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STRUCTURED HEALTH MARKUP LANGUAGE

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STRUCTURED HEALTH MARKUP LANGUAGE Powered By Docstoc
					STRUCTURED HEALTH MARKUP LANGUAGE
              SHML ®



                  DAVID J. ROTHWELL M.D.
                 HEALTH LANGUAGE CENTER
  Major Issues Affecting Patient
  Medical Record Information
• Continuing Barriers to Data Entry
• Increasing Role of Patient Choice
• Shift from Acute / Inpatient to Disease
  Prevention / Management
• Impact of Genomics
• Rapid Rise of Internet Standards
      Health Language Center
             Approach
• Convergence / Maturity of Two Major
  Technologies:
  – Internet Standards - XML
  – Natural Language Processing
• Potential to Keep Pace with Change
                             Care Process
   PMRI            Utility   Clinical Research
Provider Patient             Aggregation of Data
                             Epidemiology
   Document                  Adherence to guidelines
                             Eligibility for protocols




                                    Findings
                   NLP XML
   PMRI             SHML      Clinically Important
                               Information (minus)
      Text                     verbiage
      SDE                     Clinically Relevant
                               Content Units (CRCU)
   Natural Language Processing
• A system which turns natural language
  clinical documents into structured data for a
  variety of applications.
• The NLP method makes explicit the
  informational structure of texts, using
  linguistic method and the most advanced
  information technology available today.
              NLP (cont’d)
• Language presents information linearly in
  strings--phrases, sentences, paragraphs,
  sections, documents, discourses, …
• Information in these strings is carried by the
  semantic types of words, occurring in
  particular combinations.
                                        Dictated encounter note:
This is the second clinic visit for this 28 year old right handed female who is followed for headache and neck pain
which began one year ago. Ms. xxx was last seen in Neurology clinic on 05/05/96. At that time I recommended
Motrin, 800 mg three times a day as needed and physical therapy.
Most recently she has continued to suffer neck pain. This is describe as an aching, burning type of pain on the
right side into the scapular. This usually occurs at the end of the day. Occasionally there is some kind of stabbing
pain in the back of the neck. She also believes that occasionally she has had some numbness in the triceps of her
left arm. She has suffered from no weakness, no urine or bowel problems and no kind of gait difficulities.
Current medications are Advil, 400 mg. at bedtime as needed. She has no known drug allergies.
On exam she carries her neck in a normal position. Her neck is supple and turns in all directions with full range of
motion and freedom of movement. Her trapezoid on the right is mildly tense. She has no point tenderness over the
spine. She has full strength in her arms and fingers. She has no altered sensation in her arms to pain, vibration or
light touch. Her reflexes are 1+ and symmetric in arms and legs with downgoing toes.
Overall my impression is that the neck pain is most consistent with a diagnosis of musculoskeletal pain.
She also suffers from a small herniated disc at approximately the C-5 level, however, symptoms are mild and
surgery would not be an option at this time. Therefore, I will defer an M1LI until danger signs such as bowel or
bladder problems, focal weakness or numbness which persists or point tenderness over the neck should present in
this young women
She was instructed to take Advil, 800 mg. three times a day and watch for any G.I. effects.
It is not clear that her pain she is currently suffering is changed in any way, rather it is the same low-grade pain
she has had for the past year but now she has resolved to get it taken care of.
Apparently she is being represented by a lawyer in the accident which is what this neck pain is from.
I recommend physical therapy and the patient was instructed to return to the clinic for a follow-up in three months
for repeat examination and further management.
                        NLP
              Formats include:
• Demographic Data        •   Treatments
• Verbs                   •   Test and Result
• Patient State Data      •   Time
   – Diagnosis            •   Uncertainty (H-MODAL)
   – S-S (H-INDIC)        •   Negation
• Patient Status Data     •   Response
   – Patient
                          •   Changes
   – Anatomy (H-PTPART)
                                           INFORMATION FORMAT
                                              PATIENT STATE

