MEDICAL AND ADMINISTRATIVE INFORMATION MODELLING OF A

HOSPITAL UNIVERSITY CENTRE PNEUMOLOGY DEPARTMENT

C. ROLLANDa, B. HUETb and J.-P. BATTESTIC

‘Dept. d fnformatique, Univ. Paris, I, 12, Place du PanthPon, 75231 Paris Cedex, bInformatique
Mkdicale, Univ. Paris XIII, U.E.R. de MPdecine, 74, rue Marcel Cachin, 93012 Bobigny Cedex
and ‘Dept. de Pheumologie, HGpital Avicenne. 125, Roudt de Stalingrad, 93000 Bobigny (France)

(Received 12 December, 1981)

Instead of a technology+riented approach of a hospital information system (HIS), the

authors present a structure oriented approach built on three elements: objects, events and operations
which allow one to model a static and dynamic schema of an information system (IS). Objects of
the static schema lead to a relational model. Events expose various states of Information System;
operations allow one to build a dynamic schema. Such a schema is interesting for IS description in
order to enhance the analytical capability of the designer, to define IS solutions and to limit the
risks of errors. It allows the clinician better management of information relative to patients,
especially thanks to the dynamical schema which enables one at any monent to know the patient’s
state. Finally, it has to free clinicians from managing information and allow them to give an always
more important consideration to human relationships in medicine.

Introduction

Instead of a ‘technology-oriented approach’ of a hospital information system

(HIS) (Bakker, 1977), we choose a ‘structure-oriented approach’. The first part of our
work was presented in Montreal (Rolland et al., 1980), the second part is presented
here; it relates to clinical, biological and administrative information in a pneumology
department of a Hospital University Centre. This department managed by Professor
Battesti, was chosen to model the informational invariant of any hospital pneumology
department for two reasons: first, it is a medium-sized department of 50 beds, with
large technical facilities (hospital and University complex in northern part of Paris,
France). Second,patients represent a wide variety of pulmonary diseases: Tuberculosis,
tumors of the lung, chronic bronchitis and emphysema, asthma, interstitial lung
disease etc.. .
The functioning of such a department is complex, because analysis shows there are
many ‘objects’, viz. medical records, departments, laboratories, analytical instruments,
patients files, clinical examinations, doctors.. . ; particular attributes define them, and
on these, many operations are performed, viz. sorting of medical records, validation of
information, discussion for supplementary tests and medical practice-oriented opera-
457
Int. J. Bio-Medical Computing (13) (1982) 457-469
0020-7101/82/0000-0000/%02.75 0 Elsevier Scientific Publishers Ireland Ltd.
Printed and Published in Ireland
458 C. RoIland, B. Huet, J.-P. Battesti

tions (Medinfo 80, 1980). Moreover, between the admission and the discharge of a
patient many evenfs occur, e.g. moving of patients between different wards, sampling
of blood for tests, start of therapy, ineffective therapy report.. .
The events are distributed along the time parameter; they correspond to certain
states, allowing the system to perform one or several operations. Each operation
creates information and generates new states of the system (with limits of integrity
constraints), eventually becoming events relevant to other operations.
All these events are responsible for the system dynamic, their sequence representing
the temporal evolution of the system. The real system evolves according to events. All
the complexity of the real system has to be logically represented in the information
system (IS). The above description of the phenomena shows that it is necessary to
model at the same time structure and dynamics of a real system.
Consequently, the designer of an HIS has to invent the different types of objects,
e.g. in pneumology, requests for consultation, result of clinical examination, requests
for appointments, discharge of patient, return of patient for consultation; the dif-
ferent types of operations are, for instance, elaboration of a diagnosis, elaboration of
a therapy, process of a clinical examination.. .
The IS has to inform about the occurrences of each type; it has to evolve as a real
system according to events. To reach this objective, hospital staff has to be permanently
and immediately informed about system states: patients, occupied beds, stock of
medicines.. .
Moreover, it should always be possible to know what sequence of events has gene-
rated the sequence of actions leading to a state (e.g. why this patient begins this
therapy? Why a complementary test is necessary for another patient? Why is it neces-
sary to change the therapy of the other patient?).
This simplified analysis of phenomena in a hospital department shows that it is not
possible to limit it to this information in transit in the organization. We have also to
take into account its dynamic part: origin of this information and transformation to
reproduce a real system dynamic.
This dynamic-oriented modelling shows a partial view of a database approach,
relational (Yasnoff et al., 1977) or hierarchical (Jeanty, 1977) exclusively static-
oriented to the detriment of the analysis of its dynamic.
In this paper, we present the concepts relative to a static and dynamic schema of
an organization (‘super-schema’) and the relationships between the concepts and the
symbolizing of such a schema. The second part presents an application of those
concepts to information relative to a patient in a pneumology department; the third
part discusses and evaluates the value of such an approach.

