Modeling of Multidisciplinary Tumor Board Meetings

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At Karolinska University Hospital, we have just initiated a project with the goal of enabling openEHR-based primary documentation for multidisciplinary tumor board meetings in lung cancer care.

I have been in contact with @amanda.herbrand , who conducted a proof of concept to evaluate openEHR as a standard for data persistence in multidisciplinary tumor boards. But we are also interested to know if anyone else has worked on similar modeling projects. We would love to hear your experiences, thoughts, and ideas regarding MDTs

I will share our ideas, thoughts, and progress as we move forward with the project

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There has been, and still going on, a cross-regional work in Norway regarding documenting cancer in general, including the Multidisplinary team meetings/boards. There should be a possibility to develop structures suitable for all types of cancer and across health service providers (“hospitals”), regions and countries. Most of the archetypes already exists.

Pinging my colleagues on this, including our vendor (DIPS ASA): @Liv_Laugen @Christine_Mikalsen @JuneMarieKnappskog @kanika.kuwelker @John_Tore_Valand @bna , who could be relevant to include in a collaboration on this.

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Sounds interesting. In the U.K. there are a lot of cancer MDTs. I could see this being relevant cross borders.

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Update and modeling questions

For our MVP, we are focusing solely on the actual MDT meetings (lung cancer and solid tumors in childhood cancer). We have started identifying the information relevant to lung cancer MDTs (attaching an X-mind file) and have divided it into two main parts:

  1. Information that serves as the foundation for determining the treatment strategy, i.e., information created earlier in the process.
  2. Information that includes assessments (TNM classification, staging, etc.) and the recommended treatment strategy—this is the information actually created during the MDT meeting.

I would appreciate insights regarding how to best handle the “recommended treatment strategy.”

I have two main questions:

  1. Is the “recommended treatment strategy” best represented as an evaluation or an instruction archetype?
  2. Should this be a new archetype?

When looking at the “Clinical Investigator Recording Process,” I find it challenging to determine whether the “recommended treatment strategy” fits better as an evaluation or an instruction archetype.

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Possible Arguments for Each Approach:

The information sometimes includes more detailed elements, such as dosage and frequency, which might suggest it being an instruction. However, this information is still in the form of a recommendation. And since it is merely a recommendation and not an actual instruction, evaluation might be a better choice. In fact, there is an existing evaluation archetype called “recommendation,” which could have been appropriate, but it lacks slots for adding more detailed information.

I have reviewed the instruction archetype “Service Request,” which includes relevant data elements and, from that perspective, could be a good archetype to use in this case. However, my understanding is that after the MDT meeting, once the “recommended treatment strategy” has been established, concrete requests will be made—for example, for surgery or medical oncology treatment. These requests then function as actual instructions. This might suggest that the “treatment strategy” itself is more appropriately categorized as an evaluation.

I would love to hear your thoughts on this!
(Primärdiagnostisk) MDK LOC.xmind (334.1 KB)

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Hi Oscar! If the only reason EVALUATION.recommendation can’t be used for this purpose is that it’s lacking a slot for ‘Additional information’, I’d suggest adding that slot. In fact, this is almost a standard slot in many new archetypes for generic clinical concept such as this.

If this makes sense to you, feel free to add a change request for this archetype to add the slot :smile:

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Maybe I hadn’t fully thought this through. The cluster archetype I would use to fill the slot would need to be a new archetype containing much, if not all, of the information regarding ‘treatment strategy.’ I suppose it doesn’t really make much sense to use the EVALUATION.recommendation then. However, the INSTRUCTION.service_request, I believe, contains all the necessary data elements for treatment strategy. I just couldn’t quite understand if the information should be categorized as EVALUATIONor INSTRUCTION. But maybe I’m overthinking this? I’m not sure I fully understand the consequences of choosing EVALUATION or INSTRUCTION.

Either way, it makes sense to have a slot in EVALUATION.recommendation :smile:

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Quick reply as Im travelling. We definitely see this as needing some sort of summative evaluation. Evrn if this is partiallly executed via instructions and actions., the teatment plan itsrlf sits at a higher level. Eg the treatment plan will define the SACT regime but not individual dosages or specific schedules.

