Clinical information modeling processes for semantic interoperability of electronic health records: systematic review and inductive analysis

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Journal of the American Medical Informatics Association following peer review. The version of record is available online at: http://dx.doi.org/10.1093/jamia/ocv008[EN] [Objective] This systematic review aims to identify and compare the existing processes and methodologies that have been published in the literature for defining clinical information models (CIMs) that support the semantic interoperability of electronic health record (EHR) systems. [Material and Methods] Following the preferred reporting items for systematic reviews and meta-analyses systematic review methodology, the authors reviewed published papers between 2000 and 2013 that covered that semantic interoperability of EHRs, found by searching the PubMed, IEEE Xplore, and ScienceDirect databases. Additionally, after selection of a final group of articles, an inductive content analysis was done to summarize the steps and methodologies followed in order to build CIMs described in those articles. [Results] Three hundred and seventy-eight articles were screened and thirty six were selected for full review. The articles selected for full review were analyzed to extract relevant information for the analysis and characterized according to the steps the authors had followed for clinical information modeling. [Discussion] Most of the reviewed papers lack a detailed description of the modeling methodologies used to create CIMs. A representative example is the lack of description related to the definition of terminology bindings and the publication of the generated models. However, this systematic review confirms that most clinical information modeling activities follow very similar steps for the definition of CIMs. Having a robust and shared methodology could improve their correctness, reliability, and quality. [Conclusion] Independently of implementation technologies and standards, it is possible to find common patterns in methods for developing CIMs, suggesting the viability of defining a unified good practice methodology to be used by any clinical information modeler.This research has been partially funded by the Instituto de Salud Carlos III (Platform for Innovation in Medical Technologies and Health), grant PT13/0006/0036 and the Spanish Ministry of Economy and Competitiveness, grants TIN2010-21388-C02-01 and PTQ-12-05620.Moreno-Conde, A.; Moner Cano, D.; Da Cruz, WD.; Santos, MR.; Maldonado Segura, JA.; Robles Viejo, M.; Kalra, D. (2015). Clinical information modeling processes for semantic interoperability of electronic health records: systematic review and inductive analysis. Journal of the American Medical Informatics Association. 22(4):925-934. https://doi.org/10.1093/jamia/ocv008S925934224Goossen W Goossen-Baremans A van der Zel M . Detailed clinical models: a review. Healthc Inform Res. 2010;16:201.Beeler, G. W. (1998). HL7 Version 3—An object-oriented methodology for collaborative standards development1Presented at the International Medical Informatics Association Working Group 16 Conference on Standardisation in Medical Informatics—Towards International Consensus and Cooperation, Bermuda, 12 September, 1997.1. International Journal of Medical Informatics, 48(1-3), 151-161. doi:10.1016/s1386-5056(97)00121-4Dolin, R. H., Alschuler, L., Boyer, S., Beebe, C., Behlen, F. M., Biron, P. V., & Shabo (Shvo), A. (2006). HL7 Clinical Document Architecture, Release 2. Journal of the American Medical Informatics Association, 13(1), 30-39. doi:10.1197/jamia.m1888Fast Health Interoperability Resources (FHIR). http://www.hl7.org/fhir/. Accessed July 18, 2014.Beale T . Archetypes: constraint-based domain models for futureproof information systems. OOPSLA 2002 Workshop Behav Semant. 