Saw Ginger Baker’s African Jazz Confusion the night before last at Ronnie Scott’s in London [I had made a longer post, but it was trashed by WordPress]. Suffice to say a great experience: with Abass Dodoo (Ghana; can’t wait to see him again somewhere) on African percussion, Alec Dankworth on bass (great musician, wonderful rhythmic and melodic sensibility) and Pee Wee Ellis (a legend in his own right – ex-James Brown, Van Morrison, many others) on sax.

I love Ginger Baker’s style – his rolling, bounding river of beats just goes on and on, giving real movement and emotion to the music. This isn’t esoteric jazz or academic jazz drumming, this is something that taps into an underground river of rhythm and makes you want to get up and move, and start hitting some drums yourself. Younger ‘musicians’ and bands take note.

I have to admit I have never been able to understand the logic of the CDA design. The general idea is that a CDA (Clinical Document, defined by the HL7 Clinical Document Architecture standard) must have ‘narrative’ sections containing text, and can optionally have ‘structured’ data sections containing equivalent structured form of the data. Here it is in more detail, from [1], my bolding:

A CDA document section is wrapped by the <section> element. Each section can contain a single “narrative block” and any number of CDA entries and external references. The narrative block is a critical component of CDA and must contain the human readable content to be rendered. It is wrapped by the <text> element within the <section> element and contains XML markup that is similar to XHTML. The “originator” (defined as the application role responsible for creation of a conformant CDA document) must ensure that the attested portion of the document body is conveyed in narrative blocks such that a recipient, adhering to recipient rendering rules, will correctly render the document. This process ensures human readability and enables a recipient to receive a CDA document from anyone and faithfully render the attested content using a single style sheet.

Within a document section, the narrative block represents content to be rendered, whereas CDA entries represent structured content provided for further computer processing (e.g., decision-support applications). CDA entries typically encode content present in the narrative block of the same section… These entries are derived from classes in the RIM and enable formal representation of clinical statements in the narrative.

While the narrative blocks must always be present, the CDA entries are optional. An originator of a CDA document is not required to fully encode all narrative into CDA entries within the CDA body, nor is a recipient required to parse and interpret the complete set of CDA entries contained within the CDA body. Within an implementation, trading partners may ascribe additional originator and recipient responsibilities to create various entries and may create various templates and/or implementation guides that require the use of various entries. As a result, CDA R2 can be relatively simple to implement (i.e., just narrative blocks) or can be relatively detailed to implement (i.e., with the inclusion of many rich and expressive entries) and provides a migration pathway toward progressively richer computer-processable content.

There are various things to contemplate here. The most obvious is that CDA provides a persistent place for two representations of the same data. While this might be done as an optimisation in some health information database, it doesn’t make sense in an application-level information artefact like a CDA. One would normally have expected that either a) there was structured content which could be rendered by some algorithm into text (a commonplace feature of software applications in all industries) or that there was just b) narrative content. To achieve this, all that is needed is a single information model, that accommodates variable structuring of data (typically in a tree structure of name-value pairs). The simplest case will be a single element containing a potentially large amount of text (+/- some formatting, assuming such markup is allowed). More structuring just means more elements, most likely with the text either represented in native forms (e.g. quantities & units) or simply sliced up into smaller fragments (e.g. patient answers to separate questions).

From the quote above, it is clear that the intention of the CDA design is that the (structured) entries ‘encode’ the narrative content. It is hard to see what this really means. What would make sense would be if the narrative block were a (reproducible) text rendering of the structured data. One reason you might want to do this is to ensure that what was rendered on the screen was guaranteed to be the same no matter where the CDA document was sent. Fair enough. In that case, the rules of CDA would have to be:

1. Where there is structured data present, the narrative block must contain a faithful and standardised rendering of the structured part into an accepted HTML or XML form that everyone agrees to trust, generated by a published, standardised algorithm (the version of the algorithm probably should be included in the block).
2. Where there is no structured text, the narrative block stands on its own (but see below)…
3. Clinical sign-off is done on the narrative block, rendered to the screen (otherwise there is no purpose to the narrative block).

