MINUTES
MEETING OF
E31.25 SUBCOMMITTEE ON XML DTDs for HEALTHCARE
April 26, 1999
SHERATON CENTRE, TORONTO, ONTARIO, CANADA
Call to Order
The meeting was called to order at approximately 1:30 PM by Rachael Sokolowski, iTrust and Magnolia Technologies, and Chair, E31.25 on XML DTDs for Health Care. A list of the individuals in attendance is included at the end of the minutes.
The attendees introduced themselves and their interest in XML. Members of SDOs were present (HL7, ASTM, CEN) as well as vendors and organizations developing XML healthcare applications.
Objectives of the Meeting
The objectives of the meeting were described:
E31.25 subcommittee objectives and goals
Review areas for collaboration with other related activities
Define first work items
Set future meeting schedule for 1999 and locations
Overview of ASTM
Rachael Sokolowski provided a brief overview of the Society and its procedures. The E31 has approximately 300 members and the structure consists of Committee, and Task Group. The new effort is a Subcommittee. Rachael presented the different divisions of ASTM: Division 1 Security, Division 2 Health Records, Division 3 Data Interchange, and Division 4 General Concepts. E31.25 is a member of division 4. There was some discussion of why 25 was part of division 4 and not of division 2. A conclusion was reached that XML DTDs extend beyond the documents of the health record and therefore fall within the category of general concepts.
Overview of E31.25
The group’s objective is the development of DTDs for healthcare. This is based on the premise that a set of document types for healthcare does not exist. It is not known if health care documents have common and identifiable structures but it is generally accepted that some regularity exists. Printed documents have information conveyed in 2 ways: content and format. The content contains the words, pictures and other information and the format provides visual clues font, font size and location. Items that are presented in a style different from the paragraph text of a document are likely to have some semantic meaning.
Scope of E31.25
The development of standards and promotion of knowledge related to document type definitions (DTDs) for heath care. This subcommittee will also develop implementation guides, sample document instances, and a validation facility for verifying conformance to the voluntary standard DTDs. The DTDs will be developed to the current XML standards and adapt to future and extended specifications of the XML standard. This subcommittee will coordinate with ASTM subcommittees and committees and other outside organizations having related interests and standards.
It was noted that the scope of E31.25 needs to be changed to include the January proposal from the
Proposal for ASTM group: The ASTM E31.25 charter should include language to the following effect: The DTDs and any related work created by E31.25 activity should be transformable to the appropriate level of the Patient Record Architecture, with no loss or distortion of corresponding semantics.
Overview of E31.22 & its Relationship to E31.25
Styles for clinical documents are often applied when transcribed. The ASTM E31.22 subcommittee on Health Information Transcription and Documentation is concentrating on the formats of healthcare documents. E31.25 was formed to work in conjunction with E21.22 to standardize the structure of the content of these documents. E31.25 will create DTDs and E31.22 will create stylesheet specifications which E31.25 will generate from the DTDs.
E31.25 is soliciting participation and invite submission of document types and DTDs from vendors, regulating bodies and other organizations working on paper-based forms, transcribed documents and XML solutions in healthcare in conjunction or in parallel with E31.22. E31.22 conducted a survey on transcribed documents to begin the process of determining the most frequently transcribed reports. The most frequently transcribed document types from the 69 survey respondents were:
· Discharge Summaries
· Operative Reports
· Histories & Physicals
· Consultations
· Emergency Dept Reports
· Imaging Reports
· Progress Notes
· Clinic Notes
E31.22 received the following sample reports:
· Histories & Physicals
· Operative Reports
· Consultations
· Discharge Summaries
· Clinic/Progress/SOAP Notes
· Emergency Dept Notes
· Technology Needs
E31.25 will start with these report types. Other examples will need to be solicited.
CEN Research on Document Structures: Angel Rossi Mori
The CEN standard classifies document type and sections. Angelo Rossi Mori ‘s work includes section classifications and the medical record document types. For instance the CEN classifies document categories as:
Note / Progress note / Operation noteConsultation note / Other notes
Request / Diagnostic / Referral
Other / Report
Discharge Summary / Report of Diagnostic procedure / Other report
Notification / Infectious disease
Admission / Other
Chart / Observation / Drug
Other / Study Product
Image / Signal / Other
Other type of document
Proposed Set of Categories
Reason for contact
History in general
Personal history
Allergies
Medications
Problems
Family
Social and Environmental
Physical Exam
Investigations
Diagnoses
Treatments
Medications
Immunizations
Support
Information & community
Training and education
Administrative
Problem
Active
Inactive
Alerts
Plans
Actions (added by Tom Lincoln)
Prognosis
Outcome
Dynamic Views
Problem list (clarified as list of problems)
Current overview
Pending request
List of previous reports
List of Current Meds
Primary status for findings
Present
Possibly present
Risk of
No risk of
Family history
Goal
Jason Williams volunteered that Oceania had reviewed the CEN document categories and sections. Oceania had been able to map approximately 80% of its own document sections and categories directly to the CEM categories and sections. A few f the items that did not map easily included Chief Complaint/Reason for Visit , the distinctions between lab results/tests and the distinction between pediatric physical exam and adult physical exams.
Modeling Tools and the Development of the DTDs
Joachim raised the question of what modeling tool should be used to express the DTDs. There are issues of namespaces and tag repositories. Joachim suggested we look at UML, Unified Modeling Language to describe the DTDs. The UML would require developing a document model that described the document structure and content.
Juggy raised the question of how the ordering or positioning of elements would be encoded in UML, since no ordering is implied in UML, but it may be possible to specify how elements are to be traversed.