The conceptual modelling

Principle
To model the functioning of the pneumology department in its all generality, we
 Information modelling 459

propose to construct a picture, of perceived reality in terms of types (i.e. categories)

independent of any technical factors.
This modelling leads to a conceptual super schema which covers the conceptual
schema in the sense of the ANSI/SPARC and extends it to a drawing of the dynamic
system and an abstraction of the IS (Fig. 1).

Model of the super schema

The super schema is the result of an analysis and modelling of perceived reality,
for which the designer needs a model, which helps him to structure the reality he
analyses. For us a model is defined as a set of concepts and corresponding rules for
their utilization. The super schema, which is composed of two parts (static and dyna-
mic), is a relational one (Codd, 1970). It was theoretically defined by Rolland etal.,
1978; Rolland et al., 1979.

The concepts
In order to investigate the model, we did an analysis of a dynamical real system in
terms of categories. This analysis led to the following conclusions.
In a real system, three categories of phenomena are observed: OBJECT, OPERA-
TION, EVENT; these are interconnected. All-the links are represented by three cate-
gories of associations: MODIFY (operationobject). ASCERTAIN (object-event).
TRIGGER (event-operation).
From this analysis arise the following definitions:

An OBJECT is a concrete or abstract component of the organization that can be

particularized, e.g. patient Smith, bed number 2 in ward 538. etc.
An OPERATION is an action that can be executed alone, at a given time; it induces

Modelling of the reality, considered

as a dynamic system

c
Representation of
Super Schema Abstraction of the I.5
real world system

I
Implementation

Information
System
Fig. 1. The steps of modelling and implementation of an IS.
460 C. Rolland, B. Huet, J.-P. Battesti

state changes in one or more objects, e.g. the clinical examination of a patient is an
operation which can lead to diagnosis.
An EVENT is the ascertaining of a marked change of state of one or several objects,
which triggers the execution of one or several operations, e.g. the arrival of a patient
for consultation in pneumology is an event which triggers the operation of a clinical
examination.

To obtain a rigorous model from this descriptive step, it is necessary to use some
formalism. A relational formalism was chosen (Codd, 1972) with the following rules:

(a) Any phenomenon is represented by one or several relationships.

(b) To recognize the category of a phenomenon, we introduced types of designated
relations C. OB (C. Object), C. OP (C. Operation), C. EV (C. Event).
(c) To model the time parameter and to lead to a minimal conceptual schema (in
the meaning of Delobel), we introduced a normalized form called ‘permanent
relation’.

The classes of real objects,‘real
by several relations: C. OB type,
(Beeri et al., 1978) (Codd, 1972);
of a real system in components,
redundancy in this description.
operations, real events are respectively represented
C. OP type, C. EV type. Modelling is normalized
it corresponds to a description of the functioning
processes, elementary links. There is no semantic

Definition of each concept

Relational ‘C. OB’ type: a relation C. OB type represents a particular aspect of a
class of real objects. All the attributes of a same C. OB have the.same behaviour in
time. They are created, modified and suppressed at the same time.
A relation C. OB type translates an elementary state of the real system, e .g. a clinical
examination of a patient is represented by several C. OB relations:

(a) Result chn. exam. (N’ patient, date exam., result, n’ examn., n’ doctor)
(b) Regional clin. exam. (N’exam., n’ region, result)

(a) Describes the global examination and the result.

(b) Describes the examination by regions.

