Connecting Medical Informatics and Bio-Informatics 137

R. Engelbrecht et al. (Eds.)

IOS Press, 2005
2005 EFMI European Federation for Medical Informatics. All rights reserved.

HealthInfoCDA: Case Composition Using

Electronic Health Record Data Sources
a,b b c
Grace I. Paterson , Syed Sibte Raza Abidi , Steven D. Soroka
a
Medical Informatics, Faculty of Medicine,
b
Health Informatics Lab, Faculty of Computer Science,
c
Department of Medicine (Nephrology), Faculty of Medicine,
Dalhousie University, Halifax, NS Canada B3H 4H7

Abstract
HealthInfoCDA denotes a health informatics educational intervention for learning
about the clinical process through use of the Clinical Document Architecture (CDA).
We hypothesize those common standards for an electronic health record can provide
content for a case base for learning how to make decisions. The medical record
provides a shared context to coordinate delivery of healthcare and is a boundary object
that satisfies the informational requirement of multiple communities of practice. This
study transforms clinical narrative in three knowledge-rich modalities: case write-up,
patient record and online desk reference to develop a case base of experiential clinical
knowledge useful for medical and health informatics education. Our ultimate purpose
is to aggregate concepts into knowledge elements for case-based teaching.

Keywords:
Medical Informatics Applications; Medical Records Systems, Computerized; Case Management; Nephrology; Artificial
Intelligence; Boundary Object; Case-based Reasoning; Health Informatics Education; Medical Education; HL7 CDA

1. Introduction
The HealthInfoCDA project aims at providing an educational intervention to medical
residents treating patients with kidney disease secondary to diabetes and hypertension. A key
issue that is being investigated is achieving semantic interoperability among electronic health
resources to not only support disease management but also for lifelong learning/education.
Medical schools are shifting from passive acquisition of knowledge to active learning in a
clinical context. Problem Based Learning (PBL) is an educational method characterized by
the use of patient problems as a context for students to learn problem-solving skills and
acquire knowledge [1]. PBL curricula endorse the use of Electronic Health Record (EHR) of
actual patient problems as an educational resource depicting a clinical context for medical
students to learn both clinical sciences and problem-solving skills. EHR can be regarded as
the glue for the clinical care, medical education and health informatics communities; each
community enriches, interacts and leverages the EHR. Given the central nature of EHR in
patient carei.e. EHRs not only record operational patient data but also encompass the
working behaviour and mental models of the practitioners generating itthey are a vital and
rich source of medical/healthcare knowledge. We contend that episodic information
contained in an EHR can function as learning objects about action-related decisions for
medical and health informatics education, in particular in a PBL paradigm [2]. PBL cases,
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derived from EHR, support experiential learning in clinical settings as follows: anchoring
instruction in cases, actively involving learners, modelling professional thinking and action,
providing direction and feedback and creating a collaborative learning environment [3].
Furthermore, there is a strong association between PBL and the computational reasoning
paradigm of Case-Based Reasoning (CBR) [4] which is the motivation for this project.
The relevance of CBR-based knowledge representation with a PBL compliant teaching
framework is grounded in the fact that CBR provide analogy-based solutions to clinical
problems by manipulating knowledge derived from similar previously experienced situations
called Cases. According to the CBR methodology, a new problem is solved by finding
similar past cases and reusing their problem-solving strategy to derive a solution to the new,
yet similar, problem situation. Note that each case is described by a set of case-defining
attributes and is associated with a solution (or decision) suggested by a medical practitioner
[5]. For learning purposes we argue that for a medical student, learning to be a clinician is
contingent on exposure to large repertoire of clinical experience. In this regard, CBR cases
derived from actual patient information will provide an opportunity for learners to draw on
prior knowledge and experience to learn about how to solve such problems in the clinical
setting. Reasoning with CBR cases will also impress on the learner the dichotomy of theory
and practicei.e. clinical practice does not always follow theoretical norms. For a medical
student, CBR cases will provide an opportunity to learn how experts conceptualize medical
information in terms of constructs [6] and also to leverage on experiential knowledge
accumulated in the EHR which is then translated into a CBR case.
In this project we aim to automatically generate PBL cases, in a CBR formalism, from
narrative teaching cases and EHR. The intent is to anchor instruction in PBL cases that model
professional thinking and action and to produce a case-based curriculum resource that is
useful for medical and health informatics educators. In this paper we present a strategy to
automatically (a) extract clinical concepts from narrative EHR using lexical analysis and
natural language parsing techniques [7]; and (b) generate CBR-specific cases (akin to clinical
documents) represented using the extended markup language (XML) for the Health Level 7
( HL7) Clinical Document Architecture (CDA) specification. HL7 Templates enable formal
expressions of large portions of clinical documents without sacrificing semantic
interoperability.
To achieve the above objectives, we present HealthInfoCDA that leverages health
information standards, classification systems and templates as building blocks for a health
infostructure in a PBL context. As stated earlier, a key issue is information exchange between
these health information elements whilst ensuring semantic interoperability between the
content and the information structures. Digital documents play a role as boundary objects for
representing clinical activity across time and space and for achieving a shared understanding
between caregivers [8]. Our approach is to regard these building blocks function as boundary
objects, objects which are both plastic enough to adapt to local needs and the constraints of
the several parties employing them, yet robust enough to maintain a common identity across
sites [9, p. 393]. They provide an opportunity for learning about the representation of clinical
activity in computerized records and for building a shared understanding amongst the people
who provide clinical care to patients, produce medical education resources and participate as
health informaticians.
We use the CDA Release 2.0 to capture clinical activity associated with care [10]. CDA is a
document specification standard produced by HL7it defines a new target for clinical
information exchange that is substantially easier to hit than one based on standards for
discrete data. It delivers 80% of the value of the latter approach and, as such, hits the 80/20
sweet spot [11]. We argue that the encoding of medical information in a CDA document
facilitates sharing and exchanging information between the EHR and CBR systems. More
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specifically, our focus is to capture and represent action-related decisions associated with
renal care. We seek effective and efficient methods to represent the clinicians experience
with renal disease in a CDA form to improve health outcomes, disease management and
lifelong learning/education.

