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Scalability and Semantic Sustainability in Electronic Health Record Systems
Linköping University, Department of Biomedical Engineering, Medical Informatics. Linköping University, The Institute of Technology.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This work is a small contribution to the greater goal of making software systems used in healthcare more useful and sustainable. To come closer to that goal, health record data will need to be more computable and easier to exchange between systems.

Interoperability refers to getting systems to work together and semantics concerns the study of meanings. If Semantic interoperability is achieved then information entered in one information system is usable in other systems and reusable for many purposes. Scalability refers to the extent to which a system can gracefully grow by adding more resources. Sustainability refers more to how to best use available limited resources. Both aspects are important.

The main focus and aim of the thesis is to increase knowledge about how to support scalability and semantic sustainability. It reports explorations of how to apply aspects of the above to Electronic Health Record (EHR) systems, associated infrastructure, data structures, terminology systems, user interfaces and their mutual boundaries.

Using terminology systems is one way to improve computability and comparability of data. Modern complex ontologies and terminology systems can contain hundreds of thousands of concepts that can have many kinds of relationships to multiple other concepts. This makes visualization challenging. Many visualization approaches designed to show the local neighbourhood of a single concept node do not scale well to larger sets of nodes. The interactive TermViz approach described in this thesis, is designed to aid users to navigate and comprehend the context of several nodes simultaneously. Two applications are presented where TermViz aids management of the boundary between EHR data structures and the terminology system SNOMED CT.

The amount of available time from people skilled in health informatics is limited. Adequate methods and tools are required to develop, maintain and reuse health-IT solutions in a sustainable way. Multiple levels of modelling including a fixed reference model and another layer of flexible reusable ‘archetypes’ for domain specific data structures, is an approach with that aim used in openEHR and the ISO 13606 standard. This approach, including learning, implementing and managing it, is explored from different angles in this thesis. An architecture applying Representational State Transfer (REST) to archetype-based EHR systems, in order to address scalability, is presented. Combined with archetyping this architecture also aims at enabling a sustainable way of continuously evolving multi-vendor EHR solutions. An experimental open source implementation of it, aimed for learning and prototyping, is also presented.

Manually changing database structures used for storage every time new versions of archetypes and associated data structures are needed is likely not a sustainable activity. Thus storage systems that can handle change with minimal manual interventions are desirable. Initial explorations of performance and scalability in such systems are also reported

Graphical user interfaces focused on EHR navigation, time-perspectives and highlighting of EHR content are also presented – illustrating what can be done with computable health record data and the presented approaches.

Desirable aspects of semantic sustainability have been discussed, including: sustainable use of limited resources (such as available time of skilled people), and reduction of unnecessary risks. A semantic sustainability perspective should be inspired and informed by research in complex systems theory, and should also include striving to be highly aware of when and where technical debt is being built up. Semantic sustainability is a shared responsibility.

The combined results presented contribute to increasing knowledge about ways to support scalability and semantic sustainability in the context of electronic health record systems. Supporting tools, architectures and approaches are additional contributions.

Abstract [sv]

Syftet med denna avhandling är ytterst att göra informationssystem som används i hälso- och sjukvård, särskilt patientjournaler, mer användbara och lättarbetade. Om systemen vore lättare att utveckla och underhålla skulle fler resurser kunna läggas på att tillföra nya och mer användarvänliga funktioner.

Om journalsystem och datorprogram kan ”begripa” vad olika saker i journalen är och betyder så kan de vara till större hjälp, t.ex. genom att visa bättre patientöversikter och bidra med beslutsstöd. En del i att göra journalinnehållet begripligt och hanterbart för datorer är att använda sig av terminologisystem som t.ex. ICD-10 och SNOMED CT. En annan viktig del är datastrukturerna där man stoppar in text, mätvärden, koderna från terminologisystem etc. De flesta journalsystem har någon sorts mallar som datastrukturer. Projektet openEHR har tagit fram ett sätt att dela specifikationer av datastrukturer mellan olika journalsystem så att man lättare kan dela och återanvända dem och den journaldata som matats in i dem. Dessa specifikationer kallas ”arketyper” och arketyp-metoden beskrivs även i standarden ISO 13606.

