Virtual Medical Record (vMR)

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Coordinator

  • Kensaku Kawamoto, M.D., Ph.D. - CDS Co-Chair (kensaku.kawamoto@utah.edu)


vMR Standards

HL7 vMR Domain Analysis Model, Release 2 (balloted version from May 2013 ballot; comments in process of being incorporated)

HL7 vMR Domain Analysis Model, Release 2, supplemental files (balloted version from May 2013 ballot; comments in process of being incorporated)

HL7 vMR Domain Analysis Model, Release 1

HL7 vMR GELLO Implementation Guide

Known Issues to be Addressed in Future Specifications (Changes Already Made in Informative XML Schemas)

NOTE: see comments on vmr.xsd of XML schemas for details.

- bodySiteCode within BodySite should be optional rather than mandatory. A specific body site may be implied by the type of procedure, problem, etc., such that only the laterality is of interest (e.g., bilateral laterality for a mastectomy). This change has already been incorporated in the sample XML schemas accompanying the Release 1 Domain Analysis Model.

- A related entity should have the same relationship attributes when related to either entities or clinical statements. This significantly simplifies implementation.

Other Possible Issues to be Addressed in Future Specifications

Proposed vMR enhancements, v2013-03-11

- Some datatypes were not included that might be useful:

   ED (Encapsulated Data) would provide a means to include PDF and JPEG data, for example, in vMR messages.
   PQ Ratio is needed for certain kinds of Lab results

- All relationship classes need an ID element, in order to reference them in rules

Project Scope Statement

Project Scope Statement, v2010-03-08


Cross-Institutional CDS Needs Analysis and Associated Manuscript

CDS data needs analysis, vFinal

Manuscript presented at 2010 AMIA conference

SVN

https://svn.medical-objects.com.au/vmr/

Read only username/password: hl7/hl7

Default checkout directory at c:\vmr

To get read/write access, email Andrew McIntyre


Minutes

Minutes 2013-07-30

Minutes 2013-04-30

Minutes 2013-04-02

Minutes 2013-03-19

Minutes 2013-03-12

Minutes 2013-02-19

Minutes 2011-07-21

Minutes 2011-07-14

Minutes 2011-07-07

Minutes 2011-06-30

Minutes 2011-06-23

Minutes 2011-06-16

Minutes 2011-06-02

Minutes 2011-05-26

Minutes 2011-04-21

Minutes 2011-04-14

Minutes 2011-04-07

Minutes 2011-03-31

Minutes 2011-03-24

Minutes 2011-03-17

Minutes 2011-03-10

Minutes 2011-03-03

Minutes 2011-02-24

Minutes 2011-02-17

Minutes 2011-02-10

Minutes 2011-02-03

Minutes 2011-01-27

Minutes 2011-01-20

Minutes 2011-01-07

Minutes 2010-12-16

Minutes 2010-12-02

Minutes 2010-11-18

Minutes 2010-11-11

Minutes 2010-11-04

Minutes 2010-10-28

Minutes 2010-10-21

Minutes 2010-09-16

Minutes 2010-09-09

Minutes 2010-09-02

Minutes 2010-08-26

Minutes 2010-08-19

Minutes 2010-08-12

Minutes 2010-07-29

Minutes 2010-07-22

Minutes 2010-07-08

Minutes 2010-07-01

Minutes 2010-06-24

Minutes 2010-06-10

Minutes 2010-05-27

Minutes 2010-05-06

Minutes 2010-03-25

Minutes 2010-03-18

Minutes 2010-03-11

Minutes 2010-03-04

Minutes 2010-02-18

Minutes 2010-02-11

Minutes 2010-01-28

Minutes 2010-01-07

Minutes 2009-12-17

Minutes 2009-12-03

Minutes 2009-11-19

Minutes 2009-11-12

Minutes 2009-11-05

May 2013 Ballot, Comments, and Comment Reconciliation

Note: This section has been last updated on April 19, 2013

The following links are provided to interested parties in the community who are not voting members of HL7. Your comments will be greatly appreciated. When providing comments be sure to specify the artifact you are commenting on, the chapter/section/subsection you are referring to, the original wording, the proposed wording you recommend, and/or any comments pertaining to the artifacts. We strongly encourage you to vote directly with HL7 at the following location on the HL7 Site. Alternatively, you may submit comments directly to us. You will find a ballot submission file for each ballot submission below.

vMR DAM - Release 2 (Actual Submission to HL7)

vMR XML Implementation Guide - Release 1 (Actual Submission to HL7)

Known issues with current release: "Specify a type of dt:CD for the following three attributes: CDSContext.cdsEncounterType, CDSContext.cdsSubTopic, and SubstanceAdministrationProposal.prnReason. Currently, they are missing a type. Add IVL_RTO_PQ and IVL_RTO_INT. Deprecate IVL_RTO. Standardize frequency across procedure and substance administration proposals. Frequencies should be computable and support qualifiers."