Relation ‘C. OP’ type. A relation C. OP type represents an elementary aspect of a

class of real operations. Conversely, several C. OP relations are necessary to translate
the semantics of the same class. Moreover, the normalization C. OP type leads to its
definition from C. OB type by constraints: NOP-NOB (expression of a functional
dependency (Beeri et al., 1978) of any C. OP with a C. OB) which means that the
operations of a same C. OP modify the objects of a unique C. OB.
A relation C. OP type represents the processing unit of the real system, e.g. asking
for an appointment involves two C. operations.
 Information model&g 461

(a) Asking (n op 7, text op 7)

(b) Trace (n op 7, datop 7, n ob 7)

Relation ‘C.E.V.’ type: A relation C. EV type represents an elementary aspect of

a class of real events, and several C. EV relations are necessary to describe the class.
The normalization of the C. EV type leads to its definition from the C. OB type by
the constraints: N EV-N OB (expression of a functional dependency, Beeri et al.,
1978) of any C. EV with a C. OB and from several C. OPby the constraints NEV-NOP
(expression of a multivalued functional dependency, Beeri et al., 1978) of any C. EV
with a C. OP. The change of a particular state of an object of a unique C. OB, which
can trigger operations belonging to one or several determined C. OP, defines the result
of an event of a given C. EV.
A relation C. EV type represents the smallest change of state of the IS which can
trigger elementary transformation, e.g. the consultation by a patient is represented
by several relations C. EV.

Example: Arrival of a patient for a consultation:

(a) Trace the event C. EV2.r (evz, datevz, noba)

(b) Trace the operation triggering C ev2.2 (nev2,

---~ dateev2, nop5, dateops)

Symbolizing of the super schema

The super schema is a collection of permanent relations in which are again found
a statical (collection of C. OB) and dynamical structure (collection of C. OP and
C. EV) of a real system.
The organization dynamic is translated from a causal manner by interrelations
between C. OB, C. OP, C. EV of the dynamical schema, an event triggers operations
which modify objects. The change of state of the objects is an event which will trigger
operations that, will modify other objects, and so on.
In the case of pneumology, a figure represents a dynamical schema; it is based on
the following conventions, as shown in Fig. 2.

Representing C.OB of which

C Operation - of the association change of state
ASCERTAIN is a C.EV

___-------- - _____--------

0
C. OP triggered
C. Objet TRIGGER by the C.EV

i_______--___ -- ____------- ---

c. event

V MODIFY C. OB modified
the C.OP under
condition
iterative
by

(cl or in
manner
IL

Fig. 2. Conventions for the symbolizing of the Super-schema.

462 C. Rolland, B. Huet, J.-P. Battesti

The super schema and the invariant of IS

This approach shows the ‘invariant’of this IS, which we could define as the minimal
collection of objects, operations, events, integrity constraints and relationships that are
the basic phenomena of the organization and their links.
The analysis of the ‘invariant’ compels us to begin with the inventory of the objects
of the IS (i.e. the static schema), then the study of the relationships between those
objects; this leads us to describe the operations performed on the objects and the en-
vironment : what event starts operation? Under what conditions (integrity constraints)?
It is possible that a newly arisen occurrence in the database is interesting for this
or that entity of the organization but not indispensible for the IS basic functioning;
this suggests a communication system problem: is it necessary to transfer this in-
formation? if it is, what entity of the IS is it? How many copies? What type?

2. Super schema of information relative to a patient in a pneumology department

The analysis of the pneumology department of the hospital Avicenne (93012

Bobigny, France) led to the following results (Fig. 3):

Statical schema: the objects

OB 1: Patient id. (N’patient, name, address, date birth, profession)
OB 2: Direction to specialist (N’ patient, date sending, name dot)
OB 3: Patient’s movement (Nr patient, date, NT bed)
OB 4: Region clin. exam. (N’ examen ., n* region, result)
OB 5: Result clin. exam. (N’.patient, date exam., result, n’ dot., n’ exam.)
OB 6: Asking for an appointment (No patient, date appt, n type exam)
OB 7: Complementary test id. sending (N’ patient, date exam. n type exam, n test)
OB 8: Complementary test result return (n test, result)
OB 9: Medical therapy (N’ patient, date therapy, N’ medicine, posology , N’ dot.)
OB 10: Surgical therapy (N’ patient, date, N’ surgeon, n* intervention)
OB 11: Patient diagnosis conclusion (Nr patient, date dia, Nr dot, Nr dia. conclusion
OB 12: State of the patient (clinician view) (N’ patient, date, state)
OB 13: Bill (N’ patient, date, ntype action, account)
OB 14: Discharge sheet (N’ patient, date discharge, exit dia, N’ dot)
OB 15: State of the patient (personal view) (name, address, date of birth, state)
OB 16: General practitioner consultation (name patient, date, N’ dot)

General objects:
OB 17 : Ward (N’ ward, n’ department, quant. beds)
OB 18 : Bed (N’ ward, nr bed)
OB 19: Regioxgion, wording)
OB 20: Diagnosis conclusion (n dia, conclusion, wording)
OB 2 1: Medicines list (N’ medicine, condition)
 Information modelling 463

Arl
Ho!

