medexter ®

HL7-Standards zur klinischen Entscheidungsunterstützung

Klaus-Peter Adlassnig

Institut für Medizinische Experten- und Wissensbasierte Systeme Zentrum für Medizinische Statistik, Informatik und Intelligente Systeme Medizinische Universität Wien Spitalgasse 23 A-1090 Wien

und

Medexter Healthcare GmbH Borschkegasse 7/5 A-1090 Wien

HL7-Anwendergruppe Österreich, Jahrestagung, 21. März 2012, Wien

Knowledge packages for integration in:

- HIS

- Outpatient IS

- PDMS

- LIS

- Lab analyzer

- Physician’s office

- Telemedicine

applications

- Health portal

Clinical decision support systems

Stand-alone solutions:

- Infection control

systems

- Lab decision

support systems

- Internal medicine

decision support

systems

- Diagnostic &

therapeutic

reminder systems

Rule engines:

- Arden Syntax Compiler

& Engine & IDE &

Server & host

interface

- Fuzzy Arden Syntax

Compiler & Engine &

IDE & Server &

host interfaces

Services:

- Rule engine

integration

- SOAP & REST & XML &

HL7 interoperability

- Medical

documentation &

ontology services

- Fuzzy-based medical

text formalization

Medical Content

Medical knowledge packages

Inference systemsMedical consulting

services

Technical Frameworks Medical Services

Medexter Healthcare

Teleiatros services:

- Browser-based or

direct server access

to decision support

systems

- Writing and tele-

operating customer-

specific Arden Syntax

& Fuzzy Arden

Syntax MLMs

Telemedicaldecision support

services

medexter ®

Computers in clinical medicine—steps of natural progression

• step 1: patient administration

– admission, transfer, discharge, and billing of medical services

• step 2: documentation and access of patients’ structured medical data

– electronic health record: distributed, life-long

• step 3: patient data retrieval and analysis

– data warehouse, research databases, study support systems, quality assurance and reporting

… for a group of patients

• step 4: software systems for clinical decision support

– safety net, quality assurance and improvement

… for the individual patient

symptoms signs

test results clinical findings

biosignals images

diagnoses therapies

nursing data

• • •

standardization telecommunication

chip cards

anatomy biochemistry physiology

pathophysiology pathology nosology

therapeutic knowledge disease management

• • •

subjective experience intuition

knowledge-based systems

patient’s medical data physician’s medical knowledge

medical statistics clustering & classification data & knowledge mining

machine learning

clinical decision support medical expert systems

many patients

single patient

diagnosis therapy

prognosis management

general knowledge

general knowledge

telemedicine telemedicine integration

Medical information and knowledge-based systems

information systems

induction

deduction

medexter ®

Clinical decision support systems

patients’ structured medical data

patient management guidelines

guideline-based reminders

computerized clinical guidelines, protocols, SOPs

high-level patient and hospital analytics

prognostic prediction

illness severity scores, prediction rules

trend detection and visualization

therapy advice

drug alerts, reminders, calculations

– indication, contraindications, redundant medications, substitutions

– adverse drug events, interactions, dosage calculations, consequent orders

management of antibiotics therapy

(open-loop) control systems

diagnostic support

clinical alerts, reminders, calculations

data interpretation, (tele)monitoring

differential diagnostic consultation

– rare diseases, rare syndromes

– further or redundant investigations

– pathological signs accounted for

consensus-criteria-based evaluation

– definitions

– classification criteria

medexter ®

Arden Syntax—medical knowledge representation and

processing

medexter ®

Arden Syntax and Health Level Seven (HL7)

• A standard language for writing situation-action rules that can trigger alerts based on abnormal clinical events detected by a clinical information system.

van Bemmel, J.H., Musen, M.A. (eds.) (1997) Handbook of Medical Informatics, Springer-Verlag, Heidelberg, Glossary, p. 559.

• Each module, referred to as a Medical Logic Module (MLM), contains sufficient knowledge to make a single decision.

extended by packages of MLMs for complex clinical decision support

• Contraindication alerts, management suggestions, data interpretations, treatment protocols, and diagnosis scores are examples of the health knowledge that can be represented using MLMs.

extended by single and differential diagnostic support, temporal monitoring, control systems, computerized processing of clinical pathways and management guidelines

• The first version of the Arden Syntax (draft prepared at the Arden Homestead, New York, in 1989) was administered and issued by the American Society for Testing and Materials ASTM (1992, version 1.0; today 2.8, towards 2.9). Ownership was transferred to HL7 and the American National Standards Institute (ANSI) in 1999 with the approval of version 2.0.

medexter ®

• General MLM Layout

– Maintenance Category – Library Category – Knowledge Category – Resources Category

• Identify an MLM • Data Types • Operators

– Basic Operators – Curly Braces – List Operators – Logical Operators – Comparison Operators – String Operators – Arithmetic Operators – Other Operators

• Control Statements • Call/Write Statements and Trigger

medexter ®

Arden-Syntax-based, service-oriented

clinical decision support

medexter ®

Arden Syntax, Arden Syntax server, and health care information systems

Funktionalität

Integration

KIS, MIS, PDMS, LIS, Praxissoftware, EHR, telemedizinische Anwendungen, Gesundheitsportale, …