There are XML and UML efforts. One is XMI and the other is UXF. XMI is a submission to the OMG for a way to interchange UML data between different modeling tools. For more information on this, look at: http://www.omg.org/archives/orbos/msg00702.html
Of interest might be a discussion item from the xml-dev listserv which was included with the meeting minutes by Rachael Sokolowski:
Re: Translation between DTDs, schemas, UML, and the like
Paul Prescod ()
Mon, 25 Jan 1999 01:39:15 -0600
"A. G. McDowell" wrote:
>
> There seem to be a large number of languages devoted to listing (for
> instance) the fields that make up a customer order and describing their
> data types. To comprehend a (hypothetical) ecommerce system I might have
> to follow a relational schema for the underlying database, a UML model
> of the application classes and logic, and a schema or DTD for the XML
> used to exchange data with its customers.
>
> Is there any hope of a product that could be used to automatically
> generate some part of this? My chosen format would be UML, but I'm open
> to reasons why not.
My primary argument would be that AFAIK UML is not a language in the
computer-science/chomsky sense! It is a graphical notation. You can't
email me the UML code for "a class" (though you could mail me the mutually
incompatible output of various UML modeling programs). As I understand
it, there are initiatives afoot to make standard serializations for UML
diagrams, but those are not UML itself. If my understanding is out of
date, perhaps someone could fill me in.
Now even if we presume the existence of a standard UML serialization, I am
not confident that our goals in DTD creation and object modeling are the
same. UML describes how a system functions. Database schemas describe how
its data should be persisted. DTDs describe how the data should be
interchanged.
System function modeling is focussed on increasing reliability, usability
and reusability. Persistence modeling is focussed on reducing duplication
and providing efficient navigation and querying. Interchange is focused on
expressing very careful, very explicit constraints on what is and is not
allowed, and in what order.
I fear that if you tried to build a single schema to accomplish all of
these things, it would have to be very complex and sophisticated. It would
need to incorporate features of IDL, SQL, STEP and DTDs. Perhaps it's
possible, but I don't think that UML is anywhere close. I fear greatly
that this overcomplicated monster is what many participants expect as the
result of the W3C XML schema language effort.
Also note that XML still has a major role to play in the document world.
This implies many usability concerns that would need to be recognized by
this UBER-Schema.
Paul Prescod - ISOGEN Consulting Engineer speaking for only himself
http://itrc.uwaterloo.ca/~papresco
xml-dev: A list for W3C XML Developers. To post, mailto:
Archived as: http://www.lists.ic.ac.uk/hypermail/xml-dev/
Maybe in reply to: A. G. McDowell: "Translation between DTDs, schemas, UML, and the like"
CORBAmed Transcription Service
Juggy Jagannathan reviewed the CORBAmed Transcription service. The CORBAmed RFP is a proposal for services for the transfer of transcribed documents from repositories.
Document Type Priorities of E31.25
Transcribed documents
Vendor priorities
Forms
Review of Submissions
Transcription Templates from CareFlow|net
Juggy Jagannathan provided approximately twenty templates from transcribed documents. All of the documents contained header information; however, less than what is specified by the Patient Record Architecture (PRA) header. Most of the transcription templates include the following fields: patient name, some type of identification number, date of service, and the provider. None of the templates displayed had many sections defined; in fact, many had no sections defined. A suggestion was made for varying levels of headers. A question was raised: will al documents have the same headers? Will a letter have the same requirements for a header as a note?
GE/Marquette Medical Systems ECG Example
Steve Kordik from GE/Marquette Medical Systems presented a DTD for a resting ECG. Some things to note: the XML document instance contains the waveform data in the documents under appropriate mark-up and attributes are not used, all information is expressed in elements.
Mayo Forms
John Majerus provided examples of forms for a variety types of clinical reporting. John will forward copies of representative forms to the ASTM committee.
Action Items
Collect DTDs
Joanne Hubbard offered to submit DTDs from L&H
Transcription templates were volunteered from Careflwo|net
Jason Williams offered DTDs from Oceania
Steve Kordik offered DTDs from GE/Marquette Systems
Paper forms for a variety of clinical encounters were offered from Mayo.
Collect Documents
Review CEN work on sections and categories from CEN.
Consider adoption of the Patient record Architecture Header
Consider multiple Header Levels
Determined preferred representation of the DTDs. (XML 1.0 syntax, UML, other ideas)
Schedule a two day workshop to accelerate DTD development. Proposed dates are 7/26-7/27 in Washington DC
Next Meeting
The following meeting schedule for 1999 was discussed
5/3 –Orlando in conjunction with the ASTM meetings
7/26-7/27 – Workshop focusing on XML DTDs
9/27 – Atlanta Joint HL7 meeting
11/?? – Washington DC
Membership
For those who are not yet members of ASTM Committee E31, please contact Peggy Bonis (610-832-9711 or ) or Teresa Cendrowska (610-832-9718, ) for an E31 application. When you complete the application, note your interest in the XML Subcommittee E31.25
Adjournment
The meeting adjourned at 4:20 PM.
Attendee List for April 26, 1999
Rachael Sokolowski / iTrust/Magnolia Technologies / /Joachim Dudek / HL7 Germany /
Jason Williams / Oceania /
Joanne Hubbard / L&H /
V. “Juggy” Jagannathan / CareFlow|Net /
John Ruud / Care Data Systems /
John Majerus / Mayo Foundation /
Steve Kordik / GE-Marquette Medical /
Total : 8