                                                    FORMAT5




PARAGR   PT-DEMOG METHOD SUBJECT VERB TENSE PSTATE-DATA PSTATE-SUBJ PRECISIONS TIME                 TEXTPLUS



  AGE             PROCEDURE     DEVICE                                                  TIME-LOCS TIME-QUAL

     RACE                  EXAMTEST      DIAG                        PT

            SEX   FAMILY                   S-S                        PTPART     PTMEAS


          MALE FEMALE                            TXRES                         PTFUNC

                                                  QUALIFIERS

                                                         INFLUENCE        NORMAL

                                                                 QUANT
   Use of Medical Language Processing for
              HEDIS Measures

      "BETA BLOCKER TREATMENT AFTER A HEART ATTACK"

Hospital discharge -records in text form (natural language) are prepared
for processing, analyzed, formatted for retrieval of information, and the
following queries submitted by Aurum Medical Language Processor:

         Did the patient have an acute, myocardial infarction?
         Was the patient given a beta blocker medication?
         Did the patient have any contraindications?
* List of Beta Blockers: LOPRESSOR, METOPROLOL, NADOLOL,
CORGARD, ATENOLOL, TENORMIN, PlNDOLOL, VISKEN, PROPRANOLOL,
INDERAL, INDURAL, BETA BLOCKER, ACEBUTOLOL, BETAXOLOL,
BISOPROLOL, CARTEOLOL, CARVEDLOL, LABETALOL, PENBUT0LOL,
SOTALOL, TIMOLOL.

* List of Contraindications: HEART BLOCK, ATRIOVENTRICULAR BLOCK,
BRADYCARDIA, BRADYCARDIC, LV DYSFUNCTION, VENTRICULAR
DYSFUNCTION, DIASTOLIC DYSFUNCTION, VENTRICULAR DIASTOLIC
DYSFUNCTION, COPD, CHRONIC OBSTRUCTIVE PULMONARY DISEASE,
DIABETES MELLITUS, ASTHMA, CONGESTIVE HEART FAILURE,

* Results from database queries:
                                   Beta Blocker   Beta Blocker
                                   Given          Not Given      Total
With contraindications             42             19             61
Without contraindications          28             2              30
Total                              70             2l             91
       eXtensible Markup Language
                  (XML)

• Streamlined subset of SGML
• XML is a language
   – Document Type Definition
   – DTD defines it's use (it's grammar)
• Designed for data exchange
• Data processing oriented rather than publishing (SGML)
• Create own 'tags' -what you need to know
       • i.e. Annotate document with meaning
eXtensible Markup Language (cont’d)
              (XML)
•   Data and document are combined
•   Tagged text transforms it into data
•   Tags are granular descriptive views of text
•   Tags are metadata--information not explicit in text
•   Puts meaning and interpretation on top of text
•   Ability to catalogue all information in document
•   Preserves fundamental structure of document (PMRI)
•   Tagged data can fit into any data format or data model
                            XML Tags
              <elementType> Content </elementType>

Pneumonia
<Diagnosis> Pneumonia </Diagnosis>

Pneumonia, right lower lobe
<Diagnosis> Pneumonia <location> right lower lobe </location> </Diagnosis>

Pneumonia, right lower lobe, superior, due to Klebsiella.
<Diagnosis> Pneumonia <location> right lower lobe </location> <position>
superior</position><link>due to</link> <org>Klebsiella </org> </Diagnosis>

PRESENTATION FORMAT (one of many)
           Diagnosis:   Pneumonia
           Location:    RLL, superior
           Organism:    Klebsiella
                                 XSL
Demographic Data
Node positive carcinoma of the left breast, treated by mastectomy,
chemotherapy and radiotherapy
Radiotherapy treatment summary: the left breast and draining nodal areas
received a dose of 42.9 Gy in 13 fractions treating three times a week with 6
Mv photons. Treatment started on the 15th of September and was completed on
the 14th October, 1995.
                        Radiotherapy Treatment Summary
  Status before radiotherapy:
    Diagnosis                      Carcinoma left breast
    Spread                         Left axillary nodes
    Previous treatment             Mastectomy, chemotherapy
  Radiotherapy given
    Treatment type                 6 Mv photons
    Site                           Left chest wall and draining nodes
    Total dose given               43 Gy
    Schedule                       3 fractions/week 15 September 1995 to ...
  Follow up plan                   One visit . . .
     Structured Health Markup
             Language
• Utilizes Linguistic Model not Coding
• Utilizes XML
• Designed to Integrate both Structured Data
  Entry and Text
                     SHML and MLP
                            ®

