Logical Model
Collaboration
Scope, proposal, and next steps
The Need
 A logical model
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With a strong community behind it
That is clinically viable
That is expressive
That is structured and computable
That supports reasoning
That informs FHIR profiles
That supports “closing the quality feedback cycle”
That is implementable
The Problem (I)
 Often conflated with a physical model such as FHIR
 Often implied and not explicit
 vMR + QDM  QUICK  QI Core  QUICK’
 DAF
 SDC
 Too many variants out there
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RIM
QDM
vMR
QUICK/QIDAM/QUICK’
CEM
CIMI
FHIM
SNOMED/LOINC/RxNORM
…
The Problem (II)
 Unclear boundary between terminology and model
 Unclear boundary between expression language and model
 Often inconsistent
 Patient has diabetes (Condition)
 Presence implied
 Patient does not have diabetes (Observation)
 Absence explicit
 Pre-coordinated/conflated semantics
 Incomplete or just ‘too hard’
 Scope hard to define. Need some boundaries.
Exploration Areas for LM Collaboration
 What is a Logical Model?
 How does it differ from a physical model like FHIR?
 How does it differ from a reference model like CIMI Core?
 How does it align with clinical terminologies/ontologies such as
SNOMED CT?
 How far does it align with clinical terminologies/ontologies such as
SNOMED CT?
 Bindings only?
 At model level too?
 How can it be implemented?
 How can it be leveraged for Quality Improvement
 Can we better align (or eliminate) variants and how?
Time Frame
 First set of meeting to last 8 weeks
 Begin exploration of model/terminology alignment
 Focus: Alignment of CIMI ‘Observation Result’ with SNOMED
Observable Model
 Use Case: Systolic BP
 Goal: Implement simple prototype illustrating alignment of
approaches
 Last meeting of series on 10/13
 Group to decide how to proceed after 10/13
 Question: Should group disband and regroup under the
CIMI Modeling Task Force? Should group remain as an
exploratory task force looking at longer term questions?
Discussion to Date
CIMI/SNOMED Observable Reconciliation
Slides from Keith Campbell
Assumptions: Terminology
Taken from: http://opencimi.org/policies_cimi
 SNOMED CT is the primary reference terminology
 LOINC is also approved as a reference terminology
 SNOMED relationship concepts will be used to define
the parent-child relationships in the models
Assumption: Models
Taken from: http://opencimi.org/policies_cimi
 CIMI models shall, by design, include SNOMED CT
content
 Goal: Enable use of the SNOMED CT concept model to
support translation of data from pre coordinated to post
coordinated representations
Proposal: Naming
Overlapping naming has led to confusion about the
collaborative and/or competitive nature of CIMI and SNOMED
 The SNOMED/LOINC Observable Model has a significant
development history, and has specific, documented meaning
 An alternative yet intuitive name for a complementary CIMI
effort can reduce confusion and perceived competition
 Possibilities
 CIMI Observation Result Model
 CIMI Assertion Model
Proposal: Separation of
Concerns
Clearly and reproducibly delineate a separation of the
semantics of the terminology from the semantics of the higherorder models
 Use a simple nested structure to differentiate observable
model attributes surfaced by CIMI
 All surfaced attributes are defined with respect to the
SNOMED/LOINC observable model, although CIMI may
define “friendly” preferred names for use within the CIMI
model
 Simpler to understand and implement while “using the
SNOMED CT concept model to support translation of data
from pre coordinated to post coordinated representations”
Example: Simple nested Structure
Separate the terminology model attributes from higher-level model attributes
Existing model
Renamed model
observation
Subject of information
Code
Reason
Method
Result
assertion
Subject of information
Observable*
Reason
Method*
Result
Separated model
assertion
Subject of information
Reason
Result
observable
1
1
Code/Expression
Method
Other surfaced attributes
Alternative Names
Intuitive names that do not overlap can reduce confusion and perceived
competition
assertion/observable
observation
result/observable
observation
result/discernable
assertion/discernable
observable
assertion
Subject of information
Reason
Result
1
1
observable
observation result
Subject of information
Reason
Result
1
1
1
1
Code/Expression
Method
Other surfaced attributes
discernable
assertion
Subject of information
Reason
Result
Code/Expression
Method
Other surfaced attributes
discernable
observation result
Subject of information
Reason
Result
Code/Expression
Method
Other surfaced attributes
1
1
Code/Expression
Method
Other surfaced attributes
Defining CIMI Surfaced Attributes
Provide algorithmic support for translation between pre- and post-coordinated
forms.
SNOMED Templates are one possibility
XSL, Xquery, and other options are possible
Moving forward
How do we turn these ideas into reality?
 Naming
 Separation of concerns
 Define surfaced attributes and pre/post coordination
transformation specification
 Add any necessary concepts to a CIMI extension
 CIMI has obtained a SNOMED CT extension identifier
 CIMI is committed to create a Terminology Authority to
review and submit concepts to IHTSDO as appropriate
Validating the Proposal
Systolic Blood Pressure Use Case
Selected Initial Use Case
Representing a “systolic blood pressure taken from the
right brachial artery using a blood pressure cuff while the
patient is supine and at rest”
SNOMED Post Coordinated
Expression
271649006|Systolic blood pressure (observable entity)|:
704318007|Property type (attribute)| = |Pressure (property) (qualifier value)|,
704319004|Inheres in (attribute)| = 67170007|Lumen of artery (body structure)|,
704327008|Direct site (attribute)| = (17137000|Structure of brachial artery (body
structure):
272741003|Laterality (attribute)| = 24028007|Right (qualifier value)|),
246501002|Technique (attribute)| = 37931006|Auscultation (procedure)|,
424226004|Using device (attribute)| = 70665002|Blood pressure cuff, device (physical
object)|,
704326004|Precondition (attribute)| = (40199007|Supine body position (finding)|,
704326004|Precondition (attribute)| = (128975004|Resting state (finding)|)
Prototype Next Steps
 CIMI Team working on development of a CIMI ADL
representation of CEM Systolic Blood Pressure model
 CIMI systolic BP model to be represented using AML
 VA Team to build SNOMED CT ‘template’
 Group to determine how to map the two models in ADL/AML
 VA Team to explore and develop transformation between
iso-semantic representations
 Group to review approach
Next Steps for Collaborative
Work
Towards Better Convergence
Convergence
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Centralize logical model efforts and profile development under CIMI umbrella?
 Will CIMI be an HL7 Working Group?
 Need central governance to prevent fragmentation
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Derive FHIR profiles from CIMI logical model
 DCM profiles
 Foundational profile
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Bottom up/top down approach
 Multi-layered logical model
 DCM (Serum Creatinine)
 Mid-level logical model(s) (QuantitativeLabResult  Observation Result)
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Moving beyond assertion models
 E.g., procedures and procedure requests
 E.g., Composite orderables
 …
Cross Collaboration
 HL7/FHIM participation in CIMI logical model effort
 CIMI/HL7 participation in terminology efforts
(SNOMED, LOINC, RxNORM). Eg.,
 Extension of SNOMED CT
 Development of observable model
 Development of procedure model
 Development of orderable catalog
Validation & Adoption
 Encouraging use of CIMI profiles (not just plain FHIR
resources) in HSPC and SMART-on-FHIR projects
 Validate logical model use cases for clinical quality
improvement in HSPC and SMART-on-FHIR projects
 Who else needs to be targeted for implementation and
validation
 Argonaut
 Epic, Allscripts, Cerner, VA
 Others
 Does HSPC reach a broad enough community?