According to these rules, CDAs should be medico-legally safe. Note that a standardised algorithm is required for producing the narrative part. Without this, there is no guarantee that two sites producing the same structured content would generate the same narrative. There are other requirements of the algorithm: it must be ‘complete’ in the sense of rendering all the information present in the structured part to the screen, i.e. not hiding any of it. Further requirements would relate to the details of doing this properly. (Note that this is not the only way to render data and get sign-off – a common alternative is to render structured data in a near-to-native tree structure, with each atom being turned into text by a simple agreed transform. More on this below.)

But it didn’t have to be like this. A safer design for CDA would have been:

• to have a structured part, in which the primary data are always placed, even if the data are just a single narrative block of text, contained in a single text atom.
• if ‘standard rendering’ was necessary, the ‘narrative’ block (better to call it a ‘rendered block’ or similar) would contain the standard rendering of the structured section, generated using the published standard algorithm.
• various exceptions to generating the narrative block would then be allowed:
  • if the structured content were just a single atom of text, the narrative could omitted, and assumed to be the same as this already stored atom of text (but note: one has to be very careful about what a text field contains: it might be some funny XML, HTML, or even worse, some wiki markup, base64 rendered binary or who knows what – therefore ‘text’ would have to be carefully defined);
  • if all parties using the CDA were in possession of the standard rendering algorithm and appropriate software to use it (but this is difficult to know, since the CDA might be stored and used years later by unknown parties);
  • if all parties using the CDA agree that they would render the information in specific ways (this is not so dumb: getting safe signoff of clinical data doesn’t actually rely on the data being displayed in identical ways to all parties, but in the most natural way for the relevant speciality or individual).

Now, I happen to know that some of the key CDA designers are clinicians, and keenly aware of medico-legal and safety issues. I can only conclude that the committee-based standards process is responsible for the strange design of the CDA, which can clearly be easily abused by parties not following rules like the above. It may well be the case that someone in the CDA community has already formulated such rules. If they have, they should be published in an update of the CDA standard as soon as practically possible, including a standardised rendering algorithm.

For now, users of the CDA standard like Nehta and other bodies around the world should create local policy based on the considerations above, and formulate a watertight set of rules guaranteeing safe data.

I personally don’t agree with storing the generated result of such an algorithm at all; this would only make sense if CDAs were to be stored in the very long term, with no assumptions made about future users. But CDA is not a very useful format for that purpose, and was not designed for it. Instead, CDAs should be converted to an EHR information architecture that accounts for longitudinal patient records, distributed versioning, and model-based semantic marking.

Here is the public announcement resulting from this meeting.

[press release from the CIMI group]

The Clinical Information Modeling Initiative is an international collaboration that is dedicated to providing a common format for detailed specifications for the representation of health information content so that semantically interoperable information may be created and shared in health records, messages and documents. CIMI has been holding meetings in various locations around the world since July, 2011. All funding and resources for these meetings have been provided by the participants. At its most recent meeting in London, 29 November – 1 December 2011, the group agreed on the following principles and approach.

Principles

1. CIMI specifications will be freely available to all. The initial use cases will focus on the requirements of organisations involved in providing, funding, monitoring or governing healthcare and to providers of healthcare IT and healthcare IT standards as well as to national eHealth programs, professional organisations, health providers and clinical system developers.

2. CIMI is committed to making these specifications available in a number of formats, beginning with the Archetype Definition Language (ADL) from the openEHR Foundation (ISO 13606.2) and the Unified Modeling Language (UML) from the Object Management Group (OMG) with the intent that the users of these specifications can convert them into their local formats.

3. CIMI is committed to transparency in its work product and process.

Approach

• ADL 1.5 will be the initial formalism for representing clinical models in the repository.
• CIMI will use the openEHR constraint model (Archetype Object Model:AOM).
• Modifications will be required and will be delivered by CIMI members on a frequent basis.
• A set of UML stereotypes, XMI specifications and transformations will be concurrently developed using UML 2.0 and OCL as the constraint language.
• A Work Plan for how the AOM and target reference models will be maintained and updated will be developed and approved by the end of January 2012.
•  Lessons learned from the development and implementation of the HL7 Clinical Statement Pattern and HL7 RIM as well as from the Entry models of 13606, openEHR and the SMART (Substitutable Medical Apps, Reusable Technologies) initiative will inform baseline inputs into this process.
• A plan for establishing a repository to maintain these models will continue to be developed by the group at its meeting in January.