Medical documents



   standardization       MLP in HLC/SHML
                           Dictionaries


Documents with SIDs
                                               GENERATORS
                        Documents in CRCU’s    • SHML/DTD
                        with SHML and MLP
                                               • SHML/XSL
       MLP                     tags
                                               • SHML/XQL


                        Documents in rows of
                          standard dBMS           Other
                                                Applications
      Mapping --NLP Dictionary / SHML ®
   Term                   NLP Class      SHML ®
Altered awareness         H-INDIC--N         fs neuro
Alternate                 H-TMREP--TV        tmr
Alternating between       H-CONN--P          lprep
Altogether                H-AMT--D           mamt
Aluminosis                H-INDIC--N         fd tox
Augmentations             H-CHANGE:MORE--N   mcha
August                    NTIME1--N          tme
Aunt                      H-FAMILY--N        per kin
Auricle                   H-PTPART--N        as ear
Auriculectomy             H-TTCHIR--N        pr
Auriculo-osteodysplasia   H-INDIC--N         fd cong
Auriculotemporal          H-PTPART--ADJ      areg
Auscultate                H-TXCLIN--TV       pr
            SHML ® TAGS Traditional Set

•   Demographic data     <dem>    (subclasses)
•   Anatomic Structure   <A.S.>   (Digital Anatomist)
•   Medication           <dr>     (Multum, First Data)
•   Organisms            <or>
•   Chemical             <ch>     (nonphysiologic)
•   Devices              <dev>    (ECRI)
•   Occupation           <occ>    (National, international)
•   Procedures           <pr>     (CPT, other)
•   Diagnosis            <fd>     (ICD-9, ICD-O, Medcin)
               SHML ® TAGS (cont’d)
Verbs               <lv>       Subsets defined by MLP
Preposition         <prep>     All except time prep
Dietary/Food        <diet>     Nutrition
Time                <tm>       Exact, begin, end, frequency
Amount              <mamt>
Change              <mcha>     Less, more
Certainty           <mcer>     Uncertainty, modal, certainty
Negation            <mneg>
Stage grade         <ms-g>
Dimension           <mdim>
Adjective           <mad>
Appearance          <mapp>     Color, shape, clarity
Odor                <msmell>
Position            <ppo>      Top to bottom, laterality
Person              <per>      Masc, Fem, pronouns
Environment         <env>      Physical locations
Transparent         <transp>   Derived from entity, modified
           Additional SHML ® TAGS
Findings <Finding> Vital Signs
                   Signs/symptoms by organ system
                   Lab; Image;
                   Behaviors
                   Living              Functional status
                   Injury              Disability
                   Exposures           Compliance
                   Travel              Dental
                   ADL                 Alternative care
                   Exercise            etc.
                   Leisure, sports
                   Immunization
                   Allergy, tolerances
                   Education, counseling
         SHML ® / XML TAGGING
     <elementType>Content</elementType>

 Vocabulary Table                        Clinical Table

Terms                                   Chest Pain
                                                Location
Taxonomic knowledge                                Substernal
Hierarchical knowledge (classificatory)         Onset
Synonyms/Equivalent terms                          --hrs ago
Linguistic knowledge                               --days ago
Definitional knowledge                          Brought on by
                                                   jogging
Non-unique term knowledge                          walking
Tag knowledge                                   Relieved by
                                                   rest
                                                   nitroglycerin
SHML Vocabulary Table (Outline)
 Digestive Tract (syn G.I. Tract, Alimentary Tract)
                   Upper G.I. Tract
                              Mouth
                                       Tongue
                                       Teeth
                                       Gums
                             Pharynx
                                       Oropharynx
                                       Hypoharynx
                             Esophagus
                             Stomach
                             Lower G.I. Tract
                                       Small Intestine
                                                  Duodenum
                                                  Jegunum
                                       Large Intestine
                                                  Cecum
                                                  Appendix
                                                  Colon
                                                  Rectum
                                                  Anus
         Vocabulary Attribute Table Design---
                Anatomic Structure
Term/phrase   Relation/Attribute Term/Phrase               Relation   Relation TAG
                     (has member)