For HeD Participants - Please refer to the latest HeD schemas as several of the above issues have been addressed. You may find these there.

For comment submission - Please refer to links below and submit to cnanjo at zynx dot com:

Ballot Comment Submission Form for vMR DAM R2

Ballot Comment Submission Form for vMR XML IG R1

Sept 2011 Ballot, Comments, and Comment Reconciliation (ARCHIVE)

vMR Domain Analysis Model Ballot, September 2011 Ballot Cycle

Supplemental Files for vMR Domain Analysis Model Ballot, September 2011 Ballot Cycle

Ballot Reconciliation Spreadsheet for vMR Domain Analysis Model Ballot, September 2011 Ballot Cycle

vMR GELLO Implementation Guide Ballot, September 2011 Ballot Cycle

Ballot Reconciliation Spreadsheet for vMR GELLO Implementation Guide Ballot, September 2011 Ballot Cycle

vMR GELLO Implementation Guide Ballot, September 2011 Ballot Cycle, Revised Based on Ballot Comments


May 2010 Ballot, Comments, and Comment Reconciliation (ARCHIVE)

May 2010 vMR ballots

Reconciled comments on May 2010 informative ballots for vMR Domain Analysis Model, v2 implementation guide, and GELLO implementation guide



Archived vMR Domain Analysis Models

Prpoosed vMR XML Schemas


vMR Proposal, v2011-07-14


vMR Proposal, v2011-07-07


vMR Proposal, v2011-07-01


vMR Proposal, v2011-06-30


vMR Proposal, v2011-01-27


OpenCDS vMR Model, v2011-01-27


OpenCDS vMR Model, v2011-01-19


OpenCDS vMR Model, v2011-01-04


OpenCDS vMR Problem Model, v2010-12-02


May 2010 informative ballot for vMR Domain Analysis Model, v2010-03-28


vMR Domain Analysis Model version 2010-03-22 (zip file containing .eap Enterprise Architect File, XMI cross-platform UML file, and JPG image files of models)

vMR Domain Analysis Model version 2010-03-19a (zip file containing .eap Enterprise Architect File, JPG image files of models, and Word document on modeling notes)

- The Domain Analysis Model (DAM) will serve as the source of implementation technology-specific vMRs (e.g., for HL7 version 3, HL7 version 2, and GELLO). Its CDS input model is based on the multi-institutional CDS data needs analysis referenced above.

- .eap file can be opened by free Enterprise Architect viewer, available at http://www.sparxsystems.com.au/bin/EALite.exe, which is within http://www.sparxsystems.com.au/products/ea/downloads.html

- XMI file can be uploaded into any UML editor


Big Picture/Direction Proposals (ARCHIVE)

vMR proposal by Keith Boone, v2010-07-29

Big picture proposal by David Shields, v2010-06-07


Federal Health Information Model (FHIM) -- reference content

FHIM in XMI format, v2010-07-08

FHIM in UML format, v2010-07-08

FHIM in Rational Software Modeler format, v2010-06-24

FHIM in Rational Software Modeler format, v2010-06-24


Documents related to Family History Modeling within vMR

Family History vMR proposal by Andrew McIntyre, v2010-07-08

Family History vMR proposal by Andrew McIntyre, v2010-07-08


Documents related to Problem Modeling within vMR

zip file containing a freemind mind map file with some images this links to

This mindmap contains the Problem attributes from the AMIA paper and some other systems including ASTEC


vMR V2 Implementation Guide (Draft)

V3 Family History instance example from HL7 Clinical Genomics Work Group


vMR GELLO Implementation Guide (ARCHIVE)

May 2010 informative ballot for vMR GELLO Implementation Guide, v2010-03-28


vMR UML Model for GELLO based on ASTEC project team input, version 2010-03-17 (zip file containing .eap Enterprise Architect File and PNG image file of input model)


- The UML Model for GELLO will be derived from the Domain Analysis Model (DAM). This model will not be balloted in the May 2010 HL7 ballot cycle.