Representatives from the following organizations participated in the construction of this statement of principles and plan

• B2i Healthcare www.B2international.com
• Cambio Healthcare Systems www.cambio.se
• Canada Health Infoway/Inforoute Santé Canada www.infoway-inforoute.ca
• CDISC www.cdisc.org
• Electronic Record Services www.e-recordservices.eu
• EN 13606 Association www.en13606.org
• GE Healthcare www.gehealthcare.com
• HL7 www.hl7.org
• IHTSDO www.ihtsdo.org
• Intermountain Healthcare www.ihc.com
• JP Systems www.jpsys.com
• Kaiser Permanente www.kp.org
• Mayo Clinic www.mayoclinic.com
• MOH Holdings Singapore www.mohh.com.sg
• National Institutes of Health (USA) www.nih.gov
• NHS Connecting for Health www.connectingforhealth.nhs.uk
• Ocean Informatics www.oceaninformatics.com
• openEHR Foundation www.openehr.org
• Results4Care www.results4care.nl
• SMART www.smartplatforms.org
• South Korea Yonsei University www.yonsei.ac.kr/eng
• Tolven www.tolven.org
• Veterans Health Administration (USA) www.va.gov/health

Further Information

In the future CIMI will provide information publicly on the Internet. For immediate further information, contact Stan Huff (stan.huff@imail.org)

The Vortex in Dalston is another such place – it fits about 18 guests, and yet you can see some true jazz greats (in fact Dalston is weird – it has two venues – the Vortex and Cafe Oto hosting mostly free jazz. Now personally I mostly think FJ is a crime against humanity, but sometimes when you close your eyes and listen to some anti-musical group there, you really do believe you are in a forest full of crickets or on a moon of Jupiter). The Round Midnight bar at Angel is another fun little place – not quite so eclectic and the floor is stickier, but hey, I never saw a bad gig there.

Back to the Bulls Head. This week just gone, Never the Bride played on Thursday night. I had heard of them before, but never had the experience, as I surely would have had I been brought up in this country or at least spent the last 20 years here. I looked up a few of their YouTube clips and was amazed. This band is the real deal. Have a look at this cover of Kashmir (it’s worth it, no don’t complain that the original can’t be bettered, it’s not about that), in fact just put ‘Never the Bride’ into YouTube and listen to anything that comes up.

At the gig, the proliferation of stage gear meant at least 5 musicians, possibly going on 16. Possibly more than the audience. (One night a couple of years ago, I saw a Steely Dan cover band there, 9 players on the stage, with cables and instruments overflowing off the edge. They were great too – just like Steely Dan, I don’t think there was a bar of 4/4 anywhere to be heard). It turned out that NTB were 5 this gig, plus they brought a bunch of mostly interesting guests onto the stage during the evening, which was fun, but to be honest, there really wasn’t any comparison. NTB play like a band that could punch holes in Wembley Arena (not that I like Wembley. It’s crap. Outdoor is nice. Pubs are nice….).

Anyway, NTB’s two leading ladies, Nikki Lamborn and Catherine Feeney are something else. Nikki is in somewhat in the Janis Joplin/Bonnie Raitt mould, a real rock singer with huge dynamic and emotional range (I actually hate those sort of comparisons, just giving you an idea here…. she’s probably better…). Feeney (mostly a keyboardist) is the rhythmic/melodic motor, and I am not talking outboards here. This is where being at the tiny Bulls Head really works – keyboard players get a proper grand piano to play on, which makes for total clarity and raw beautiful power. I hadn’t seen any of the other musicians before but they were all first class – you can find out about them here.

I suspect I will become one of the ‘hooked’… I am already combing the guides for next gigs (e.g. Farnham 8 Dec). What is weird about this experience (and some other bands you see at the Bulls Head) is that you sort of know you are seeing the same thing as big name rock royalty – you know you should not be able to get this close, it feels a bit naughty to be able to go and see greatness in your living room. Well, all I can say is …. don’t tell anyone!

So if you want to see some really great rock with soul, go and see Never the Bride.

BTW, thanks as always to the people at the Bulls Head. They are always cool, friendly, the guy on the desk knows how to mix perfectly for a small venue, the selection of wine and beer is decent, what more to say?