Om två olika journalsystem använder samma datastruktur, t.ex. med hjälp av samma arketyper, så kan de utväxla patientdata mellan varandra (de uppnår s.k. semantisk interoperabilitet). Begreppet ”Semantic sustainability” definieras i avhandlingen som ett förhållningssätt som är bredare än semantisk interoperabilitet. Det syftar till att möjliggöra långsiktigt hållbar utveckling av semantik (betydelse) i journalsystem och genom att hantera risker och resurser förståndigt. Förhållningssättet baserar sig på forskning och erfarenheter från systemutveckling och hantering av komplexa system och är avsett att stödja beslutsfattare, och de som utvecklar och underhåller journalsystem, relaterade system och strukturer.

För att datorsystem ska kunna växa vid ökad användning ,utan att hamna i återvändsgränder avseende prestanda, så bör vissa designprinciper för skalbarhet följas. Avhandlingen presenterar en systemarkitektur baserad på sådana principer och på arketyp-metoden. Denna arkitektur gör det möjligt att bygga system med delsystem från flera olika leverantörer. Skalbarheten i några lagringslösningar redovisas också.

Slutligen redovisas prototyper av gränssnitt för patientöversikter och journalläsning.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 204 p.
Series
Linköping Studies in Science and Technology. Dissertations, ISSN 0345-7524 ; 1499
National Category
Information Systems Other Medical Sciences not elsewhere specified Other Computer and Information Science Human Computer Interaction
Identifiers
URN: urn:nbn:se:liu:diva-87702ISBN: 978-91-7519-699-2 (print)OAI: oai:DiVA.org:liu-87702DiVA: diva2:599752
Public defence
2013-02-15, Berzeliussalen, Campus US, Universitetssjukhuset, Linköping, 09:15 (English)
Opponent
Supervisors
Available from: 2013-01-22 Created: 2013-01-22 Last updated: 2014-10-08Bibliographically approved
List of papers
1. Interactive Visualization and Navigation of Complex Terminology Systems, Exemplified by SNOMED CT
Open this publication in new window or tab >>Interactive Visualization and Navigation of Complex Terminology Systems, Exemplified by SNOMED CT
2006 (English)In: Ubiquity: Technologies for Better Health in Aging Societies - Proceedings of MIE2006 / [ed] Arie Hasman, Reinhold Haux, Johan van der Lei, Etienne De Clercq, Francis Roger-France, IOS Press , 2006, 851-856 p.Conference paper, Published paper (Refereed)
Abstract [en]

Free-text queries are natural entries into the exploration of complex terminology systems. The way search results are presented has impact on the users ability to grasp the overall structure of the system. Complex hierarchies like the one used in SNOMED CT, where nodes have multiple parents (IS-A) and several other relationship types, makes visualization challenging. This paper presents a prototype, Term Viz, applying well known methods like "focus+context" and self-organizing layouts from the fields of Information Visualization and Graph Drawing to terminologies like SNOMED CT and ICD-10. The user can simultaneously focus on several nodes in the terminologies and then use interactive animated graph navigation and semantic zooming to further explore the terminology systems without loosing context. The prototype, based on Open Source Java components, demonstrates how a number of Information Visualisation methods can aid the exploration of medical terminologies with millions of elements and can serve as a base for further development.