Anatomic Structure    as          Integumentary System     is a       Anatomic Structure
Anatomic Structure    as          Breast                   is a       Anatomic Structure
Anatomic Structure    as          Musculoskeletal System   is a       Anatomic Structure
Anatomic Structure    as          Digestive System         is a       Anatomic Structure
Digestive System      as          Digestive Tract          is a       Anatomic Structure
Digestive System      as          Digestive Organs         is a       Anatomic Structure
Digestive Tract       as          Upper GI Tract           is a       Anatomic Structure
Digestive Tract       as          Lower GI Tract           is a       Anatomic Structure
Upper G. I. Tract     as          Mouth                    is a       Anatomic Structure
Oral                  syn         Mouth                    BLANK      BLANK
Upper G. I. Tract     as          Pharynx                  is a       Anatomic Structure
Upper G. I. Tract     as          Esophagus                is a       Anatomic Structure
Upper G. I. Tract     as          Stomach                  is a       Anatomic Structure
Mouth                 as          Lips                     is a       Anatomic Structure
Mouth                 as          Tongue                   is a       Anatomic Structure
Mouth                 as          Palate                   is a       Anatomic Structure
Roof of mouth         syn         Palate                   BLANK      BLANK
Tongue                as          Posterior third           is a      Anatomic Structure
Tongue                as          Anterior 2/3              is a      Anatomic Structure
    Vocabulary Attribute Table Design---Findings
Term/phrase            Relation       Term/phrase                  Relation Tag
                       (has member)
                                      Finding                            is a   Source
Finding                 Finding       Finding constitutional (fc)
Finding                 Finding       Finding tissue(ft)
Finding                 Finding       Finding integumentary (fs integ)
Finding                 Finding       Finding musculoskeletal (fsmss)
Finding                 Finding       Finding respiratory (fs resp)
Finding                 Finding       Finding neurologic (fs neuro)
Finding neurological    Finding       Dyslexia                           is a   Finding
Finding neurological    Finding       Aphasia                            is a   Finding
Finding neurological    Finding       Phobia                             is a   Finding
Phobia                  Finding       Acrophobia                         is a   Finding
Phobia                  Finding       Claustrophobia                     is a   Finding
    SHML and NLP: Example #2
                 ®


*SID=NE1519 017A.11.01
ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED
PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100 , WITH
PREMATURE VENTRICULAR CONTRACTIONS AND POSSIBLE OLD INFERIOR
AND ANTEROSEPTAL MYOCARDIAL INFARCTS .

                           WITH


ON THE 16TH HOSPITAL                     AND
DAY , AN ELECTRO-
CARDIOGRAM SHOWED      PREMATURE                      AND
PROBABLE ATRIAL        VENTRICULAR
FIBRILLATION AT A      CONTRACTIONS
VENTRICULAR RATE OF                    POSSIBLE OLD     POSSIBLE OLD
100                                    INFERIOR         ANTEROSEPTAL
                                       MYOCARDIAL       MYOCARDIAL
                                       INFARCTS         INFARCTS
    SHML and NLP: Example #2.1
                    ®

*SID=NE1519 017A.11.01
ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE ATRIAL
FIBRILLATION AT A VENTRICULAR RATE OF 100 , WITH PREMATURE VENTRICULAR
CONTRACTIONS AND POSSIBLE OLD INFERIOR AND ANTEROSEPTAL MYOCARDIAL
INFARCTS .

<CONNECTIVE><CONJOINED><CONN><P>WITH</P></CONN></CONJOINED>
<PATIENT-STATE>
    <METHOD><PROCEDURE><T>AN</T><N><pr>ELECTROCARDIOGRAM</pr></N>
               </PROCEDURE></METHOD>
    <VERB><TV tense=“[PAST]”><show>SHOWED</show></TV>
            <EVENT-TIME><P>ON</P><T>THE </T><ADJ>16TH</ADJ>
                   <N><env>HOSPITAL</env></N><N><tmloc>DAY</tmloc></N> ,
            </EVENT-TIME></VERB>
    <PSTATE-DATA>
     <S-S><N><fns>FIBRILLATION</fns></N><P>AT</P>
          <MODS><MODAL><ADJ><mcer>PROBABLE</mcer></ADJ></MODAL>
                  <PTPART><ADJ><ans>ATRIAL</ans></ADJ></PTPART></MODS></S-S>
     <PTFUNC><T>A</T><N><fun>RATE</fun></N><P>OF</P>
          <MODS><PTPART><ADJ><ans>VENTRICULAR</ans></ADJ></PTPART></MODS>
        </PTFUNC>
     <QUANT><Q-N><NUM><Q><numb>100</numb><Q>,</NUM></QN></QUANT></PSTATE-DATA>
</PATIENT-STATE>
                                                                             next...
   SHML and NLP: Example #2.2
                   ®

*SID=NE1519 017A.11.01
ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE
ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100 , WITH PREMATURE
VENTRICULAR CONTRACTIONS AND POSSIBLE OLD INFERIOR AND
ANTEROSEPTAL MYOCARDIAL INFARCTS .