- .eap file can be opened by free Enterprise Architect viewer, available at http://www.sparxsystems.com.au/bin/EALite.exe, which is within http://www.sparxsystems.com.au/products/ea/downloads.html

- XMI file can be uploaded into any UML editor


Archived vMR UML Models for GELLO

vMR UML Model for GELLO, Medical-Objects, version 2009-12-17


Working/Reference Content

Discussion of RIM to VMR mapping


Other Working/Reference Documents

GreenCCD GELLO Class Model with VMR-related annotations, v2011-04-21

GreenCCD GELLO Class Model with VMR-related annotations, v2011-04-14

Clinical Statement GELLO Class Model

GreenCCD GELLO Class Model with VMR-related annotations, v2011-04-07

VMR direction proposal, Medical Objects, v2011-03-03

vMR topology proposal, v2011-02-24

Green CDA pre-publication package from Structured Documents Work Group, v2011-02-17

Green CDA derived EAP and GELLO files, v2011-02-17

VMR direction proposal, Medical Objects, v2011-02-17

ASTEC VMR model, 2010-10-26

Medical-Objects VMR proposed model, 2010-10-13

CDS Inputs and Outputs Analysis from September 2008 VMR Ballot for Comments

September 2008 VMR Ballot for Comment

vMR Use Case Example from Keith Boone, 2010-09-02

GELLO vMR Use Cases

Model transformation white paper from Galen Mulrooney

HL7 V3 Pedigree schemas and sample

Updated vMR Project Scope Document endorsed unanimously by 13 vMR project participants on 1/28/10 project call

Updated vMR Project Scope Document circulated to CDS list for comment on 1/27/10

1/21/10 face-to-face CDS Work Group Minutes draft, in which consensus committee vision and direction for vMR work is documented in Q3 notes

Representing data from CDA sample in a vMR instance, 2010-01-28

Peer Review Comments, 2010-01-20

Representing vMR Data in HL7 V2 Messages

Example CCD Instance as HL7 V2 Message

Thoughts on Distinctions Between CCD and vMR, v2010-01-20

UK NHS Individual Health Record (IHR) Model and Background, v2010-01

Strawman vMR derived from CDA, 2010-01-07

Strawman vMR expressed in GELLO format, 2010-01-07

Sample CCD Document

vMR Refactor Proposal from Medical Objects, v2009-12-03

Comments on 12/03/09 refactor proposal and results of group discusioon on 12/03/09

vMR Refactor Proposal from Medical Objects, v2009-11-19

Comparison of vMR Strawman Model vs PCC Content Modules, v2009-11-16.xls.zip

vMR Family History GELLO Use Cases, v2009-11-19

vMR Family History Model From GELLO Use Cases, v2009-11-19


ISO 21090 Datatypes References

These links reference the HL7 SVN server. If required, supply a username of "anonymous" and a blank password.

ISO 21090 Healthcare Datatypes Published Standard

ISO 21090 Healthcare Datatypes XML Schema

Other documents:

ISO Datatypes in GELLO Format

ISO 21090 data types in GELLO format

HL7 V3 Datatypes SVN

The HL7 V3 Datatypes SVN is browsable from here.

Snip from Abstract datatypes standard as to why we are using ISO datatypes

The data types defined in this specification are not intended to be implemented solely based on the details presented herein. For example, this specification does not differentiate between the information that should be represented explicitly in any technical representation such as XML and the information that should be derived from the explicit representation. This document corresponds broadly to the RM-ODP informational view ("concerned with the kinds of information handled by the system and constraints on the use and interpretation of that information"). The ISO data types specification is an ITS for these data types that corresponds to the RM-ODP computational view ("concerned with the functional decomposition of the system into a set of objects"). See [1] for further information.


What should be the primary objectives of this effort for the short term (next 3-6 months)?

Tentative: Generation of community consensus on

  1. what types of patient data may be used as inputs for CDS;
  2. what types of inferences may be returned as outputs by a CDS engine; and
  3. the simplest possible information models for these data


What should be our approach to fulfilling the objectives in a timely manner?