2002.ISO 13606:2008 - Health informatics - Electronic health record communication. 2008. www.iso.org/iso/catalogue_detail.htm?csnumber=40784.OpenEHR. http://www.openehr.org/. Accessed July 18, 2014.Clinical Information Modeling Initiative (CIMI). http://www.opencimi.org/. Accessed July 18, 2014.Goossen WT . Using detailed clinical models to bridge the gap between clinicians and HIT. Stud Health Technol Inf. 2008;141:3–10.Oniki TA Coyle JF Parker CG . Lessons learned in detailed clinical modeling at Intermountain Healthcare. J Am Med Inform Assoc. 2014. Advance access published; doi:10.1136/amiajnl-2014-002875.Jacobson I Booch G Rumbaugh J . The Unified Software Development Process. Massachusetts, USA: Addison-Wesley Reading; 1999.Ahn, S., Huff, S. M., Kim, Y., & Kalra, D. (2013). Quality metrics for detailed clinical models. International Journal of Medical Informatics, 82(5), 408-417. doi:10.1016/j.ijmedinf.2012.09.006Kalra D . Editorial principles for the development of standards for the structure and content of health records. 2012. https://www.rcplondon.ac.uk/sites/default/files/documents/editorial-principles-for-the-development-of-record-standards.pdf. Accessed July 16, 2014.Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 339(jul21 1), b2535-b2535. doi:10.1136/bmj.b2535Transparent reporting of systematic reviews and meta-analyses (PRISMA). http://www.prisma-statement.org/. Accessed July 18, 2014.US National Library of Medicine. http://www.pubmed.gov. Accessed July 18, 2014.IEEE Xplore Digital Library. http://ieeexplore.ieee.org/. Accessed July 18, 2014.ScienceDirect. http://www.sciencedirect.com/. Accessed July 18, 2014.Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107-115. doi:10.1111/j.1365-2648.2007.04569.xRinner C Kohler M Hübner-Bloder G . Creating ISO/EN 13606 archetypes based on clinical information needs. In: Proceedings of EFMI Special Topic Conference, 14–15 April 2011, Lǎsko, Slovenia e-Health Across Borders Without Boundaries. 2011:14–15.Muñoz Carrero A Romero Gutiérrez A Marco Cuenca G . Manual práctico de interoperabilidad semántica para entornos sanitarios basada en arquetipos. Unidad de investigación en Telemedicina y e-Salud. Instituto de Salud Carlos III - Ministerio de Economía y Competitividad. 2013.Kalra D . Editorial principles for the development of standards for the structure and content of health records. 2012. https://www.rcplondon.ac.uk/sites/default/files/documents/editorial-principles-for-the-development-of-record-standards.pdf . Accessed July 18, 2015.Yuksel, M., & Dogac, A. (2011). Interoperability of Medical Device Information and the Clinical Applications: An HL7 RMIM based on the ISO/IEEE 11073 DIM. IEEE Transactions on Information Technology in Biomedicine, 15(4), 557-566. doi:10.1109/titb.2011.2151868Nagy M Hanzlicek P Precková P . Semantic interoperability in Czech healthcare environment supported by HL7 version 3. Methods Inf Med. 2010;49:186.LOPEZ, D., & BLOBEL, B. (2009). A development framework for semantically interoperable health information systems. International Journal of Medical Informatics, 78(2), 83-103. doi:10.1016/j.ijmedinf.2008.05.009Lopez DM Blobel B . Enhanced semantic interoperability by profiling health informatics standards. Methods Inf Med. 2009;48:170–177.Lopez DM Blobel B . Enhanced semantic interpretability by healthcare standards profiling. Stud Health Technol Inform. 