2. Materials and Methods

The HealthInfoCDA project team developed an information flow model to document
healthcare activities and patient care data collection. Storyboards, or use case paths, the
term preferred in the ISO 17113 Health Informatics standard [12]are narratives that collect
domain knowledge and describe processes pertaining to the interactions between people and
the healthcare system. They help the reader understand the flow of information in the clinical
environment.
For EHR creation, we started with a single clinical communication for the specific task of
patient discharge. Our hypothesis is that we can improve the quality of discharge summaries
for chronic kidney disease patients by using a template to prompt medical residents to enter
relevant data. For our pilot test of the template, clinical educators produced CDA documents
from a simulated chart. These were automatically scored against the gold standard CDA
document produced by the investigators. The characteristics of the difference inform the case
composition process. It may illustrate a record keeping gap that can be addressed in the case
base for the CBR system [13].
For the longitudinal EHR, we used the chart of a patient with chronic renal failure secondary
to hypertension and diabetes. This record spanned over 20 years and included clinical care
communications originating from family physicians, specialists, surgeons, nurses, social
workers, laboratory technicians, educators and pharmacists.
The EHR to HealthInfoCDA case transformation methodology is based on Abidis case
acquisition and transcription info-structure (CATI) methodology [5]. Phase I attempts to
establish structural mapping and Phase II attempts to establish content mapping.