- Create straw-man UML diagrams for vMR - Discuss/modify UML diagrams as initial approach to arriving at common vMR consensus - Explore ballotable formats Potential initial ballot: UML Domain Analysis Model (DAM) Potential further ballot: HL7 v3 model based on DAM - Need to be aware of U.S. meaningful use criteria (e.g., for use of SNOMED for problem lists), other international requirements


What should be our decision making process?

- Use standard HL7 processes (attempt consensus; if needed, majority vote to decide on most issues at this stage in the process)


Other current work of note to this project

  1. GELLO
  2. Infobutton
  3. NQF's Quality Data Set (QDS)
  4. IHE - PCC Content Modules
  5. SAEAF
  6. RIMBAA


What is a vMR?

The vMR is based on the HL7 V3 model and datatypes. It is a "virtual" interface and is optimised for point in time clinical decision support. While it could be used as the basis for an EHR design it is intended to be simplified, to represent a snapshot and to omit important concepts that should exist in a real EHR.

In particular concepts such as audit trail, result history and display forms are omitted and only data relevant to making decisions based on the current patient state are represented. The hard bit is excluding as much complexity as possible while ensuring that any decisions made are safe and based on adequate data.

It is intended that each EHR system would create an "Adaptor" or "Facade" to present patient data in a consistent form so that the clinical decision logic can be common across many systems. Obviously some systems will be missing data and it is likely that the data will not be in a HL7 V3 form and this is where the word virtual comes in, there needs to be a translation layer to transform data into a form that complies with the VMR. There are many potential ways to do this ranging from creating a CDA document, a HL7 V3 message, a SOAP service or even creating HL7 V2 message(s) that contain the required structured data to allow the creation of a vMR interface. A direct database access layer is also possible. So documents, messages, services, archetypes/templates, CCD instances and database queries for example could all populate the vMR.

The aim is to allow a CDS language access to a standard model to reliably access patient data about the current patient's "Observations" (eg haemoglobin) or "Family History" or eg "Surgical History"/"Problem List". This is the single patient "Context" but other contexts are relevant. Access to population based data is very important for public health monitoring (perhaps context "Population"?) and in the case of templates access to data during the editing process (context "Template").

SAEAF Framework

The project is currently under active development and these ideas are not fixed or standardized but give some idea as to what a vMR should be. An attempt to try and conceptualize the requirements using the HL7 "SAEAF" famework - the "Services Aware Enterprise Application Framework" is below. The SAEAF framework, when used in an agile manner shows great promise in structuring thoughts on the topic and allowing alignment when people come at the problems from different world views.

vMR modelled in SAEAF
Enterprise View Information View Computational View Engineering View Technology View
Conceptual HL7/ISO Datatypes Classes in the vMR Model vMR Examples
Platform Independent vMR UML Model ISO 21090 datatypes GELLO Class definition
Platform Specific LRA Models CCD RMIM View


More on the 'virtual' in vMR

Noone has an exact implementation of the vMR. It will always need to be mapped to local structures. It needs to handle missing data items, for example if the local structure doesn't have a smoking history for patient, the vMR needs to know it doesn't have it - it is null. Another example would be if the Allergies section of a populated instance of a patient's electronic medical record is not filled in - is this 'No - there are no allergies' or is this a null value? A test for the vMR is that is needs to be addressable by CDS languages such as GELLO. (The vMR is for clinical decision support). It exists for CDS, then it is gone.


Distinction from reference models

As an artefact of the HL7 standards community it might seem that this notion of a vMR is confused with that of a specialization of the RIM such as a RMIM. Remember it is a simpler, snapshot view and it's a slightly different view at that. So instead of top level Entities and Acts, we have explicit links, such as Patient (Entity) has Observation (Act). The vMR has a context which would often be a patient context, but it could be a population one. This context builds a specific patient class property rather than following the RIM links (ie Person playing the role patient..). So the link is clearer (perhaps) and stuff at the RMIM level can be exposed as top level constructs.

Additional classes can be included such as ProblemList, FamilyHistory and Procedures.


Potential vMR sources

So what's to be in and what's to be out? Ideally we'd be in the Goldilocks zone with a one pager that keeps most people happy. We should borrow the SNOMED-CT editorial policy of 'URU' - understandable, reproducible and useful. Here is a list of some potential vMR class sources:

  1. SAGE vMR model
  2. HL7 Care Record Model
  3. Logical Record Architecture (NHS)
  4. Different participating institutions’ vMR models
  5. Comment-only HL7 vMR ballot
  6. RMIMs such as Clinical Genomics

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