Reminder und Alarme, Monitoring, Surveillance, Entscheidungsunterstützung für Diagnostik und Therapiewahl, …

operativ: - Harmonisierung der Inputdaten - Arden-Syntax-MLMs - Erklärungskomponente

erforschend: - Regellernen und -tuning - Daten- und Konzeptmining

* Daten- und Wissensbasen-Zentrum

medexter ®

• web-services-based Arden Syntax server including

- Arden Syntax engine - MLM manager - XML-protocol-based interfaces, e.g., SOAP, REST, and HL7 - a project-specific data and knowledge services center may be hosted

• Java libraries - Arden Syntax compiler - Arden Syntax engine

Arden Syntax server and software components

Arden Syntax development & test

environment

data & knowledge services center

Arden Syntax rule engine

knowledge

knowledge

results

data

healt

h c

are

in

form

ati

on

syste

m

results

reporting tools

knowledge administration

data

inte

rfaces

2)

Arden Syntax server 1)

1) integrated, local, or remote2) local and web services, web frontend

Arden Syntax development & test

environment

data & knowledge services center

Arden Syntax rule engine

knowledge

knowledge

results

data

healt

h c

are

in

form

ati

on

syste

m

results

reporting tools

knowledge administration

data

inte

rfaces

2)

Arden Syntax server 1)

1) integrated, local, or remote2) local and web services, web frontend

Fuzzy Arden Syntax

• extension to fuzzy sets, operators, statements, and parallel execution

• Arden Syntax integrated development and test environment (IDE) including

- Medical logic module (MLM) editor and authoring tool - Arden Syntax compiler (syntax versions 2.1, 2.5, 2.6, 2.7, and 2.8) - Arden Syntax engine - MLM test environment - MLM export component

• command-line Arden Syntax compiler

medexter ®

Crisp sets vs. fuzzy sets

yes/no decision

gradual transition

age

1

Y young

0 threshold

U = [0, 120]

Y U with Y = {(µY (x)/ x)x U}

µY: U [0, 1]

1

1 + (0.04 x)2 x U 0 age

1

Y young

threshold 0

U = [0, 120]

Y U with Y = {(Y (x)/ x)x U}

Y: U {0, 1}

Y (x) = x U 0 x > threshold

1 x ≤ threshold

1 x ≤ threshold

x > threshold µY (x) =

0

medexter ®

Interoperability

Monitoring of

healthcare-associated infections

Interpretation von

Hepatitis-Serologie-Befunden (I)

Interpretation of

hepatitis serology test results (II)

Integration into

i.s.h.med

medexter ®

GELLO/vMR—Query and expression language / accessing a

virtual medical record data model

medexter ®

GELLO/vMR and Health Level Seven (HL7)

• An object-oriented (OO) query and expression language for decision support

• Originally developed as a guideline expression language for query statements and decision rules

• Based on the existing object constraint language (OCL) and HL7’s reference information model (RIM)

• The GELLO language can be used to

– Build up queries to extract and manipulate data from medical records

– Construct decision criteria by building up expressions to reason about particular data features/values

• Proposal to use a virtual medical record (vMR) that provides a standard interface to heterogeneous medical record systems

• Includes using of terminologies/ontologies such as SNOMED CT and LOINC

• 2005 adopted as international standard by HL7 and the American National Standards Institute (ANSI)

Innovation project “Standards-based CDS”

of the Veterans Health Administration, USA

Web User

InterfaceArden Syntax

GELLO/vMR

MDWS

VistA_1 VistA_2

(3) Patient DFN

(3) Patient DFN

(3) Patient DFN

(4) return NHN

(2) Patient DFN

(1) Patient Lookup

(2) Patient DFN

(1) Patient Lookup

(3) get NHN

(4) return NHN

(3) get NHN

(4) return NHN

Innovation Initiative # 209 -

Clinical Decision Support

Transaction Diagram

medexter ®

Clinical decision support with Arden Syntax and GELLO/vMR • CDS platforms

– based on Arden Syntax and Fuzzy Arden Syntax

with data (sometimes) and knowledge services center and extended interoperability (web-services, XML data interfaces, libraries)

• integrated into or interconnected with

– CareVue and ICIP PDMSs (by Philips)

monitoring and reporting of ICU-acquired infections (ICUs and NICUs)

– ICM (by Dräger)

ICU decision support modules (Universitätsklinikum Erlangen)

– i.s.h.med HIS (by Siemens AG)

dosing of immunosuppressive drugs for kidney transplant patients

prediction of metastases in melanoma patients

standard operating procedures for chemotherapy treatment of melanoma patients

– medico//s HIS (by Siemens AG)

laboratory-based clinical reminders

– Soarian HIS (by Siemens AG) and Orbis HIS (by Agfa)

hepatitis serology test interpretation

– VistA HIS (by Department of Veterans Affairs)

service-oriented, standards-based CDS (clinical reminders and patient report cards)

– Monitoring adverse drug events (FFG project with Salzburger Universitätsklinikum)

– Teleiatros, iPhone, iPad

remote CDS, mHealth