2008;136:735.Knaup, P., Garde, S., & Haux, R. (2007). Systematic planning of patient records for cooperative care and multicenter research. International Journal of Medical Informatics, 76(2-3), 109-117. doi:10.1016/j.ijmedinf.2006.08.002Goossen, W. T. F., Ozbolt, J. G., Coenen, A., Park, H.-A., Mead, C., Ehnfors, M., & Marin, H. F. (2004). Development of a Provisional Domain Model for the Nursing Process for Use within the Health Level 7 Reference Information Model. Journal of the American Medical Informatics Association, 11(3), 186-194. doi:10.1197/jamia.m1085Anderson, H. V., Weintraub, W. S., Radford, M. J., Kremers, M. S., Roe, M. T., Shaw, R. E., … Tcheng, J. E. (2013). Standardized Cardiovascular Data for Clinical Research, Registries, and Patient Care. Journal of the American College of Cardiology, 61(18), 1835-1846. doi:10.1016/j.jacc.2012.12.047Jian, W.-S., Hsu, C.-Y., Hao, T.-H., Wen, H.-C., Hsu, M.-H., Lee, Y.-L., … Chang, P. (2007). Building a portable data and information interoperability infrastructure—framework for a standard Taiwan Electronic Medical Record Template. Computer Methods and Programs in Biomedicine, 88(2), 102-111. doi:10.1016/j.cmpb.2007.07.014Spigolon, D. N., & Moro, C. M. C. (2012). Arquétipos do conjunto de dados essenciais de enfermagem para atendimento de portadoras de endometriose. Revista Gaúcha de Enfermagem, 33(4), 22-32. doi:10.1590/s1983-14472012000400003Späth, M. B., & Grimson, J. (2011). Applying the archetype approach to the database of a biobank information management system. International Journal of Medical Informatics, 80(3), 205-226. doi:10.1016/j.ijmedinf.2010.11.002Smith, K., & Kalra, D. (2008). Electronic health records in complementary and alternative medicine. International Journal of Medical Informatics, 77(9), 576-588. doi:10.1016/j.ijmedinf.2007.11.005Bax, M. P., Kalra, D., & Santos, M. R. (2012). Dealing with the Archetypes Development Process for a Regional EHR System. Applied Clinical Informatics, 03(03), 258-275. doi:10.4338/aci-2011-12-ra-0074Moner D Moreno A Maldonado JA . Using archetypes for defining CDA templates. Stud Health Technol Inform. 2012;180:53–57.Moner D Maldonado JA Boscá D . CEN EN13606 normalisation framework implementation experiences. In: Seamless Care, Safe Care: The Challenges of Interoperability and Patient Safety in Health Care: Proceedings of the EFMI Special Topic Conference, June 2–4, 2010; Reykjavik, Iceland. IOS Press; 2010: 136.Marcos, M., Maldonado, J. A., Martínez-Salvador, B., Boscá, D., & Robles, M. (2013). Interoperability of clinical decision-support systems and electronic health records using archetypes: A case study in clinical trial eligibility. Journal of Biomedical Informatics, 46(4), 676-689. doi:10.1016/j.jbi.2013.05.004Leslie H . International developments in openEHR archetypes and templates. Health Inf Manag J. 2008;37:38.Kohl CD Garde S Knaup P . Facilitating secondary use of medical data by using openEHR archetypes. Stud Health Technol Inform. 2009;160:1117–1121.Garde, S., Hovenga, E., Buck, J., & Knaup, P. (2007). Expressing clinical data sets with openEHR archetypes: A solid basis for ubiquitous computing. International Journal of Medical Informatics, 76, S334-S341. doi:10.1016/j.ijmedinf.2007.02.004Garcia D Moro CM Cicogna PE . Method to integrate clinical guidelines into the electronic health record (EHR) by applying the archetypes approach. Stud Health Technol Inform. 