Clin.Inform.

ion.
HoSp
ic /

Fig. 3. Super-schema of medical and administrative information in a pneumology department.

464 C. Rolland,B. Huet, J.-P. Battesti

OB 22: Doctor’s list (N’ dot., name, address, phone)

OB 23 : Laboratories (NT speciality)
OB 24: Type exam list (n type exam, N’ labo, cond. sampling, cond. execution,
cond. result return, wording, indications, interpretation)

Dynamical schema

(a) Operations
OP 1: Request for specialized consultation
OP 2: Hospitalization
OP 3: Examination of the patient by anatomical regions
OP 4: Global synthesis about clinical information of the patient
OP 5: Hospitalization after clinical examination
OP 6: Request for an appointment for complementary tests
OP 7: Despatch of complementary tests results
OP 8: Return of complementary tests results
OP 9: Action for surgical therapy
OP 10: Elaboration of a conclusion about diagnosis
OPll: Writing out of a prescription
OP 12: Writing out of a new prescription
OP 13: Action (second) for surgical therapy
OP 14: Elaboration of a conclusion about diagnosis
OP 15: Duration of the right’ time for application or beginning of application of the
right therapy
OP 16: Processing of the bill
OP 17: Processing of the discharge sheet
OP 18: The patient goes for a consultation with a general practitioner
OP 19: The patient goes to hospital
OP 20: The patient returns for consultation

(b) Events
EV 1: Admission of the patient to the hospital
EV 2: Arrival of the patient for a consultation
EV 3: The doctor obtains all the clinical information
EV 4: Despatch of the complementary tests to the laboratory
EV 5 : The doctor receives the information of all the complementary tests
EV 6: The doctor judges that the state of the patient does not require hospital
treatment
EV 7: The patient does not feel well
EV 8: The doctor recommends him to go and see a specialist
 Information modelling 465

(c) Conditions
c 1: Emergency case for a patient
C 2: The clinician decides to ask for complementary tests
c 3: Hospitalization is necessary for complementary tests and for application of a
therapy
C 4: The clinician does not obtain enough complementary information
C 5: The clinician is able to organize a therapy
C 6: The patient agrees to have surgical therapy
c 7: There is no counter indication
C 8: The diagnosis is already known
C 9: The clinician confirms the diagnosis, but changes the therapy
C 10: The clinician is able to make a diagnosis
C 11: The diagnosis is confirmed
c 12: The diagnosis is modified

Comments on the dynamic schema

The static schema is a collection of objects which interests hospital departments
and have to be represented in the HIS. The grouping of objects in classes leads to a
synthetic view of information. Their description explains the particular states of a
class of real objects. For instance, the class ‘patient’ shows several aspects corresponding
to several situations of a patient in a hospital pneumology department (i.e. all the suc-
cessive states of the patient) (Fig. 4). Another example concerns the objects OB 5 and
OB 4 that refer to all information about clinical examinations; all the objects OB 9
tell us about all the successive medical therapies; the occurrances OB 8 and OB 7 show
the identification and results of complementary tests; finally, OB 2 shows the patient’s
hospitalization.
The dynamic schema defines the rules of change from one state to another and
explains why and how a patient is in a determined state; here this schema analyses
the diagnosis and therapy approach and their relationship with the administrative
department; in this manner, all the sequences of the possible states of a patient are
observed. For example, a possible sequence is EV 2, EV 3, EV 4; it represents the start
of consultation, consultation itself and the doctor’s decision relative to the patient.
The sequence EV 2, EV 3, EV 4, EV 5 leads to diagnosis, after the first EV 4, the
known information relative to the patient is insufficient; this implies a second run in
the circuit EV 4, EV 5 to obtain enough information to make a diagnosis.

3. Discussion and evaluation

This model is a useful tool for the information problem description; it is centred
on the infological view of Langefors (1980).

The super-schema allows one to obtain IS description

Hospital staff knows its information problem from particular points of view:
 466 C. Rolland, B. Huet, J.-P. Battesti

_ { Patient \ _

-w
Fig. 4. Relationships between patient
c3
id--““__*:__ ^_-1 ~I-- _*I--_ _I-:-^r”

Administrative staff, medical staff, surgical staff, pneumology staff, emergency staff.
All have a partial and personal view.
In fact, it is the designer’s responsibility to obtain a complete and consistent de-
scription of IS; to do it, he needs a model giving a total description (static t dynamic)
of all HIS particular aspects. Our proposed model gives a global and complete view
of the real world leading to a HIS conceptual schema definition. The concepts of our
model are precisely defined; neither possible ambiguity in their use, nor real difficulty
are possible when building a conceptual schema.

