icegov2009 - tutorial 4 - e-health standards in practice: challenges and opportunities
TRANSCRIPT
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E-Health Standards in Practice: Challenges and OpportunitiesChallenges and Opportunities
Jennifer ZelmerChief Executive Officer, IHTSDO
ICEGOV 2009Bogota, November 10-13, 2009
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Today’s Tutorial
� Why e-health?� Workshop case: H1N1
� Interoperabilty: key drivers for e-health standards� Interoperabilty: key drivers for e-health standards� Workshop case: reimbursement for physician consult
� Major types of e-health standards in use today� Examples of standards in practice� Lessons learned and key considerations
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Information is key to health and health care
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Complexity of the real world of health care
� The major reality of health and health care is driven by biological variability and human systems
� Biological variability is hugely diverse, dynamic, and uncontrolled� Biological variability is hugely diverse, dynamic, and uncontrolled� emerging infections (e.g. HIV, H1N1)� cancer
� Human response to disease, scientific knowledge, and technology are also explosive in their rates of change
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Health Information for the 21st Century
� Person-oriented� Respectful of privacy and secure� High quality� High quality� Relevant � Inter-operable� Flexible� User-Friendly and accessible
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Progress Made But Challenges Remain
� Of adults with health problems surveyed� 1 in 2 had to tell same story to multiple providers� 1 in 2 had to tell same story to multiple providers� 1 in 5 sent for duplicate tests by multiple providers� 1 in 5 reported that records/tests didn’t reach office in time for
appointment
Source: Commonwealth Fund Survey
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Just some of the challenges ...
� What is the patient’s problem list?� Is a new drug safe to prescribe?� What are the latest test results?� What are the latest test results?� Is recommended preventive care due?� How long are patients waiting?� Can I learn from others about how to improve care?� How can we pay health care providers fairly and efficiently?� How can we track resources and outcomes in a health system?� etc.
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What happens when ...
� You move, you travel ... and you still need healthcare� A friend has a life-threatening allergy� A family member’s doctor retires� A family member’s doctor retires� Clinicians in your hospital trained somewhere else or practice in
more than one site� A medical device is withdrawn� A health region’s boundaries change� You want to be able to select the best IT systems available globally
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A Global Challenge
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Shared Goals: Real & Lasting Change
� Safe, effective, and responsive health services� Appropriate information sharing between providers
and with patients/clients� Better chronic disease management and public
health surveillance� Help clinicians and patients make better decisions� Engaging patients� Reducing duplication and other inefficiencies� etc.
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Approaches Vary
� Centralized vs. Decentralized decisions� Organizational arrangements� Funding mechanisms� Funding mechanisms� Engagement of the public� Engagement of clinicians� Etc.
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As Do Areas of Focus/Progress
� Focus on administrative tools vs. enabling better care� In clinical applications
� Primary vs. Secondary/Tertiary Care� Primary vs. Secondary/Tertiary Care� Degree of specialized systems (e.g. outbreak management or e-
prescribing) vs. integrated solutions� Extent of focus on telehealth, public health surveillance, etc.
� The challenge of renewal of legacy systems� Engagement of, and support for, patients and citizens� Quality improvement & accountability� Etc.
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Nobody has it all solved ...
... But in many ways we share challenges & a vision
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Common Themes Internationally (1)
� Information to enable patient/client care, e.g.� Electronic health records (for professionals and individuals)� Knowledgebases � Knowledgebases � Clinical decision support� Access to care, chronic disease management, and similar
services� Integration with medical devices, telehealth, etc.
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Common Themes Internationally (2)
� Increasing use of information and communications technologies by patients/clients� To find information about health and health care� To find information about health and health care� To monitor health using medical devices� To choose health care options and schedule appointments� To communicate with health professionals� To access and contribute to a personal health record� etc.
� Ensuring privacy, confidentiality, and security
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Common Themes Internationally (3)
� Health system uses of information also matter, e.g.� Quality improvement & health policy� Accountability
• Research• Public health� Accountability
� Funding� Increasing the flexibility, integration, and use of information� Growing international cooperation in health information
� Standards, systems, best practices, policies, etc.� Building capacity – people, infrastructure, etc.� Focus on benefits evaluation & best practices
• Public health
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“In the highly interconnected and readily traversed ‘global village’ of
A problem shared is a problem halved
22/04/201017
readily traversed ‘global village’ of our time, one nation’s problem soon becomes every nation’s problem”
Source: Smolinski et al (2003) Microbial Threats to Health : Emergence, Detection and Response
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Workshop Case #1: H1N1
????
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Information Challenges for Policy Makers: Selected Examples� How widespread is H1N1 in my jurisdiction?
� Who is most at risk?� How severe are cases?� How severe are cases?
� How is my health system coping with cases?� Who needs to be vaccinated?
� How do I reach them?
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New Ways of Monitoring Outbreaks
Model estimates for the mid-Atlantic region (black) vs.CDC-reported ILI percentages (red)
J Source: Ginsberg et al. Nature 000, 1-3 (2008) doi:10.1038/nature07634
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The Question of Vaccination: A Case Study
� Have there been cases of H1N1 in your country?� Has your country begun or planned H1N1 vaccination?� Is priority being given to certain groups in the population?� Is priority being given to certain groups in the population?� Can your country systematically identify everyone under age 65 who
has diabetes or asthma [...]?� Can you contact them?
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The Results ...
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Information enabling change ...