WITH
    ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED
      PROBABLE ATRIAL FIBRILLATION AT A VENTRICULAR RATE OF 100

<CONNECTIVE><CONJOINED><CONN>AND</CONN></CONJOINED>

<PATIENT-STATE>
     <PSTATE-DATA>
        <S-S><ADJ><H-INDIC><tmloc>PREMATURE</tmloc></H-INDIC></ADJ></S-S>
        <PTPART><ADJ><H-PTPART><ans>VENTRICULAR</ans></H-PTPART></ADJ></PTPART>
        <PTFUNC><N><H-PTFUNC><fun>CONTRACTIONS</fun></H-PTFUNC></N></PTFUNC>
     </PSTATE-DATA>
</PATIENT-STATE>
                                                                next ...
   SHML and NLP: Example #2.3
                   ®

*SID=NE1519 017A.11.01
ON THE 16TH HOSPITAL DAY , AN ELECTROCARDIOGRAM SHOWED PROBABLE ATRIAL
FIBRILLATION AT A VENTRICULAR RATE OF 100 , WITH PREMATURE VENTRICULAR
CONTRACTIONS AND POSSIBLE OLD INFERIOR AND ANTEROSEPTAL MYOCARDIAL
INFARCTS .

<CONNECTIVE><CONJOINED><CONN>AND</CONN></CONJOINED>
<PATIENT-STATE><PSTATE-DATA>
      <DIAG><N><H-DIAG><ft>INFARCTS</ft></H-DIAG></N>
          <EVENT-TIME><ADJ><H-TMLOC><tmls>OLD</tmls></H-TMLOC></ADJ></EVENT-TIME>
          <MODS><MODAL><ADJ><H-MODAL><mcer>POSSIBLE</mcer></H-MODAL></ADJ>
                 </MODAL><MODS></DIAG>
      <PTPART><ADJ><H-PTAREA><ppo>INFERIOR</ppo></H-PTAREA></ADJ>
               <ADJ><H-PTPART><as_cv>MYOCARDIAL</as_cv></H-PTPART></ADJ>
      </PTPART></PSTATE-DATA></PATIENT-STATE>
<PATIENT-STATE><PSTATE-DATA>
      <DIAG><N><H-DIAG><ft>INFARCTS</ft></H-DIAG></N>
          <EVENT-TIME><ADJ><H-TMLOC><tmls>OLD</tmls></H-TMLOC></ADJ></EVENT-TIME>
          <MODS><MODAL><ADJ><H-MODAL><mcer>POSSIBLE</mcer></H-MODAL></ADJ>
                 </MODAL><MODS></DIAG>
      <PTPART><ADJ><H-PTPART><ppo>ANTEROSEPTAL</ppo></H-PTPART></ADJ>
               <ADJ><H-PTPART><as_cv>MYOCARDIAL</as_cv></H-PTPART></ADJ>
      </PTPART></PSTATE-DATA></PATIENT-STATE>
</CONNECTIVE></CONNECTIVE></CONNECTIVE>
                                        Dictated encounter note:
This is the second clinic visit for this 28 year old right handed female who is followed for headache and neck pain
which began one year ago. Ms. xxx was last seen in Neurology clinic on 05/05/96. At that time I recommended
Motrin, 800 mg three times a day as needed and physical therapy.
Most recently she has continued to suffer neck pain. This is describe as an aching, burning type of pain on the
right side into the scapular. This usually occurs at the end of the day. Occasionally there is some kind of stabbing
pain in the back of the neck. She also believes that occasionally she has had some numbness in the triceps of her
left arm. She has suffered from no weakness, no urine or bowel problems and no kind of gait difficulities.
Current medications are Advil, 400 mg. at bedtime as needed. She has no known drug allergies.
On exam she carries her neck in a normal position. Her neck is supple and turns in all directions with full range of
motion and freedom of movement. Her trapezoid on the right is mildly tense. She has no point tenderness over the
spine. She has full strength in her arms and fingers. She has no altered sensation in her arms to pain, vibration or
light touch. Her reflexes are 1+ and symmetric in arms and legs with downgoing toes.
Overall my impression is that the neck pain is most consistent with a diagnosis of musculoskeletal pain.
She also suffers from a small herniated disc at approximately the C-5 level, however, symptoms are mild and
surgery would not be an option at this time. Therefore, I will defer an M1LI until danger signs such as bowel or
bladder problems, focal weakness or numbness which persists or point tenderness over the neck should present in
this young women
She was instructed to take Advil, 800 mg. three times a day and watch for any G.I. effects.
It is not clear that her pain she is currently suffering is changed in any way, rather it is the same low-grade pain
she has had for the past year but now she has resolved to get it taken care of.
Apparently she is being represented by a lawyer in the accident which is what this neck pain is from.
I recommend physical therapy and the patient was instructed to return to the clinic for a follow-up in three months
for repeat examination and further management.
                                                SHML® TAGGING
<Age>                28 yrs
<Gender>             female
<Time>               end of day
<Symptom>            pain <Quality> stabbing <Time.> occasional <Location> back of
                     neck
<Symptom>            pain <Verb> described as <Modifier> burning type of <Laterally>
                     right <Location>side <Radiating> into the <Location> scapula