Place, publisher, year, edition, pages
IOS Press, 2006
Series
Studies in Health Technology and Informatics, ISSN 0926-9630 ; 124
Keyword
Terminology, Information Visualization, SNOMED CT, Medical Informatics
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-38011 (URN)000281143200121 ()17108619 (PubMedID)41106 (Local ID)978-1-58603-647-8 (ISBN)41106 (Archive number)41106 (OAI)
Conference
International Congress of the European Federation for Medical Informatics, 27-30 August 2006, Maastricht, The Netherlands
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2013-05-15
2. Visualizing sets of SNOMED CT concepts to support consistent terminology implementation and reuse of clinical data
Open this publication in new window or tab >>Visualizing sets of SNOMED CT concepts to support consistent terminology implementation and reuse of clinical data
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Inconsistent use of concepts is an obstacle when implementing SNOMED CT to improve comparability of information. Terminology implementation should be approached by common strategies for navigating and selecting proper concepts. This study aims to explore ways of illustrating common pathways and ancestors of particular sets of concepts, to support consistent use of SNOMED CT in EHR-system implementation processes. The prototype presented here is an interactive web-based reimplementation of the terminology visualization tool TermViz. The open source prototype contains terminological features that are of relevance when exploring and comparing sets of concepts in SNOMED CT. This includes interactively rearranging graphs, fetching more concept nodes, illustrating least common parents and shared pathways in merged graphs etc. Future work should focus on evaluating the developed prototype in order to assess its applicability in EHR-system-implementation contexts.

Keyword
Clinical terminology, Implementation, SNOMED CT, Information Visualization
National Category
Information Systems
Identifiers
urn:nbn:se:liu:diva-87693 (URN)
Available from: 2013-01-22 Created: 2013-01-22 Last updated: 2013-01-23
3. Integration of Tools for Binding Archetypes to SNOMED CT
Open this publication in new window or tab >>Integration of Tools for Binding Archetypes to SNOMED CT
Show others...
2008 (English)In: BMC Medical Informatics and Decision Making, ISSN 1472-6947, Vol. 8, no S7Article in journal (Refereed) Published
Abstract [en]

Background

The Archetype formalism and the associated Archetype Definition Language have been proposed as an ISO standard for specifying models of components of electronic healthcare records as a means of achieving interoperability between clinical systems. This paper presents an archetype editor with support for manual or semi-automatic creation of bindings between archetypes and terminology systems.

Methods

Lexical and semantic methods are applied in order to obtain automatic mapping suggestions. Information visualisation methods are also used to assist the user in exploration and selection of mappings.

Results

An integrated tool for archetype authoring, semi-automatic SNOMED CT terminology binding assistance and terminology visualization was created and released as open source.

Conclusion

Finding the right terms to bind is a difficult task but the effort to achieve terminology bindings may be reduced with the help of the described approach. The methods and tools presented are general, but here only bindings between SNOMED CT and archetypes based on the openEHR reference model are presented in detail.

Background

The Archetype formalism and the associated Archetype Definition Language have been proposed as an ISO standard for specifying models of components of electronic healthcare records as a means of achieving interoperability between clinical systems. This paper presents an archetype editor with support for manual or semi-automatic creation of bindings between archetypes and terminology systems.

Methods

Lexical and semantic methods are applied in order to obtain automatic mapping suggestions. Information visualisation methods are also used to assist the user in exploration and selection of mappings.

Results

An integrated tool for archetype authoring, semi-automatic SNOMED CT terminology binding assistance and terminology visualization was created and released as open source.

Conclusion

Finding the right terms to bind is a difficult task but the effort to achieve terminology bindings may be reduced with the help of the described approach. The methods and tools presented are general, but here only bindings between SNOMED CT and archetypes based on the openEHR reference model are presented in detail.