Melancholia (dir. Lars von Trier): *** We need to talk about Kevin (dir. Lynne Ramsay) ***** The battle of Warsaw: 1920 (dir. Jerzy Hoffman) *** Incendies **** (dir. Denis Villeneuve) Tinker, Tailor, Soldier, Spy **** (dir. Tomas Alfredson) The Skin I Live In **1/2 (dir. Pedro Almodovar) The Debt ***1/2 (dir. John Madden).

Melancholia (dir. Lars von Trier): ***. What was Lars von Trier thinking? Well in the first half of the film, it seems clear enough, actually. Everything is there: the background of doom, the human events, the unfolding realisation that all the female characters are mad… The images are often beautiful, save one great yawning missed opportunity: if a giant planet is THIS CLOSE to earth (any planet sufficiently close is giant), wouldn’t it be beautiful, by its alien nature, its colours, the sheer fact of a sister planet being RIGHT THERE? But Lars gave us some cheap video effect instead. What was he thinking? The second half tottered on, the feeling of doom well exhausted by the 2/3 point. I think Kifer Sutherland may have had this on his mind when he offed himself. Don’t get me wrong, I am in the club of 28 people worldwide who sort of love LvT, even though all his films are a bit sick. He could have done better though, even on his own terms.

We need to talk about Kevin (dir. Lynne Ramsay) *****. This is one of those rare masterpieces of disturbing psychology that makes you start looking differently at ordinary people on the street. Tilda Swinton really produces a perfect performance: a mother who tries to love her child while hating him for hating her, for being so damned incomprensible, while loving him in those few moments when she seems to be able to imagine the chaos and fear that must be his internal world.

By a stroke of luck I saw this film without knowing the story so had the pleasure (if you can call it that) of being blown away in the same way as the rest of Kevin’s family in the film by the horror of his actions. The genius of the film is that you get to the final act (possibly with nothing left of your fingernails), and to realise that everything you have seen up until then is completely seamless with the denouement. It has probably written a new chapter on how to deliver all the information in a completely natural way, at the right time and the right place, without the viewer realising anything, and then at the end you think: oh god, of course, all the signs were there.

The battle of Warsaw: 1920 (dir. Jerzy Hoffman) *** This epic Polish film is disorganised and over-ambitious, but riveting viewing – entertaining, educational and not without charm. My IMDB review.

Incendies **** (dir. Denis Villeneuve). Although pushing the boundary of credibility, this film feels real, and viscerally captures the personal horrors of victims of war in Lebanon, and in middle east conflicts in general. War seems to equal not just violence, but chaos – the breaking of every possible social rule and structure imaginable. It turns men into beasts, but the beasts still have souls, so do their victims, not all of whom are men…

Tinker, Tailor, Soldier, Spy **** (dir. Tomas Alfredson). I’m not into spy novels as such, but enjoyed this film no less for it. It really feels like a le Carre novel – in this spy world, heated arguments in MI5 rooms and rented apartments full of dusty files are the foreground to the main game, the nasty and brutal events taking place out in the real world. Wonderful performance by Gary Oldman, also Colin Firth, and a rakish Tom Hardy. First rate.

The Skin I Live In **1/2 (dir. Pedro Almodovar) . Stylish, well acted, but the story doesn’t really work. But one has to keep watching anyway – you never know if it will make sense by the end or not. Antonio Banderas shows (yet again) what a great actor he is (seems he can do any genre). Pedro: like Lars, you are also a bit sick, in a way that lots of people love, sort of. But here you were pushing it. Get back to Flower of my Secret, Volver, Hable con Ella please. Actually, that was a bit sick too…

The monstrosity of Christ is the love either in paradox or in dialectics – and I believe, may be the pathway beyond the current popular-absolutist rule of finance, spectacle, and surveillance.

Although we can argue about the faith part of this (or even reject it out of hand), the two sides this statement resonate nowhere better right now than at tent city in the forecourt of St Paul’s cathedral, in the heart of the City of London.

By a stroke of luck my companion and I happened upon a talk entitled ‘The Corporate Governance of the Square Mile’ led by George Monbiot, John Christensen, and a Father Taylor, and so we spent the next 90 minutes inside the ‘Tent City University’ straining to hear a discourse that went right to the core of what is rotten in the city of London. The particular topic – the Corporation of the City of London (itself an archaic structure cunningly serving the needs of London square mile financial overlords and protected more by opaqueness than power) – is just a detail in the overall story of the economic disaster in which we find ourselves today. Stuart Fraser, Chairman of the Corporation of London had also come (into the lion’s den, so to speak) to right what he felt were/would be misspoken half-truths about the Corporation. Well done for that. A debate needs both sides present.