Recommendation coild work but so dar our understanding is that the content is really quite complex so we devised a specific treatment plan archetype which we will share. Wd could convert to a cluster but the recommendation wrapper would be very lean.

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Checkout:
Use Case Onkologie incubator.

We had exactly this use-case in HiGHmed, some of these are outdated or need more love, we are still working on a backflow ( @Leo can maybe say more about this ) of some of the archetypes (genomics archetypes on the international ckm where e.g. done as part of this together with other members of the community CRS4 …) .
Here is the template the colleagues did for the MTB recommendation itself maybe its of any help :wink:

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I wasn’t directly involved in the project myself, but there is such a project in the HighMed CKM. Feel free to reach out to me if you’d like to access it, or you can contact my colleague who was directly involved in the project. We modeled the MTB recommendation as an EVALUATION class. There is also an archetype available here: https://ckm.highmed.org/ckm/archetypes/1246.145.1454.

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We have a very similar requirement coming up - which is an MTB recommendation for ‘Genetic cancer risk’ (usually on the basis of a tumour sample from an index case).

I’d still definitely see this a some sort of Evaluation / recommendation and not an Instruction. So I guess it then comes down to whether there is any advantage to specialising/ extending the generic Recommendation archetype, or whether the MTB Recommendation(s) are so specific that a specialisation (or cluster extension) is not really that helpful.

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Hi again,

This is an archetype I’ve created to record the treatment recommendation agreed upon during an MDT meeting. It’s based on my understanding of the information typically documented in this context, and how that information is structured and connected.

I hope it makes sense, and I’d really appreciate any feedback or thoughts you might have. :slight_smile:

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Hi Oscar,
Can you share the archetype, just for reading? From Archetype Designer, click the share-button, and paste the link here.
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As my AD is connected to a GitHub repository, I don’t have the share-button. But I hope this is useful.
openEHR-EHR-EVALUATION.cancer_treatment_strategy.v0 (2).adl (10.2 KB)

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Copied to my account in AD. The link will die after a while, don’t remember for how long it will be active.

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Good move … It is worth setting up a specific seperate AD account for this purpose?

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Or maybe a “codebin for archetypes and templates”?

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Coming late to this party, but I have a few observations…

How you represent such things depends on their content. If the ‘strategy’ is literally just an assessment of some kind i.e. a judgment that a certain general treatment pathway should be followed, then it is some kind of ‘Evaluation’. If it takes the form of worked out orders (e.g. for chemo, with dosages & timing etc determined), then it is some kind of ‘Instruction’.

Having looked at a few of these kinds of things in the past, I would expect it is really more of a Care Plan, which will be some combination of the following:

  • assessment / diagnosis (probably referring to some already reached diagnosis)
    • = citation/ reference to prior Evaluation
  • recommended treatment pathway in general terms for this patient, e.g. surgery + chemo but no radio
    • = Evaluation representing a recommendation
  • goal(s)
    • = Evaluation representing goals
  • order(s)
    • for surgery
    • headline order for a specific chemo protocol
    • any other Rx, therapy
  • etc

We don’t need all the details here, I’m just pointing out that you probably want to consider all the information relevant to the condition not just the notion of a ‘recommendation’ in isolation.

However, it doesn’t stop there obviously. The chemo part will take the form of order sets and a ‘Plan’ for administration, e.g. for Ewing’s Sarcoma, alternating cycles of vincristine/doxorubicin/cyclophosphamide and ifosfamide/etoposide (VDC/IE). openEHR currently has nothing that directly represents either ‘order set’ or Plan. For the former, you can get by with a Composition containing Instructions, possibly with relevant Observations, e.g. of weight, body surface area etc, and any dose modifications from the standard form of the chosen protocol.

For the Plan, we ideally would use the Task Plan representation (see RCHOPS-21 plan here) You’ll see this Plan structure consists of Tasks, Wait states, Decision nodes and Events.

Outside of Task Planning (not yet implemented), there is no direct representation of these things available. The best you could do is represent the orders using Instructions above, and then the actual administrations using Actions (and any related Observations, e.g. patient reactions etc), but you have no easy way to represent the Plan.

Some of us have plans to make Plans a reality in the near future, but it’s not there today.

I would still recommend looking at the overall picture, since this ‘recommendation’ item is just one fragment in the overall picture.

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