... with interoperability a key
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HealthInformation
Applied Use Cases
Priv
acy,
Con
fiden
tialit
y an
d S
ecur
ity
Thinking About E-HealthG
over
nanc
e
Applied Use Cases
Data & Tools
Standards
Infrastructure
Priv
acy,
Con
fiden
tialit
y an
d S
ecur
ity
Source: Adapted from Canadian Institute for Health Information
Gov
erna
nce
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Capture once, use many times (in a privacy sensitive manner)� For direct client/patient care
� At the point of care� By the client/patient� By the client/patient� Same provider, different time� Different provider(s)
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Capture once, use many times (in a privacy sensitive manner)� For direct client/patient care� For public health surveillance� For health outcomes analysis� For health outcomes analysis� For informing health policy� For accountability and public reporting� For costing and funding� For clinical research� For health services research� For ...
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Without Standards…
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Standards-based Interoperability
STANDARDS
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Workshop Case #2: Paying for Care
????
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The scenario
� John Smith visits his doctor because he has a bad eye infection. His doctor is entitled to bill the insurance plan for the consultation at a standard rate. standard rate.
� To process payment, the insurance company needs to know� which patient was cared for� when� by whom� for what
� Create a form that would capture this information
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Discussion Questions
� What was the first field on your form?� How did you identify the patient?� How did you identify the doctor?� How did you identify the doctor?� What form did you use for the date? Did you include the consultation
time?� How did you describe the reason for visit?
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Two (of many) Possible Scenarios
� Physician ID (numeric, 9 digits)
� Patient ID (alphanumeric,
� Patient name (free text, 60 char)
� Patient address� Patient ID (alphanumeric, 12 digits)
� Date of consult (YYYYMMDD)
� Reason for visit (SNOMED encoded term for main problem)
� Patient address� Physician name (free text,
60 char)� Date of consultation
(DDMMMYYYY)� Reason for visit (free text,
200 char)
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E-Health Standards in Use Today
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Different Types of e-Health Standards
Governance &organizational
Privacy, confidentiality,Technical (e.g.for devices)
Privacy, confidentiality,Security, & access
Information architecture, Models, & structures
Identifiers
Informationexchange
Content
for devices)
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Standards Can Exist at Different Levels within these Broad Domains
GroupingGrouping
Classification
Terminology
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Another view: Interoperability & standards levels
� Machine Transportability Communication� Agreed communication interfaces
� Machine Readability Accessing info� Technology based, � Operational workflows focused
� Machine interpretability Connecting systemsEngagement � Engagement
� Clinician, � Secondary data users � Technology implementers
� Regional Connectivity & EHR.� Agreed structure and meaning
� Co-operability Connecting people� Clinician Driven leading to agreed process, eg care planning� Policy driven
Source: MOHHoldings, Singapore
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A Wide Range of Relevant Organisations
� WONCA
� OpenEHR
� ICH MedDRA� DICOM
� WHO
� LOINC
� IUPAC
� ICN
� OHT
� IHTSDO
� CDISC
� ISO TC 215/CEN TC 251� HL7
� IEEE
� Continua
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The Vision for IHTSDO
� To enhance the health of human-kind by facilitating better health information management
� To contribute to improved delivery of care by clinical and social care � To contribute to improved delivery of care by clinical and social care professions
� To facilitate the accurate sharing of clinical and related health information, and the semantic interoperability of health records
� Member-driven organization, pooling resources for shared benefit
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Terminology: SNOMED CT as an Example
� Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®)
� A comprehensive clinical terminology covering diseases, clinical � A comprehensive clinical terminology covering diseases, clinical findings, and procedures
� Represents the meaning of concepts using formal definitions� Language independent� > 315,000 active concepts, ~ 806,000 descriptions, ~ 1M
defining relationships in international release� Helps to structure and computerize health records allowing for a
consistent way of indexing, storing, retrieving and aggregating clinical data
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To a clinician, these are related. But what about to a computer?
� Myocardial infarction� Myocardial infarct� MI� AMI� Heart attack� Infarction of heart� Cardiac infarction� ...
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Enabling decision support: An Example
� Influenza vaccination reminder
� decision support program criterion:� decision support program criterion:� chronic cardiorespiratory disorders
� patient record:� mild persistent asthma
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Using Standards in Practice
Selected Examples
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Use in Clinical Environments
� For capture, exchange, and use of clinical information� Primary care� Specialist care
”Standards
Inside”� Specialist care� Tertiary care� Health systems
Inside”
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Use by Patients and Families
� For example for use in personal health history application and in personal health records
� Use usually transparent to user but intended� Use usually transparent to user but intendedto facilitate interoperability, data exchange,and decision support
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Use in Public Health, e.g.
� Public health reporting (e.g. Notifiable diseases)� Biosurveillance� Track and analyze information about vaccinations, public health � Track and analyze information about vaccinations, public health
investigations, etc.� Cancer registries� Enabling research to understand factors that influence health� Etc.
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Use in Support of Public Policy
� Frequently need to combine information from many different sources to track trends or compare results using health indicators
� Requires standards for data capture, information exchange, � Requires standards for data capture, information exchange, identifiers, analysis, and more
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The Challenge – and Opportunity – Ahead
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Thinking about a standards process for ehealth …� Diverse standard users and use cases
� Current and future� Importance of balance� Importance of balance� What about governance?
� Establishing criteria and mechanisms for consultation/consensus-building
� How to ensure quality and sustainability of the process?� Links with related activities in other jurisdictions & industries� Facilitating adoption of standards – what are the levers?� Compliance testing – opportunities and challenges� Implications for implementation and evaluation
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The Journey Ahead ...
www.ihtsdo.org
How do we make it easier to use ehealth and ehealth standards than not to?