The talks were worthwhile (Rev. Taylor who has worked within the corporation of London, and spoke eloquently on it), and I will probably revisit the tent city for more. Everyone was civil, despite the yawning gulf between Monbiot et al (recent article on the Corporation of the City of London), and Fraser (who replies here to some accusations).

What struck me today was the composition of the audience, as well as the speakers. There is always a segment consisting of people boiling in furious rage (and I can’t necessarily judge them for it – for my own subjective reaction to the slow-burn fiasco of the state of the planet is one of dejected detachment – and that is hardly more defensible) who fail to make it past the expression of such emotions, and enter meaningfully into a discussion. Which means that rather than doing research, learning facts, and constructing analyses and arguments, they make noise. They are the voice of all of us, if we simply want to express rage. Yes, there were a few of those. But mostly, the crowd was educated, over 40, and articulate. Dressed just like me. Everyone seems to know that the whole game is rotten. We just can’t see how to act.

The sad thing I felt is that on the steps of St Paul’s this afternoon there was an awful lot of human intelligence, going unheard. What great debates could these 200 or so people entertain? We’ll never know, because there is no place for intelligent, normal people to effectively discuss the problems of the day, much less produce decisions on what to do about it. The best we can do is hope that our friendly neighbourhood iconoclasts such as Monbiot say the right things for us. But it really isn’t good enough. Such people can only articulate their view, and what they see as the priorities. We really need to do better.

My suggestion on how is to consider the main topic: money. We need to make individual efforts on a) understanding the monetary system (earlier in the day I bought a book called ’23 Things they don’t tell you about Capitalism’ by Ha-Joon Chang – as good a place to start as any) and b) start thinking about how to overturn it. No, I don’t mean in some incoherent revolutionary way, I mean by subtle means available to us, including digital currencies and local currency systems. I will elaborate on these in later posts.

For now – on a Sunday – it seems appropriate (irreligious though I am) to meditate on the deep malaise at the heart of today’s civilisation, and the tiny hope I have when I see hundreds of people just like me spending their evening at St Paul’s, not inside in the anaesthetised comfort of worship-as-usual, but outside in the blasting wind among the tents of the younger generation, looking for a different kind of salvation. I have a feeling that only we can create it.

To the tent-dwellers: I salute you. Maintain the rage.

Acknowledgement: Adriána Daniláková for the great photos

I created two slideshows to explain my views on these matters (DCM_and_data_types and DCM_and_reference_model [both PDF]). Below is an extract of my arguments in these slideshows, based on experience, for adopting a particular approach to data types and reference model within the stated mission the DCM forum, which is to find formalism and attendant models in which to express universally shareable detailed clinical models. Naturally, my view on ‘the answer’ to that question is ‘openEHR (ADL/AOM) archetypes, templates and terminology’, but what I am providing below is not an argument supporting that, but one proposing how to proceed with respect to the ‘underlying models’.

[The following are extracts from the above slideshows; you don't need to read both]

Basic concepts

Assumptions

• DCMs are based on an underlying model (ULM), rather than each being an independent model (e.g. Classes, RBD tables) for domain definitions
• DCMs are not themselves part of the software (although some generated artefact might be)
• This is the raison d’être for DCMs –to get out of the mess of endlessly growing and unmaintainable software and databases
• We assume that the ULM provides a shared definition of data and (some) semantics, i.e.
• Basis of at least data interoperability
• And potentially software interoperablity
• Therefore… DCMs cannot ‘break’ the ULM

‘Based on an underlying model’ means:

• The underlying model provides the ‘primitives’ needed for DCM modelling
• DCMs don’t have to redefine these primitives
• The underlying model provides commonly required patterns for doing DCMs

The golden rule:

• Every instance of a DCM element is also a valid instance of the corresponding ULM element
• Breaking this rule means:
• non-interoperable DCM instances
• No assumptions can be made by software

Data Types

The need for clinical DTs is well-known in health informatics, and everyone agrees that types such as are required:

• Identifiers
• Text, coded text
• Various quantity types, Ordinals, Dates, times, durations
• Time specification types
• Multimedia / encapsulated data
• Esoteric types

