Dr. Luciana Cavalini's short presentation at the International Workshop on e-Health in Emerging Economies - IWEEE - in 2010. See: http://www.mlhim.org http://gplus.to/MLHIM and http://gplus.to/MLHIMComm for more information about semantic interoperability in healthcare. #mlhim #semantic_interoperability #health_informatics

1. Healthcare Knowledge Modelling
Projects for Multilevel-Based
Information Systems
Dra. Luciana Tricai Cavalini, MD, MSc, PhD
“Multilevel Healthcare Information Modeling”
Laboratory – Associated to INCT-MACC
UFF/UERJ

2. What do the citizens want?
• “How do you provide to me: • And better still:
▫ Safe ▫ Prevent me getting ill
▫ Effective ▫ And don’t harm me in the
▫ Reproducible process”
▫ State-of-the-art
▫ 21st Century medicine
▫ Wherever I am
▫ Whatever the time
▫ Whatever is wrong with me

3. Paper
records can’t
handle it

4. Hardware is not the problem anymore...

5. ...or is it?

6. No, it is not!

8. “International Standard paper sizes
should be used”

9. “Attention is drawn to the
potentialities of the new
methods of mechanical
systems and data processing”

10. 45 years later...

14. What about software?

16. Brazilian Healthcare Card
Investment:
•Federal Budget (until 2009) = R$327 million
•Unesco = R$74,3 million
•Total (until 2009) = R$401 million
Equivalent the the Aeolian Park in Bahia:
•90MW (it illuminates a 400,000 inhab city)
•Annual profit estimated in R$41 million

17. “A Unique Health Identifier alone won't prevent duplicate creation.
Make sure your strategy includes a focus on data quality and
data governance, too.”
Alex Paris, “Why a Unique Health Identifier Falls Short”

18. *Interoperability*
- Cough
-For 3 months
-Low fever
-A: TB? Ca?
-Chest X-ray
-Nodule in
-Bronchoalveolar Right apex
lavage:
-Bronchogenic
carcinoma

19. *Interoperability*
- Cough
-For 3 months
-Low fever - Cough
-A: TB? Ca? -Chest X-ray
-For 3 months
-Nodule in
-Low fever
Right apex
-A: TB? Ca?
- Cough
-Chest X-ray
-For 3 months
-Nodule in
-Low fever
Right apex
-A: TB? Ca?
-Bronchoalveolar lavage:
-Bronchogenic carcinoma

20. Interoperability?
- Cough
-For 3 months
-Low fever
-A: TB? Ca?
Garage Software
-Chest X-ray
-Nodule in
-Bronchoalveolar Right apex
lavage:
-Bronchogenic
HL7v2 Messages
carcinoma
CEN 13606 Extracts

21. Where is the Context?

22. Here is the Context!

23. Traditional Modelling

24. Single-Level Modelling Issues
 Information is modelled in a way that “serves” the current needs of the healthcare system
 The addition of new concepts or the change of existing concepts implies in re-factoring the whole
system (re-modelling, re-implementation, re-test, re-distribution)
 High cost, slowness in the integration of new knowledge to the systems etc.

25. Multilevel Modelling

26. The MLHIM and openEHR Specifications
• Multilevel (or dual) Modelling: software development and
knowledge modelling are separated
• The Reference Model is implemented in software
• The knowledge is modelled in Concept Constraint
Definitions - CCDs (“archetypes” in the openEHR specs)

27. MLHIM and openEHR Models
Your application (EHR, CPOE etc)
MLHIM and openEHR
Knowledge Modelling
specifications
(CCDs or Archetypes)
Reference Model

28. FLOSS Available Tools (1)
• Implementations of the Reference Model:
▫ 2 Java Implementations by the openEHR Foundation
▫ 1 Grails implementation by Pablo Pazos (Uruguay)
▫ 1 Python Implementation by the MLHIM Laboratory
▫ 1 Ruby Implementation in course by a collaboration between a Japanese
research group and the MLHIM Laboratory
▫ 2 other implementation projects by the MLHIm Laboratory:
 Lua
 C++

29. http://www.openehr.org

30. https://launchpad.net/mlhim

31. https://launchpad.net/oship

32. http://www.mlhim.org
http://www.oship.org

33. FLOSS Available Tools (2)
• Archetype Editors (in ADL):
▫ Ocean Archetype Editor (Windows-only)
▫ LinkEHR (source code by request, there are bugs)
▫ LiU Archetype Editor (outdated)
• Templates Editors (in OET, OPT):
▫ None (only the proprietary Ocean Template Designer)
• Constraint Definition Designer Project (in XML):
▫ Only full-FLOSS and multiplatform tool
▫ Combined CCD and Template editor
▫ Baseado on Freemind, Plone and other ideas

34. https://launchpad.net/cdd

35. FLOSS Available Tools (3)
• Archetype Repository:
▫ None (openEHR Foundation’s CKM is proprietary)
• The Healthcare Knowledge Component Repository Project:
▫ Repository of the XML Schemas of CCDs
▫ Based on Plone 4
▫ Functionalities:
 All the famous Plone’s CMS and WFM features
 XML Schema validation
 API to CDD, OSHIP and the Multilevel Authoring for Guidelines (MAG)

36. https://launchpad.net/hkcr

38. FLOSS Available Tools (4)
• Terminology and Vocabulary Servers:
▫ LexGrid (http://www.lexgrid.org)
▫ LexBIG (http://preview.tinyurl.com/29ybeuf)
▫ Unified Medical Language System (UMLS)
(http://www.nlm.nih.gov/research/umls)

39. http://www.lexgrid.org

40. http://preview.tinyurl.com/29ybeuf

41. http://www.nlm.nih.gov/research/umls

42. Knowledge Modelling (1)
• Our governance model proposes:
▫ Openness and transparency in decision making and operational
procedures
▫ Deliberative systems based on universal suffrage and
representativensess
▫ Cost-effective financing models, based on equitable and public
distribution of resources, including direct funding, collaborative work,
research and education projects etc.
▫ Coordinated and federation principles-based decentralization

43. Knowledge Modelling(2)
• Our governance model proposes :
▫ Preference for the use of validated instruments (including their
translations) for the development of CCDs
▫ Preferential use of knowledge modelling strategies derived from the
collaborative computing (web based or presential)
▫ Knowledge modelling might be based on expert panels in exceptional
situations
▫ Publication of the knowledge modelling artifacts on a public, open access,
FLOSS-based repository, maintained by the healthcare system
manager in each one of the three levels of government

44. My Conclusions
• I think that the path for the development of citizen-centered, longitudinal, semantic
coherent healthcare information systems is based on this tripod:
▫ Multilevel modelling
▫ Adoption of standardized terminologies
▫ Adoption of a Unique Citizen Identifier
• Emerging countries have some competitive advantages in healthcare IT:
▫ Usually, the Big Customer is just one (the government)
▫ We are starting almost from scratch
▫ Emerging countries are much more FLOSS-friendly
▫ All needed tools are available or being developen in FLOSS
• What’s next:
▫ Invite more partners to participate (government, academy, industry, third sector, FLOSS
community)
▫ Go to work!

45. Special Thanks to:
Tim Cook
Mike Bainbridge
Thank you! Sergio Freire
lutricav@vm.uff.br
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