2.1 Phase I: Structural Mapping between CDA-based EHR and Case

The HL7 community of practice assigns unique identifiers to code sets and common
templates available for reuse:
1. Metadata for case indexing using Object Identifiers (OID) for over 100 code sets
2. Templates for common concepts from the NHS Clinical Statement Model, including
Allergy and Adverse Reaction, Blood Pressure, Height, Weight, Temperature,
Smoking/Tobacco Consumption and Alcohol Intake [14]
The HL7 Reference Information Model (RIM) defines two classes specifically for CDA
structured documents. The Class:Document is a specialization of the Act class and is used for
attributes needed for document management. It has an attribute,
Document:bibliographicDesignationText, defined as the citation for a cataloged document
that permits its identification, location and/or retrieval from common collections [15]. This
attribute is useful for retrieval of a document from a specific electronic resource in the
infostructure. CDA is used for clinical and reference documents in the HealthInfoCDA
project.
The first step in identifying the situation-action content is the processing of a text corpus
created from teaching cases, EHR instances and guidelines. The case entries and supporting
tutor guides are from the Case-Oriented Problem-Stimulated (COPS) Undergraduate
Medical Education curriculum, Dalhousie University. The goal for these cases is to enable
the student to understand the manifestations, pathogenesis and management of common
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chronic metabolic disorders of diabetes mellitus and its associated complications which
involve the renal system.
Our diabetic patient develops chronic kidney disease. He is followed for over 20 years. The
patients episode of care dictates the most appropriate site for care. The paper record includes
care in multiple settings and exceeds 300 pages. We select a representative sample for use in
this study (Table 1).
Table 1. Clinical Documents from Patients Paper Chart
Form Settings Count Dates
Discharge Summary Community hospital 1 1982/05/28
Acute care hospital 2 2002/11/12
2003/06/14
Clinic Letter Nephrology Clinic 4 2002/10/29
2002/11/06
2002/12/18
2003/04/07
Protocols Acute care-Erythropoietin 1 2003/04/01
Consultation Community hospital 1 2003/07/29
Operative Report Acute care hospital 1 2002/11/29
Diagnostic Imaging Community hospital 1 2002/10/23
There are evidence-based marker therapies to prevent or retard kidney disease in patients
with diabetes. Such knowledge about marker therapies is pivotal to the design of a health
informatics educational intervention. We add electronic guidelines to our text corpus from
two sources: 1) Diabetes: an Instant Reference, a web portal supported as a separate project in
Dalhousies Health Informatics Laboratory and updated in 2005 to reflect the changes in the
most recent guidelines [16]; and 2) Therapeutic Choices [17] published by the Canadian
Pharmacists Association on their e-therapeutics website.
To ensure inter-case matching accuracy, we define both a numerical and vocabulary domain
for each HealthInfoCDA case attribute value, and standardize the EHR values with respect to
the pre-defined case content. Phase 2 of our EHR to HealthInfoCDA transformation
methodology deals with these tasks.

2.2 Phase 2: Content Equivalence

We utilize Unified Medical Language System (UMLS) MetaMap Transfer (MMTx) software
to parse the narratives in the text corpus (EHR, teaching cases and therapeutic guidelines)
and to map clinical concepts to unique UMLS concept identifiers. MMTx program takes an
input sentence, separates it into phrases, identifies the medical concepts and assigns proper
semantic categories to them according to the knowledge embedded in UMLS [18]. The
MMTx program maps biomedical text in the clinical narrative to concepts in the UMLS
Metathesaurus. We downloaded MMTx software from website, http://mmtx.nlm.nih.gov.
We manually filter the output to select the best match for a clinical concept. The text corpus
is also processed by SnoCode from MedSight Informatique Inc. This natural language
processing software encodes the clinical concepts in SNOMED International. SNOMED is
the coding language of choice for the NHS clinical statement model. SNOMED has been
added as a source vocabulary to the UMLS Metathesaurus in the 2005 version. The UMLS
and SNOMED ontologies serve as semiotic vehicles for sharing medical knowledge and
matching two concepts.
MMTx output consists of information on how the candidate concept matches up to words in
the original phrase. There may be lexical variation in the matching. We use scoring criteria
for coding accuracy ranging from 0 (no information found) to 4 (perfect matching) [19].
 G.I. Paterson et al. / HealthInfoCDA: Case Composition 141