2012;192:871–875.Duftschmid, G., Rinner, C., Kohler, M., Huebner-Bloder, G., Saboor, S., & Ammenwerth, E. (2013). The EHR-ARCHE project: Satisfying clinical information needs in a Shared Electronic Health Record System based on IHE XDS and Archetypes. International Journal of Medical Informatics, 82(12), 1195-1207. doi:10.1016/j.ijmedinf.2013.08.002Dias, R. D., Cook, T. W., & Freire, S. M. (2011). Modeling healthcare authorization and claim submissions using the openEHR dual-model approach. BMC Medical Informatics and Decision Making, 11(1). doi:10.1186/1472-6947-11-60Buck, J., Garde, S., Kohl, C. D., & Knaup-Gregori, P. (2009). Towards a comprehensive electronic patient record to support an innovative individual care concept for premature infants using the openEHR approach. International Journal of Medical Informatics, 78(8), 521-531. doi:10.1016/j.ijmedinf.2009.03.001Puentes, J., Roux, M., Montagner, J., & Lecornu, L. (2012). Development framework for a patient-centered record. Computer Methods and Programs in Biomedicine, 108(3), 1036-1051. doi:10.1016/j.cmpb.2012.06.007Liu, D., Wang, X., Pan, F., Yang, P., Xu, Y., Tang, X., … Rao, K. (2010). Harmonization of health data at national level: A pilot study in China. International Journal of Medical Informatics, 79(6), 450-458. doi:10.1016/j.ijmedinf.2010.03.002Liu, D., Wang, X., Pan, F., Xu, Y., Yang, P., & Rao, K. (2008). Web-based infectious disease reporting using XML forms. International Journal of Medical Informatics, 77(9), 630-640. doi:10.1016/j.ijmedinf.2007.10.011Kim, Y., & Park, H.-A. (2011). Development and Validation of Detailed Clinical Models for Nursing Problems in Perinatal care. Applied Clinical Informatics, 02(02), 225-239. doi:10.4338/aci-2011-01-ra-0007Khan, W. A., Hussain, M., Afzal, M., Amin, M. B., Saleem, M. A., & Lee, S. (2013). Personalized-Detailed Clinical Model for Data Interoperability Among Clinical Standards. Telemedicine and e-Health, 19(8), 632-642. doi:10.1089/tmj.2012.0189Jing, X., Kay, S., Marley, T., Hardiker, N. R., & Cimino, J. J. (2012). Incorporating personalized gene sequence variants, molecular genetics knowledge, and health knowledge into an EHR prototype based on the Continuity of Care Record standard. Journal of Biomedical Informatics, 45(1), 82-92. doi:10.1016/j.jbi.2011.09.001Hsu, W., Taira, R. K., El-Saden, S., Kangarloo, H., & Bui, A. A. T. (2012). Context-Based Electronic Health Record: Toward Patient Specific Healthcare. IEEE Transactions on Information Technology in Biomedicine, 16(2), 228-234. doi:10.1109/titb.2012.2186149Hoy D Hardiker NR McNicoll IT . Collaborative development of clinical templates as a national resource. Int J Med Inf. 2009;78:S3–S8.Buyl, R., & Nyssen, M. (2009). Structured electronic physiotherapy records. International Journal of Medical Informatics, 78(7), 473-481. doi:10.1016/j.ijmedinf.2009.02.007D’Amore JD Mandel JC Kreda DA . Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative. J Am Med Inform Assoc. 2014. Advance access published; doi:10.1136/amiajnl-2014-002883.Kalra D Tapuria A Austin T . Quality requirements for EHR archetypes. In: MIE; 2012: 48–52.Garde S Hovenga EJ Gränz J . Managing archetypes for sustainable and semantically interoperable electronic health records. Electron J Health Inform. 2007;2:e9.Madsen M Leslie H Hovenga EJS . Sustainable clinical knowledge management: an archetype development life cycle. Stud Health Technol Inform. 2010;151:115–132.Kohl CD Garde S Knaup P . Facilitating the openEHR approach-organizational structures for defining high-quality archetypes. Stud Health Technol Inform. 2008;136:437.Stroetmann VN Kalra D Lewalle P . Semantic interoperability for better health and safer healthcare. European Commission, Directorate-General Information Society and Media; 2009. http://dx.doi.org/10.2759/38514