The model enhances the designer 3 analytical capability

As opposed to a process-oriented model (Franta, 1977), our model doesnot confuse
events and operations. A dynamic description of the reality expressed by a simple and
accessible concept is a fruitful output, especially appreciated by our research staff
of the pneumology department because they obtain a better control of their infor-
mation problem. As a result of using the model we obtained more direct and efficient
interaction between lung specialists and designers. Users were more confident in
designer’s capability to comprehend their information problem and then to solve it.
 Informationmode&g 461

The model makes the designer less dependent of the users: with an initial collection
of facts he could develop his description, while controlling consistency, correctness
and omissions. He could determine independently of any comments whether the
analysis has been completed. Conversely, he knows when he needs more facts in order
to complete or to correct his description.

The super schema is useful for the IS solution definition

The schema is a tool for future IS development. If the information problem is com-
plex, it is beneficial to undertake progressively technical design and future system
construction. In this case, the information problem must be split into many parts.
It is obviously necessary to develop a communication system between a pneumology
department and a biochemistry department. The clinician, who ascertains the EV 3
event and the need to ask complementary tests, has to transmit a message correspon-
ding to the information of OB 7. For example, consider the EV 4, EV 5 events and the
OB 6, OB 7, OB 8 objects; this phase necessitates several steps: request for an appoint-
ment for this or that complementary test for the patient SMITH, despatch of OB 6
(with an empty value for the attribute date call) to the laboratory by the pneumology
department and returning OB 6 with a value for date call; despatch of a biological
sample to the laboratory with the object OB 7; the object OB 8 is sent back to the
pneumology department after analysis by laboratory. However, this division is often
arbitrary.
It is clear that this does not burden the design task nor complicates the interface
and the implementation aspects. By means of the IS dynamic conceptual schema it
is possible to clearly find where the border between the parts could be established.
The dynamic associations between objects, operations and events represented in
the IS dynamic conceptual schema illustrate the connections between any part of
future systems and arrange elements in order to reduce the arbitrariness of the division.

A tool to define the application domain of any technique

For any complex or non-complex IS, the solution is simultaneously technical and
administrative: technical because actions and events will be automatically processed;
administrative because people will be totally responsible for the excution. We insist
on the fact that in our case the designer must also establish a border between the
technical part and the administrative part. This border introduced in the diagram
representation of the IS dynamic conceptual schema allows the designer to appreciate
the consistency of any part and to evaluate the complexity and adequacy of the inter-
faces needed. Of course, the more complex the IS, the more extended and varied the
technical and administrative parts, and the more difficult is to establish and evaluate
the interfaces.

The conceptual approach limits the risks of errors

This division into static and dynamic schemas draws attention to two major risks:
 468 C. Rolland, B. Huet, J.-P, Battesti

(a) Non-adapted technological system. An information processing machine works

upon logical objects and creates other logical objects, establishing logical and
temporal relationships between them. The technological risk is to keep tech-
nology under control for the necessary structure of organization IS, and not
the other way. It is, therefore, necessary to analyse IS-perceived reality and to
implement technological entities corresponding to a structural analysis of the
organization.
(b) Static risk. This is the ‘databases risk’; it consists of a reductionist approach
because only a static view is considered. This risk is clearly shown here, be-
cause it ignores two (event, operation) out of three concepts; consequently,
the dynamic aspect of the IS is not integrated into the analysis.

The biggest hospital information systems implemented in the U.S.A. belong to the
latter class (Estrim and Uzgalis, 1979; Beaman et al., 1979; Sneider et al, 1979;
McShane et al., 1979; Walton et al., 1979).

Conclusion

Among the many responsibilities the clinician has to assume, one is that of manage-
ment of information relative to the patient. To have the best possible information in
the shortest time, this management has to rely on a coherent view of the information
relative to this patient.
In the special frame of medical information management, the patient must always
firstly be considered from the point of view of human relationships in respect of
medical ethics and medical deontology. The biggest advantage of clinical-oriented
information systems with a static and dynamic view is to help clinicians to absorb
patient management from medical data processing people; this will allow medical staff
to devote a greater share of time to human relationships.

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