Place, publisher, year, edition, pages
Springer, 2008
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-43812 (URN)10.1186/1472-6947-8-S1-S7 (DOI)000277030600007 ()74857 (Local ID)74857 (Archive number)74857 (OAI)
Note

Original Publication: Erik Sundvall, Rahil Qamar, Mikael Nyström, Mattias Forss, Håkan Petersson, Hans Åhlfeldt and Alan Rector, Integration of Tools for Binding Archetypes to SNOMED CT, 2008, BMC Medical Informatics and Decision Making, (8), S7. http://dx.doi.org/10.1186/1472-6947-8-S1-S7 Licensee: BioMed Central http://www.biomedcentral.com/

Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2015-09-22
4. Applying representational state transfer (REST) architecture to archetype-based electronic health record systems
Open this publication in new window or tab >>Applying representational state transfer (REST) architecture to archetype-based electronic health record systems
Show others...
2013 (English)In: BMC Medical Informatics and Decision Making, ISSN 1472-6947, E-ISSN 1472-6947, Vol. 13, no 57Article in journal (Refereed) Published
Abstract [en]

Background

The openEHR project and the closely related ISO 13606 standard have defined structures supporting the content of Electronic Health Records (EHRs). However, there is not yet any finalized openEHR specification of a service interface to aid application developers in creating, accessing, and storing the EHR content.

The aim of this paper is to explore how the Representational State Transfer (REST) architectural style can be used as a basis for a platform-independent, HTTP-based openEHR service interface. Associated benefits and tradeoffs of such a design are also explored.

Results

The main contribution is the formalization of the openEHR storage, retrieval, and version-handling semantics and related services into an implementable HTTP-based service interface. The modular design makes it possible to prototype, test, replicate, distribute, cache, and load-balance the system using ordinary web technology. Other contributions are approaches to query and retrieval of the EHR content that takes caching, logging, and distribution into account. Triggering on EHR change events is also explored.

A final contribution is an open source openEHR implementation using the above-mentioned approaches to create LiU EEE, an educational EHR environment intended to help newcomers and developers experiment with and learn about the archetype-based EHR approach and enable rapid prototyping.

Conclusions

Using REST addressed many architectural concerns in a successful way, but an additional messaging component was needed to address some architectural aspects. Many of our approaches are likely of value to other archetype-based EHR implementations and may contribute to associated service model specifications.

Place, publisher, year, edition, pages
BioMed Central, 2013
National Category
Information Systems
Identifiers
urn:nbn:se:liu:diva-87696 (URN)10.1186/1472-6947-13-57 (DOI)000320998000001 ()
Available from: 2013-01-22 Created: 2013-01-22 Last updated: 2017-12-06
5. Performance of XML Databases for Epidemiological Queries in Archetype-Based EHRs
Open this publication in new window or tab >>Performance of XML Databases for Epidemiological Queries in Archetype-Based EHRs
2012 (English)In: Proceedings Scandinavian Conference on Health Informatics 2012, Linköping: Linköping University Electronic Press, 2012, 51-57 p.Conference paper, Published paper (Refereed)
Abstract [en]

There are very few published studies regarding the performance of persistence mechanisms for systems that use the openEHR multi level modelling approach. This paper addresses the performance and size of XML databases that store openEHR compliant documents. Database size and response times to epidemiological queries are described. An anonymized relational epidemiology database and associated epidemiological queries were used to generate openEHR XML documents that were stored and queried in four opensource XML databases. The XML databases were considerably slower and required much more space than the relational database. For population-wide epidemiological queries the response times scaled in order of magnitude at the same rate as the number of records (total database size) but were orders of magnitude slower than the original relational database. For individual focused clinical queries where patient ID was specified the response times were acceptable. This study suggests that the tested XML database configurations without further optimizations are not suitable as persistence mechanisms for openEHR-based systems in production if population-wide ad hoc querying is needed.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012
Series
Linköping Electronic Conference Proceedings, ISSN 1650-3686 (print), 1650-3740 (online) ; 70
Keyword
Medical Record Systems, Computerized; Database Management Systems, Archetypes, XML Databases, openEHR
National Category
Computer and Information Science
Identifiers
urn:nbn:se:liu:diva-84401 (URN)978-91-7519-758-6 (ISBN)
Conference
Scandinavian Conference on Health Informatics 2012, October 2-3, Linköping, Sweden
Available from: 2012-10-05 Created: 2012-10-05 Last updated: 2015-04-30Bibliographically approved
6. Approaches to learning openEHR: a qualitative survey, observations, and suggestions
Open this publication in new window or tab >>Approaches to learning openEHR: a qualitative survey, observations, and suggestions
2016 (English)In: Proceedings from the 14th Scandinavian Conference on Health Informatics 2016: Gothenburg, Sweden, April 6-7 2016 / [ed] Daniel Karlsson, Andrius Budrionis, Ann Bygholm, Mariann Fossum, Conceicao Granja, Gunnar Hartvigsen, Ole Hejlesen, Maria Hägglund, Monika Alise Johansen, Carl E Moe, Luis Marco-Ruiz, Vivian Vimarlund, Kassaye Y Yigzaw, Linköping: Linköping University Electronic Press, 2016, Vol. 122, 29-36 p.Conference paper, Published paper (Refereed)
Abstract [en]

