over the rim version 2

Auckland IHIC meeting August 31 2007

Mike Mair FRANZCO


EHR

An examination of the ‘act’ metaphysic in the HL7 Reference Information

Model and vs 3


Personal Project

• After a ‘unified theory’

• I studied human interaction

• Identified a ‘natural segmentation’ of language’

• Leads to a Quantal theory of human behaviour and interaction, Meeting/parting/story a key ‘parser’


The Catastrophe Theory Metaphor for the Process of Text Generation: The Predator Prey Cycle

The Process of Human Interaction


process

The Record

Meeting

Process

Parting


The basic medical input template

• SOAP: subjective, objective, assessment, plan – from Lawerence Weed

• Would the aggregation of attested SOAPs be enough for an EHR?


Zap them with templates…


The long and winding road….


DiseaseCourse

AssessmentObjects

ManagementObjects

Conceptual Model for Standards NZ work group 1997: Encounters in Two Episodes, One Disease Course

Episode of Care

Episode of Care


The Health Event Summary (HES) and the CDA

• The HES solution in search of a format

• CDA was a ‘no brainer’ for this

• A container rather than a document

• CDA format has wide global acceptance

• The CDA is an ‘attested unit’, an independent data resource

• Later proposed to ISOTC215 in the ‘immunological model’ for access control


The Immunological Model


IGM, the IGG pentameter

The Immunological Model


Regional Server data store

List of CDA Headers(or Access Objects)

Provider Server data store

Attestable UnitDocument informationEncounter dataService actorsService targetsClinical digest Locates

CDA documentsource

Accessapproved

Encrpytionkey transfer


Regional(SOAP)Server

Datastore

Regional(SOAP)Server

Datastore

Requestor

Datastore

Provider(originatingOrganization) SSLSOAP security

SOAP EnvelopeDigital signaturePublic key certificateSOAP encryptionRole-base access control

Secure Socket Layer (SSL) SecurityCleint/Server authenticationSupporting SOAP encryption

SSL

SSL

2 CDA request in SOAP envelope

3 Route

request

to

neig

bour if n

ecessa

ry

3 Get com

plete CDA from

Provider if request and

access role matched

1 Request t

o neighbour server

CDA Documentin SOAP Envelop

SOAP Security


The document exchange XDS from IHE

• Uses CDA

• Separates Header and Body and uses the Header as a pointer

• Similar in concept to the immunological model?


CDA specifications

• CDA documents are encoded in Extensible Markup Language

• They derive their machine process able meaning from the HL7 RIM

• They use the HL7 Version 3 data types

• BUT: Adoption appears to be ‘held up’


The RIM’S bold and simple scheme

• Entities• Roles• Role relationships • Acts

• These were meant to form a simple ‘language’ for healthcare communication

• The conception was explicitly modelled on Austin’s ‘Speech Act Theory’


Act ‘moods’

• Every Act has a mandatory moodCode attribute, which distinguishes the Act as a factual statement or in some other manner such as a command, possibility, and goal.


Semantic interoperability

• Both HL7 vs 3 and the CDA are committed to the goal of semantic interoperability for healthcare

• Ten years in gestation, implementation of this has been slow and difficult

• Those that succeeded are beset with problems, particularly with the need to extend the RIM with local vocabularies


Barry Smith in 2006

“ The United Kingdom is implementing an electronic health record system for all its hospitals, employing HL7 Version 3. The project reportedly has ground to a halt because the contractors cannot make HL7 work.”

http://colab.cim3.net/file/work/hit/hitop/HITOP12202005.doc


“Analyzing the Key Variables in the Adoption Process of HL7”

“ The result from this study indicates that it is necessary to enhance the standard to overcome particular limitations and facilitate the implementation of inter-institutional software interfaces based on HL7”

Analyzing the Key Variables in the Adoption Process of HL7Alejandro E. Flores, Khin Than WinHealth Informatics Research Centre, University of Wollongong, Australia


Alan Rector, Manchester, UK

• Snomed + Version 3 = CHAOS

• Procedures are ‘situations’

• Description logic for ontologies, no single ‘ontology’

• Not an ‘act’ in sight in his epistemology


EHR


It is time to take another look at Vs3….


Some classifications of language

• Syntagmatic/Paradigmatic Jacobsen

• Langue/Parole De Saussure

• Competence/Performance Chomsky

• Expression/Content Hjelmslev

• Syntax/Semantics/Pragmatics Morris, Peirce

• Others…


Lexical Meaning/Situated meaning

• De Saussure: Langue/Parole– “Acts of speaking (la Parole) are invariably

individual, variable, whimsical, and inventive. There is no principle of unity within speech considered in this way, and therefore, it is not amenable to scientific study.”


Semantics, Syntax, Pragmatics and the RIM

• The structure of the RIM is claimed to be a contribution to ‘Pragmatics’

• Yet the value of using it is to confer ‘Semantic Interoperability’

• Appears to confuse lexical meaning and contextual meaning. Only the first is ‘Semantic’


Pragmatics

• What we say and what we know that the other person will know that we meant

• A mother’s silence can be loud enough to drown out the patter of little feet

• Pure rhetoric?