<History Finding>    numbness <Location> triceps <Laterality> left
<History Finding>    weakness <Negation> no
<History Finding>    urine problem <Negation> no
<History Finding>    bowel problem <Negation> no
<History Finding>    gait difficulties <Negation> no

<Medications>        Advil <Dose> 400 mg <Time> current <Time> bedtime <Frequency>prn
<Allergies>          drug allergies <Negation> no known

<Physical Finding>   normal position <Location> neck
<Physical Finding>   supple <Location> neck
<Physical Finding>   range of motion <Location> neck <Amount> full
<Physical Finding>   freedom of movement <Location> neck
<Physical Finding>   tense <Modifier> mildly <Location> trapezoid <Laterality> right
<Physical Finding>   point tenderness <Negation> no <Location> spine
<Physical Finding>   strength <Amount> full <Location> arms
<Physical Finding>   strength <Amount> full <Location> fingers
<Physical Finding>   reflexes <Result> l's <Location> arm
<Physical Finding>   reflexes <Result> l's <Location> toes
      SHML® Tagging of Encounter
• Demographic     28 y/o female



• Symptoms        Stabbing, aching, burning pain, back of neck
                  Pain radiating to right side into scapula
                  Pain occurs occasional, usually end of day
                  Numbness of left triceps occasional

• History         No urine problems
                  No bowel problems
                  No gait problems


• Allergies       No drug allergies
        SHML ® Tagging (cont’d)
Medications     Advil, 400 mg.hs,prn


Physical Exam   Neck, normal position
                Neck supple
                Neck full range of motion
                Neck freedom of movement
                Right Trapezoid mildly tense
                Spine no point tenderness
                Arms, full strength
                Fingers, full strength
                Arms 1+ reflexes
                Legs 1+ reflexes
Impression      Musculoskeletal pain
                Herniated disc, C-5 level, small symptoms mild

Plan            Surgery not an option at this time
                MRI deferred until/should
                             bowel findings
                             bladder findings
                             focal weakness (which persists)
                             focal numbness (which persists)
                             point tenderness(neck)
                Anvil 800 mg.tid, watch for G.I. side effects
                Physical therapy
  Potential of SHML Approach®




• Ability to Resolve Ambiguity
• Ability to Deal with Multiple Hierarchies
                NLP / SHML ®

Depression
     <fs psy>           psychological
     <ft>               depression of surface, shape
     <mcha>             depression of WBC, platelet

 “ST segment depression” - idiom (phrasal term)
                  NLP / SHML ®

  EKG         revealed     sinus     bradycardia
<pr cv ekg>   <show>                  <fs cv>

