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EHR Clinical Forms: Requirements

The caBIG® Clinical Information Suite is a form driven system for data entry by physicians, nursing staff, and ancillary providers. Changes in the health care landscape across the United States over the last several years has led to new requirements for data structure and semantics. These new requirements have led to the need to deal with "meaningful use" semantics in our form structures. One prominent requirement is the need for any EHR system to use the new semantics in order for providers using these systems to be paid for the care they provide to particular patients. Hence lack of adoption of these data standards could lead to diminished availability for cancer patient care if the physician market shrinks through financial attrition.

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The EHR Clinical Forms use case has two primary goals. The first goal involves a form designer and construction of a clinical data entry form for use in the graphical user interface of the caBIG® Clinical Information Suite. This form must be semantically consistent and based on HL7 Reference Information Model (RIM) objects, HL7 structural vocabulary, and Office of the National Coordinator (ONC) required code systems for meaningful use. (caBIG® wishes to adhere to regulations /and rules from the ONC). The second goal involves the data entry person (a physician, nurse or other health care provider) who defines the value set requirements for the form elements, identifies the rules for skip patterns and form element arrangement, and eventually enters and persists clinical data.

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A user of the caBIG® Clinical Information Suite uses the 7th Edition of the American Joint Committee on Cancer (AJCC) Cancer Classification system to stage cancer patients. The 8th Edition has now come out and the user would like to upgrade the system to meet the requirements of the state cancer registry. Re-coding the infrastructure for all cancer types in Java is expected to be quite expensive and time consuming. The user queries the ECCF registry for "AJCC Cancer Classification" and finds a plugin reasoner service that implements an OWL version of the AJCC 8th Edition classification system capable of inferring an anatomic stage based on data directly from pathology, imaging, and clinical exam input through a service. The user's system is now able to move with the speed of Cancer Registry requirements rather than the pace of the software vendor.