Next-Generation Global Biomonitoring: Large-scale, Automated Reconstruction of Ecological Networks

We foresee a new global-scale, ecological approach to biomonitoring emerging within the next decade that can detect ecosystem change accurately, cheaply, and generically. Next-generation sequencing of DNA sampled from the Earth's environments would provide data for the relative abundance of operational taxonomic units or ecological functions. Machine-learning methods would then be used to reconstruct the ecological networks of interactions implicit in the raw NGS data. Ultimately, we envision the development of autonomous samplers that would sample nucleic acids and upload NGS sequence data to the cloud for network reconstruction. Large numbers of these samplers, in a global array, would allow sensitive automated biomonitoring of the Earth's major ecosystems at high spatial and temporal resolution, revolutionising our understanding of ecosystem change

Health, education, and social care provision after diagnosis of childhood visual disability

Aim: To investigate the health, education, and social care provision for children newly diagnosed with visual disability.Method: This was a national prospective study, the British Childhood Visual Impairment and Blindness Study 2 (BCVIS2), ascertaining new diagnoses of visual impairment or severe visual impairment and blindness (SVIBL), or equivalent vi-sion. Data collection was performed by managing clinicians up to 1-year follow-up, and included health and developmental needs, and health, education, and social care provision.Results: BCVIS2 identified 784 children newly diagnosed with visual impairment/SVIBL (313 with visual impairment, 471 with SVIBL). Most children had associated systemic disorders (559 [71%], 167 [54%] with visual impairment, and 392 [84%] with SVIBL). Care from multidisciplinary teams was provided for 549 children (70%). Two-thirds (515) had not received an Education, Health, and Care Plan (EHCP). Fewer children with visual impairment had seen a specialist teacher (SVIBL 35%, visual impairment 28%, χ2p < 0.001), or had an EHCP (11% vs 7%, χ2p < 0 . 01).Interpretation: Families need additional support from managing clinicians to access recommended complex interventions such as the use of multidisciplinary teams and educational support. This need is pressing, as the population of children with visual impairment/SVIBL is expected to grow in size and complexity.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited

An Unusual Consolidation: Lobar Pulmonary Hemorrhage Due to Antithrombotic Therapy

Alveolar hemorrhage is a rare yet devastating clinical entity if not identified and treated aggressively. Exceedingly rare are the cases of anticoagulant-induced alveolar hemorrhage with very few cases described in the current literature. The nonspecific presentation of an alveolar hemorrhage makes its diagnosis and appropriate treatment difficult in the emergency department. We report a case of a patient on warfarin for atrial fibrillation who was initially misdiagnosed as having community-acquired pneumonia, but subsequently was identified to have a fatal alveolar hemorrhage

An Unusual Consolidation: Lobar Pulmonary Hemorrhage Due to Antithrombotic Therapy

Alveolar hemorrhage is a rare yet devastating clinical entity if not identified and treated aggressively. Exceedingly rare are the cases of anticoagulant-induced alveolar hemorrhage with very few cases described in the current literature. The nonspecific presentation of an alveolar hemorrhage makes its diagnosis and appropriate treatment difficult in the emergency department. We report a case of a patient on warfarin for atrial fibrillation who was initially misdiagnosed as having community-acquired pneumonia, but subsequently was identified to have a fatal alveolar hemorrhage

Red Alder-Conifer Stands in Alaska: An Example of Mixed Species Management to Enhance Structural and Biological Complexity

There is worldwide interest in managing forests to improve biodiversity, enhance ecosystem services and assure long-term sustainability of forest resources. An increasingly important goal of forest management is to increase stand diversity and improve wildlife and aquatic habitat. Well-planned silvicultural systems containing a mixture of broadleaf-conifer species have potential to enhance stand diversity and provide other ecosystem services earlier than typical even-aged conifer plantations. Here, we use the example of mixed Sitka spruce/western hemlock and red alder in young, managed stands in southeast Alaska to achieve these goals. We briefly describe the silvics of Sitka spruce, western hemlock and red alder plantations as pure conifer stands or pure broadleaf stands. Then, we synthesize studies of mixed red alder-Sitka spruce/western hemlock stands in southeast Alaska and present their potential for improving stand structural complexity, biodiversity and other ecosystem services over pure conifer forests. Finally, we discuss some of the opportunities and potential tradeoffs for managing mixed broadleaf-conifer stands for providing a number of natural resources and the influence of these broadleaf-conifer forests on ecosystem linkages and processes

Analisi paleogenetica dei cacciatori-raccoglitori della Sicilia: nuovi dati sul primo popolamento dell’isola

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