Approaches such as ISO 13606 and openEHR aim to address data reusability by defining clinical data structures called archetypes and templates, based on a reference model. A problem with these approaches is that parts of them currently are rather difficult to learn. It can be hard to imagine what an archetype-based clinical system combined with modern terminology systems will look like and what consequences different modeling choices have, without seeing and experimenting with an operational system. This paper reports findings from a survey among openEHR learners and educators combined with observations of related openEHR mailing list discussions. The paper ends with an opinion piece, where we discuss potentially fruitful ways to learn, explore, and extend archetype-based EHR systems using visualization and examples.The findings highlight potential stumble blocks and solutions and should be of interest for both educators and self-learners.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016
Series
Linköping Electronic Conference Proceedings, ISSN 1650-3686 (print), 1650-3740 (online) ; 122
Keyword
Electronic Health Records; Software; Learning; Standards
National Category
Information Systems
Identifiers
urn:nbn:se:liu:diva-87701 (URN)9789176857762 (ISBN)
Conference
The 14th Scandinavian Conference on Health Informatics 2016, Gothenburg, Sweden, April 6-7 2016
Available from: 2013-01-22 Created: 2013-01-22 Last updated: 2016-09-14Bibliographically approved
7. Graphical Overview and Navigation of Electronic Health Records in a prototyping environment using Google Earth and openEHR Archetypes
Open this publication in new window or tab >>Graphical Overview and Navigation of Electronic Health Records in a prototyping environment using Google Earth and openEHR Archetypes
Show others...
2007 (English)In: MEDINFO 2007 - Proceedings of the 12th World Congress on Health (Medical) Informatics – Building Sustainable Health Systems / [ed] Klaus A. Kuhn, James R. Warren, Tze-Yun Leong, IOS Press, 2007, 1043-1047 p.Conference paper, Published paper (Refereed)
Abstract [en]

This paper describes selected earlier approaches to graphically relating events to each other and to time; some new combinations are also suggested. These are then combined into a unified prototyping environment for visualization and navigation of electronic health records. Google Earth (GE) is used for handling display and interaction of clinical information stored using openEHR data structures and ‘archetypes’. The strength of the approach comes from GE's sophisticated handling of detail levels, from coarse overviews to fine-grained details that has been combined with linear, polar and region-based views of clinical events related to time. The system should be easy to learn since all the visualization styles can use the same navigation.

The structured and multifaceted approach to handling time that is possible with archetyped openEHR data lends itself well to visualizing and integration with openEHR components is provided in the environment.

Place, publisher, year, edition, pages
IOS Press, 2007
Series
Studies in Health Technology and Informatics, ISSN 0926-9630 ; 129
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-38012 (URN)17911874 (PubMedID)41107 (Local ID)978-1-58603-774-1 (ISBN)41107 (Archive number)41107 (OAI)
Conference
12th World Congress on Health (Medical) Informatics – Building Sustainable Health Systems (MEDINFO 2007), 20-24 August 2007, Brisbane, Australia
Funder
EU, FP7, Seventh Framework Programme
Available from: 2012-09-27 Created: 2009-10-10 Last updated: 2015-09-22Bibliographically approved

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