                         <as cv>     Heart
                         <as resp>   Repiratory
                         <as mss>    Within bone
                         <ft>        Rectal sinus, (fistula)
     Use with Structured Data Entry
Chest Pain
   Onset                  tmbeg
             # hrs ago
             # days ago
    Duration              tmd
             20 min
             1 day
    Location              A.S.
    Laterality            ppo-lat
    Character             fi-SS-
    Brought on by         fac
    Associated with       fi-SS
    Aggravated            li
    Relieved by           li
    Severity              mamt
    Radiating to          li
    Trend                 fres
     Structured Health Markup Language
                SHML ® /XML
• Adopt rules, notation that are in place for SGML/XML for the
  medical record (PMRI)
• Create an architecture for data types
   – Structure the EMR
• Utilize XML rules, notation for content (semantics)
   – eXtensible Markup Language (XML)
• SHML/XML works with language; it does not reinvent it!!!
• XML provides structure and contextual meaning to a document
• XML is a self describing data structure
STRUCTURED HEALTH MARKUP LANGUAGE
              SHML®

     • Subcomponent of XML
     • Health DTD for validation tags and their rendering
     • Tags assigned to terms/phrases and CRCUs
        – Tags specific for health
        – Tags specific for NLP
     • Structured
        – Defines a syntax of tags
        – Rules of well-formedness
     • XSL eXtensible Style Language for rendering
 SHML vs MLP elementType’s
            ®


• MLP (syntactic) part-of-speech elementType’s are
  based on major word classes, e.g. nouns (N),
  adjectives (ADJ), tensed verbs (TV), adverbs
  (D),… E.g. shortness of breath, <N>;
• MLP co-occurrence semantic elementType’s are
  based on word usage (context), e.g. shortness of
  breath, <H-INDIC>;
• SHML semantic elementType’s are based on
  medical knowledge (classification), e.g. shortness
  of breath, <fs_resp>.
               SHML® DTD for CRCU’s
<? XML VERSION=“1.0 ?>
<!DOCTYPE STRUCTURED HEALTH MARKUP LANGUAGE “shml.dtd”>
<!ELEMENT PATIENT-STATE
                (PARAGR, PT-DEMOG, METHOD, SUBJECT, VERB, TENSE,
                 PSTATE-DATA, PRECISIONS, TIME, TEXTPLUS)>
<!ELEMENT PATIENT-TREATMENTS
                (PARAGR, PT-DEMOG, TREATMENT, STATE-SUBJ, PRECISIONS,
                 TIME, TEXTPLUS)>
<!ELEMENT LABTEST
                (PARAGR,PT-DEMOG, INST, PT, TEST-INFO, VERB, TIME,
                 TEXTPLUS)>
<!ELEMENT PARAG (#PCDATA)*>
<!ELEMENT PT-DEMOG (AGE, RACE, SEX, FAMILY)>
<!ELEMENT AGE (#PCDATA)*>
<!ELEMENT RACE (#PCDATA)*>
<!ELEMENT SEX (MALE, FEMALE)>
<!ELEMENT MALE (#PCDATA)*>
<!ELEMENT FEMALE (#PCDATA)*>
<!ELEMENT METHOD (PROCEDURE, EXAMTEST, DEVICE)>
<!ELEMENT TREATMENT (GEN, CHIR, MED, COMP)>
<!ELEMENT PROCEDURE (#PCDATA)*>
<!ELEMENT EXAMTEST (#PCDATA)*>                                     ...etc.
    Presentation of Data (Reformatting)

An echocardiogram performed in the Coronary Care Unit
shows dilated left atrium, moderate global LV dysfunction,
ejection fraction of 30%, moderate global RV dysfunction,
severe mitral regurgitation.

    pr cv:                Echocardiogram
    Env (place):          CCU
    Finding cv:           Dilated left atrium
                          Moderate global LV dysfunction
                          Ejection fraction 30%
                          Moderate global RV dysfunction
                          Severe mitral regurgitation
     Mission of HLC / SHML                        ®


• Define a granular representation of terms and phrases that
  within a given language (domain) unambiguously define
  clinical concepts
• Provide for an adequate representation of these terms and
  concepts in a simple and easily understood architecture
• Provide for discrete mapping to any other “nomenclature”
  and/or “code set”
• Utilize easily available, inexpensive and widely supported
  tools for authoring, maintenance and use
• Provide this as a non-proprietary standard under the
  auspices of a private not-for-profit entity

				
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