
+
low :INT [0..1]
high :INT [0..1]
lowIsInclusive :boolean [0..1]
highIsInclusive :boolean [0..1]
iso-21090-datatypes-simplified-vmr::
QTY
iso-21090-datatypes-simplified-v mr::AD
+
+
part :ADXP [1..*]
use :CS [0..*]
iso-21090-datatypes-simplified-v mr::CD
iso-21090-datatypes-simplified-v mr::IVL_PQ
+
+
+
+
low :PQ [0..1]
high :PQ [0..1]
lowIsInclusive :boolean [0..1]
highIsInclusive :boolean [0..1]
+
+
+
+
codeSystem :string
code :string
codeSystemName :string [0..1]
displayName :ST [0..1]
iso-21090-datatypes-simplified-v mr::CS
+
code :string
iso-21090-datatypes-simplified-v mr::INT
+
value :int
iso-21090-datatypes-simplified-v mr::PQ
+
+
value :decimal
unit :string
iso-21090-datatypes-simplified-v mr::
REAL
+
value :decimal
iso-21090-datatypes-simplified-v mr::IVL_RTO
+
+
+
+
low :RTO [0..1]
high :RTO [0..1]
lowIsInclusive :boolean [0..1]
highIsInclusive :boolean [0..1]
iso-21090-datatypes-simplified-v mr::EN
+
+
part :ENXP [1..*]
use :CS [0..*]
iso-21090-datatypes-simplified-v mr::
RTO
+
+
numerator :PQ
denominator :PQ
iso-21090-datatypes-simplified-v mr::II
iso-21090-datatypes-simplified-v mr::IVL_REAL
+
+
+
low :REAL [0..1]
high :REAL [0..1]
lowIsInclusive :boolean [0..1]
+
+
root :string
extension :string [0..1]
iso-21090-datatypes-simplified-v mr::TS
+
value :string
CDS Inputs
class cdsInput
CDSContext
+
+
+
+
+
cdsSystemUserType :CD [0..1]
cdsSystemUserPreferredLanguage :CD [0..1]
cdsInformationRecipientType :CD [0..1]
cdsInformationRecipientPreferredLanguage :CD [0..1]
cdsSystemUserTaskContext :CD [0..1]
+vmrInput 1
+cdsContext
CDSInput
+
0..1
+cdsResource
templateId :II [1..*]
0..*
CDSResource
v mr::VMR
+
templateId :II [0..*]
+
+
cdsResourceType :CD
resourceContents :anyType
CDS Outputs
class cdsOutput
CDSOutput
+vmrOutput
0..1
v mr::VMR
+
templateId :II [1..*]
+simpleOutput
0..1
dataTypes::
iso-21090-datatypes-simplified-vmr::ANY
vMR Payload
class v mr
+relatedEntity
0..*
VMR
+
Entity
templateId :II [1..*]
EntityRelationship
+
+
+
+
+
targetRole :CD
relationshipTimeInterval :IVL_TS [0..1]
id :II
templateId :II [0..*]
entityType :CD [0..1]
0..*
+relatedEntityInRole
Person
+
+
+
name :EN [0..*]
address :AD [0..*]
telecom :TEL [0..*]
ClinicalStatementEntityInRoleRelationship
+
+patient
1
Ev aluatedPerson
+
+
+
+
+
+
+
+
birthTime :TS [0..1]
ethnicity :CD [0..*]
gender :CD [0..1]
race :CD [0..*]
preferredLanguage :CD [0..1]
age :PQ [0..1]
isDeceased :BL [0..1]
ageAtDeath :PQ [0..1]
role :CD
ClinicalStatementRelationship
+
targetRelationshipToSource :CD
+relatedClinicalStatement
0..*
ClinicalStatement
+clinicalStatement
0..*
+
+
+
id :II
templateId :II [0..*]
dataSourceType :CD [0..1]
Example Clinical Statement
class problem
ProblemBase
DeniedProblem
+
+
+
+
Problem
+
+
+
+
+
problemCode :CD
problemEffectiveTime :IVL_TS [0..1]
diagnosticEventTime :IVL_TS
affectedBodySite :BodySite [0..*]
importance :CD [0..1]
severity :CD [0..1]
problemStatus :CD
ageAtOnset :PQ [0..1]
wasCauseOfDeath :BL [0..1]
+relatedClinicalStatement 0..*
ClinicalStatement
BodySite
+
+
bodySiteCode :CD
laterality :CD [0..1]
+
+
+
id :II
templateId :II [0..*]
dataSourceType :CD [0..1]
vMR Ballot Reconciliation – Overview
• Domain Analysis Model
– 47 affirmative, 2 negative
• GELLO implementation guide
– 34 affirmative, 0 negative
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
Trigger
Queries for
(http://hssp-dss.wikispaces.com)
Patient data,
knowledge modules to use
required pt
data
Standard Data Models:
Patient Data
Sources
Client Decision
HL7 Virtual
Medical
Support
AppsRecord (vMR) Standard
[ http://wiki.hl7.org/index.php?title= Institution A
Virtual_Medical_Record_(vMR) ]
Conclusions about patient
Decision Support
Service
Queries for
required pt
data
Client Decision
Support Apps
Knowledge
Modules
Patient Data
Sources
Institution B
CDS Services – Example
Eval.
VMR
Result
Decision Support
Service
CCD
EHR System
Pt
data
Patient Data
Sources
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
Backup Slides
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
DSS Invocation - Wrapper
NQF knowledge module
vMR payload
DSS Invocation - Payload
Age & gender
Past encounters
Past mammographies
DSS Response - Wrapper
NQF evaluation result
NQF evaluation result
payload using vMR
DSS Response - Payload
Denominator criteria met
Numerator criteria met