C.S. Peirce on Pragmatics

“Pragmatics. "is pure rhetoric. Its task is to ascertain the laws by which in every scientific intelligence one sign gives birth to another, and especially one thought brings forth another."

How do we get from there to the epistemology of the RIM?


Peirce on Syntax, Semantics

• Syntax. ". We may term it pure grammar." Syntax is the study that relates signs to one another.

• Semantics. "The second is logic proper," which "is the formal science of the conditions of the truth of representations."


Semantics: “the formal science of the conditions of the truth of

representations”

• Semantics is the study that relates signs to things in the world and patterns of signs to corresponding patterns that occur among the things the signs refer to.

• Peircian logic became the basis of the “conceptual graph”


Link to the Semantic Web

• “Conceptual Graphs are easily integrated with the Semantic Web as it is, the mapping being apparently very straightforward “ Berners Lee

http://www.w3.org/DesignIssues/CG.html


The Logical Positivist view

• ‘Speech act theory’ was a reaction to the logical positive view of language limited to the referential or denotative functions

• In its most extreme form was an attack on philosophy, dismissed as language games

• Everything that cannot be clearly stated was banished to the realm of mysticism or tautology.


Austin’s trichotomy: language does more than communicate truth

• Locutionary: words used without intending to convey a meaning e.g. ‘…”it is raining” is a sentence in English’

• Illocutionary: words used to intending to convey a meaning e.g. “it is raining” when it is raining..

• Perlocutionary: words used which have a consequence in behaviour e.g. “it is raining” with the result that somebody shuts a window.


RIM mood codes derived from thisData with a purpose?

• : EVN (Event) meaning that the Act is describing something that occurred

• DEF (definition) which means that the Act is providing a master file type of description

• INT (intent) where the Act is describing and action plan or order

• GOL (goal) for describing a desired outcome• EVN.CRT (event criterion) must apply for an

associated service


Speech Act theory problematic

• Implies that persistence is dependent on collective intentionality

• Although the agreement to support a standard may be from ‘collective intentionality’ the constituted items of such a standard are persistent entities in their own right


What is speech act theory doing (and not doing) for linguistics

• Pragmatics can mean both more and less than ‘speech acts’

• Speech act theory beyond Austin• Searle: ‘the construction of social reality’• Levinson: on the psychology of ‘relevance’• Grice: the co operative principle, and

conversational implicature

• ‘Their dependence on ‘intentionality’ is a flaw for a theory of meaning’ -Chomsky


Doubts on Speech Act Theory for Health Informatics

• There is a background concern about whether reality is truly knowable outside for our categorical perceptions (from Kant)

• Does this need endless restatement every time we harvest a fact, by calling it an ‘act’?

• An observation is represented by a ‘sign’. if it is persistent, it’s a ‘substance’ (semiotic triangle)

• We could get the context information from elsewhere, e.g. the CDA header


Gunther Schadow on the act of injecting someone with something

• “I agree that the act of injecting is not a speech act, yet the medical record does not contain injections per se, but rather someone’s talking about injection as an order or a report.

• The shared care record contains speech acts (even a simple assertive statement is a speech act) of which the physical act of injecting is simply reflected as propositional content.

• Trying to separate propositional content from its speech act is futile, because in the end, we have to represent both in a linguistic form.

• Propositional content is tied to speech act just as one side of a coin is tied to the other.” from ‘HL7 RIM under scrutiny’


Speech may be a form of action but words and situations are not

• Origin of words is in ‘reification’ of process• Results of speech acts are to deliver

‘situations’, which are entities not actions• The constitution of institutional facts may

involve actions (after Searle) but institutional facts themselves are entities

• Observations may be actions, but the information thus harvested is ‘signs’

• A ‘sign’ is an entity, not an act!


Three challenges to the RIM

• The claim that the RIM confers semantic interoperability appears to be wrong.

• Calling constituted institutional facts “acts” may be wrong, and confusing

• Insisting that each fragment of data carries a full set of meta data may be unnecessary and redundant


Modern views on speech and action

• The concept of ‘embodied cognition’• ‘Intentional attunement’ is mediated by

Mirror neurones• There is direct synchronous modelling of

speech and action among the participants• Now studied with functional magnetic

resonance imaging (fMRI)• This has become a ‘hard science’, and will

leave ‘Speech Act Theory’ behind.


The minimalist model for an EHR and building up repositories:

• Universal container, CDA,

• Universal access control : IHE and XDS

• Universal meta data for content represented in headers (including medical)

• Archetype like clinical content objects

• A Darwinian model for the ‘currency’ of clinical concepts in both senses.


The Semantic Web for healthcare?

• On semantic interoperability: “The good news is that it is now a solvable problem, the bad news is that it is really, really hard.” Charles Mead

• On the Semantic Web, it also helps to understand what service exposed a particular piece of data and how that service communicates “You need the ontology, the information model and services,” he said. “If you have one and don’t have the others, it won’t help.”

-but does the RIM help??

• http://www.govhealthit.com/article96736-11-13-06-Print


EHR


Thanks for listening

over the rim version 2

Documents

hl7 version

hl7 work

hl7 rimthey

act metaphysic

key variables

patterns of signs

scientific study

data typesbut