Possible starting points for DCM

• Existing published models?
• ISO 21090 / HL7v3
• openEHR
• Grahame Grieve’s Resources For Health data types
• A proprietary model, brought into the open?
• Intermountain Health
• A de novo model we build for DCM

My analysis then follows. My recommendations:

• Decide on a starting point that everyone can at least agree as the starting point!
• E.g. Grahame’s DTs
• Work on this to ensure it covers required types
• E.g. Some missing ones from openEHR –DV_PROPORTION
• Missing types from HL7/21090
• Then…. Determine a minimal definition of each class required for DCMs
• Only the core types have to be done initially, e.g.
• basic Identifiers
• Text, CodedText, Code
• Quantity, Count, Ordinal
• Date, Time, DateTime, Duration
• Boolean

Reference Model

Starting point:

• Data Types are the most basic patterns required
• The Reference Model is just higher-level patterns

Therefore…

• Rather than debating what reference model among published EHR and other models should be used, we should…
• Identify the key patterns needed for creating real DCMs, and define our DCM-RM based on that
• The DCM-RM should also provide good semantics for computing with data

I then go on to describe what an RM pattern is, and provide a lot of examples from openEHR, globally applicable to health, based on the list in this previous post.

My recommendations for the RM for DCM:

• A. The key is to define an RM consisting of the key patterns that need to be archetyped/ constrained in DCMs, leaving out details of messaging etc
• 1. Some of openEHR’sRM is potentially directly usable for this purpose, due to the archetype history
• 2. Some pieces of other models also useful –see e.g. Singapore LIM, various CDA patterns etc
• B. Don’t start ‘building’ this DCM-RM as a separate exercise; instead, define some key archetypes to be built and use these to determine what bits of the RM are needed
• C. Convertabilityof DCMs based on the DCM-RM to real world RMs has to be considered.

Dilbert - advances in healthcare

Every so often a new and interesting answer to this question pops up…John Halamka just published an excellent list of 7 things that make healthcare (and by extension, health-related computing) hard in this post. Given his day job, this list can be taken as something very close to reality rather than being purely speculative. I mentioned a few of these things peripherally in an old blog post on the e-health standards crisis. Halamka’s comments just make me think that the The Innovator’s Prescription (Clayton M Christensen, Jerome H Grossman, Jason Hwang) really does provide an excellent analysis on how to think about economics and health care.

For a bit of history on the economic analysis of healthcare, including the amoral view on health of right-wing US commentator Rush Limbaugh, see here.

For a philosophical point of view, see these posts by Colin Farrelly (Professor and Queen’s National Scholar in the Dept of Political Studies at Queen’s University) – part 1, part 2.

Grahame Grieve recently put up his list of why healthcare is special, which touches on computing, sociology and economics.

In 2005 I wrote a paper for IMIA called ‘Why is the EHR so hard‘, in which I took a biomedical/social complexity viewpoint (more or less ignoring Halamka’s points above), and used EHR requirements as a way of looking at health complexity:

• information and efficient user interface reflecting multiple levels of hierarchical biological and social organisation;
• mobile patients;
• longevity of information (e.g. 100 years);
• multi-lingual;
• data shared and authored by multiple users simultaneously;
• integrated with knowledge bases such as terminology and clinical guidelines;
• wide geographical availability of a given record to multiple carers and applications;
• consent-based, potentially finegrained privacy rules on information use (with exceptions for emergency access);
• multiple sources of constant change to requirements including medical technology, clinical procedures and guidelines, genomic/proteomic medicine;
• reliable medico-legal support for all users.

Even just perusing the above resources which I happen to have to hand, health does indeed looking more daunting than other domains. Maybe we should quit and try something easier? I’m thinking of a) climbing Mt Everest, b) building a house on the moon and c) convincing the world that TV is evil.

~~~ post script ~~~

In my haste to put this up, I completely forgot the final item I meant to include in this list of indicators of health’s ‘wicked nature’ – and that is Alan Rector’s (Professor of Medical Informatics, School of Computer Science, University of Manchester) famous paper “Clinical Terminology: why is it so hard?“. This was one inspiration (and a proper scholarly one) for my little EHR paper above, but far more importantly laid out much of the ground for enquiry into representing health in ontologies and terminologies.