We use the XML-based HL7 standard, CDA, to standardize our case structure and link
clinical documents to each other. Health care activity occurs within a context of who, whom,
when, where, how and why. HL7 developed a service action model of healthcare processes
which focused on context. The application of this model produced a simplification of the
HL7 RIM [20]. When we transform the teaching cases and the actual patient record, the
information should be readily represented as a set of actions in a longitudinal record. This
identifies who did what and the target that the action influences. The information available
about circumstances -- such as location, time, manner, reason and motive -- is entered into the
CDA.

3. Results
We chose UMLS and SNOMED as the switching languages between concepts in the case
base and the knowledge resources. The mean accuracy score assigned to concept encoding in
UMLS was 3.6. The text should be pre-processed to remove punctuation, such as hyphens, to
improve the mapping.
The clinical documentation represented in CDA includes Laboratory Report, Physician
Note, Referral Form Ambulatory Care, Consultation Letter, Clinic Letter, Operative Report
and Discharge Summary. The relationships between the generic drug names in the teaching
case and the brand names in the patient chart are made visible through online linkage to the
Nova Scotia Formulary. For example, the patient is prescribed gemfibrozil, which is shown
on the formulary with brand name Lopid.
For EHR creation, the clinical educator uses a patient chart for the usual transcription and
dictation process, and then uses the HL7 Template to try to express the same information.
The HL7 Template provides a structure and concurrent coding to the data entry process. It
supports pulling information from linked resources, such as the Nova Scotia Drug Formulary.
The clinician enters the summary information as free text. Problems encountered in the pilot
study are resolved with the clinical educators prior to recruiting medical residents to use the
HL7 Template.
Health Informatics students access the case base through a web portal. It displays the EHR
as a linked set of CDA documents with information presented in the same way as the hospital
forms. Our added value is to integrate clinical concept definitions, links to reference
resources, XML viewer and record linkage for longitudinal record for a patient. This makes
visible the complexities of the clinical action-related decision process to the health
informaticians.
The EHRs are real-life cases that depict both a clinical situation and an associated solution.
They are a source of diagnostic-quality operable clinical cases. They contain knowledge
about what clinical activities were done and in what context. SNOMED International and
UMLS will be initially tested as the controlled vocabularies for querying the case base.

4. Discussion
A case base can serve to teach the clinical care process, healthcare delivery models, and the
manifestations, pathogenesis and management of disease. A semantic analysis of the clinical
discourse used for teaching, reference material and medical records can be used for thesauri
discovery for a domain. Patient information is coded in EHRs. The ability to link from patient
records to reference sources is affected by the choice of coding system. The digital case base
can help bridge between the educational settings a student encounters. If a standardized
terminology-architecture interface is achieved through an HL7 CDA specification, it will
serve to support education as well as clinical care. Education cases that focus on chronic
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disease teach longitudinal record keeping. They are useful for teaching medical students the
medical records management process and for illustrating to health informatics students the
complexities of the clinical action-related decision process.

5. Acknowledgements:
We acknowledge content authors Sonia Salisbury, Meng Tan, Sarah Seaman, and Michael
West; template designers Zhihong Wang and Ron Soper; funder of the server, HEALNet
NCE; and scholarship funding from the Canadian Institutes of Health Research (CIHR)
PhD/Postdoctoral Strategic Training Program in Health Informatics.

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7. Address for correspondence

Grace I. Paterson, Medical Informatics, Faculty of Medicine, Dalhousie University, 5849 University Avenue
Halifax, NS Canada B3H 4H7, Email: grace.paterson@dal.ca,
URLs: http://informatics.medicine.dal.ca and http://healthinfo.med.dal.ca