interoperability in health informatics: saving data from obsolescence, and putting the patient first...

Interoperability in Health Informatics:saving data from obsolescence,

and putting the patient first

Thomas BealeOcean Informatics, Australia

Sponsored by: www.OceanInformatics.biz

© 2005 Ocean Informatics

* * * Programme * * *

• The problems of health IT

• The problem of Interoperability

• Ontological basis for solutions

• Standards

• Strategy


The ProblemClinical Reality ICT Requirement

Life-time Healthcare EHR valid for 120 years

Complexity & change in medicine

Future-proof HIS

Multi-contact health Interoperability of sites

Preventative medicine,

epidemiology, population studies

Real decision support; queryable (=standardised) longitudinal, patient-centric EHR

Mobile patient – leisure, military, professional, regugee

National & global interoperability


The human view


The engineering view



• The problems of health


• 3 principles for solutions

• Standards

• Strategy


The Clinical Information Trail

referral

orderresult

discharge

referral

order result

referral

orderresult

Chest infection GP reviewGP visit Back to foot clinic

Main GP

Foot ulcer foot clinic (hospital)

hospital

Diabetol.

See specialist

DI & path

ImagingRenal function test

Stroke – hospital

hospital2

GP2

See other GP on holiday CT scan

Soc. worker

rehabilitation

Non-interoperable data

discharge

referral

workflow?interoperability

Repeated tests

Clinical errors

System-wide planningLimited Dec support

CostsPatient-centred view?


First Improvement - Messages

referral

Chest infection GP reviewGP visit Back to foot clinic

Main GP

Foot ulcer foot clinic (hospital)

hospital

Diabetol.

See specialist

DI & path

ImagingRenal function test

Stroke – hospital

hospital2

GP2

See other GP on holiday CT scan

Soc. worker

rehabilitation

Still non-interoperable data!

discharge

referral

order

order result

discharge referral

orderresult

referral

result

Which items to copy?Fixed Structures

Interop = stovepipesNo EHR…

Who is managing care?Relevant clinical info?

Medico-legal support?


Introducing the EHR

referral

hospital

Diabetol.

Main GP

DI & path

hospital2

GP2

Soc. worker

discharge

referral

order

order result

discharge referral

orderresult

referral

result

StandardisedShared EHR

EHR VISIBILITY

S h a r e d C a r e, L o n g i t u d i n a l, p a t i e n t – c e n t r e dS h a r e d C a r e, L o n g i t u d i n a l, p a t i e n t – c e n t r e d

The Patient

Copying controllableFixed Structures

Interop = std busPatient-centred view

Carers can communicateRelevant clinical info

Medico-legal support


Difficult Questions revisited (1)

• Which items are copied to shared EHR?– Rule-based – e.g. “current meds”, “therapeutic

precautions” + major event categories + ad hoc requests ...these rules must be able to evolve...security/consent...

• Where is the master copy of each item?– Usually in the shared EHR, to enable standardised

reads...but if EHR technology used at care sites, could be there as well – “system of EHR systems”

• Where & how to achieve interoperability?– Standards-based middleware + web services– highly enabled if EPRs are converted to EHR

technology


Difficult Questions revisited (2)

• Where is the “EHR”?– The patient-centred, longitudinal, shared care EHR is in

its own servers – where? Depends...– Governance by e.g. GP organisations, local health

authorities or other trusted bodies

• Who is in charge of the EHR? – The patient can be in charge of consent– GP or other carer can be clinical “co-driver”

• How does decision support work?– It now has a standardised & longitudinal database to

work with


Difficult Questions revisited (3)• Who is managing the patient’s care?

– Could be anyone, but now there is a mechanism to communicate who it is

• How does each clinician determine where the relevant information for next decision is?– By using shared EHR: problem- and issue-threading,

other derived information structures; relies on fidelity of EPR->EHR synchronisation

• How are medico-legal problems addressed?– All decisions in the EHR are linked back to their input

items – via causal links, issues, problem classifiers etc– Only one place – shared EHR – needs to have reliable

technology for non-repudiation, notary, etc


Strategic Issues for the interoperable EHR• Technical

– Consolidated versus “pure federated” EHR– Where are EHRs, what governance?– Human users and other systems need access to EHR– Centralised and distributed deployment possible– Problem of language and vocabulary

• Socio-political– Doctors’ Fear of making their information so available– Confidentiality needs of patients– Fear of doctors losing control (?!) over patient care– Differing national legislation on privacy & consent– Clinician fear of more data entry– Cost and consequences of user training


Practice MgtEPREPR EPR

A multi-layer EHR strategy

Care

Delivery

Patient-centred EHR

Shared-carePatient-centred

Longitudinal

secure

EHRShared-care

Patient-centred

Longitudinal

secure

Wide-areaaccess Meta-data items (EHR Index)

additional indexing?

EHR Extracts






• Standards

• Strategy


Principles for “good” models

• 1 - Limited scope – targeted at one area such as demographics, workflow, ehr– Why? Same principle as low-coupled software

• 2 - Separation of viewpoints - RM/ODP EV, IV, CV– Why? Separates information (fine-grained) and service (coarse-

grained) semantics; don’t hardwire policies & bus process into the software

• 3 - Ontologically layered– Why? Separates progressively more specific & changeable

concepts into modular layers, allows division of what is hard-wired into software and what is knowledge available at runtime

• A good standard will usually have components reflecting these separations…


Is “ontology” just academic preciousness?

• Ontologies exist wherever there are definitions of the meaning of symbols, such as words

• Definitions can be in the form of a UML model (implicit), a functional specification, a clinical terminology (explicit), etc

• So if we care about any kind of model, we are using ontology

• But…usually we are not conscious of it, and mix ontological levels up…

• Leading to brittle, unmaintainable software


Ontologies and modelling

• ISO OSI is a well-known attempt to consciously design layers of models based on ontological thinking, I.e. layers of meaning, and is still influential

• TCP/IP is a post-hoc description of layers which emerged from organic development

• The big question is always: how much of any domain’s ontology will you hard-wire into the software & db schemas?


Ontological levels in health

Level 1 – data-sharing(persistence/exchange)

Level 2 – invariantdomain concepts

Level 3 – variantre-usable domain concepts

Level 4 – variantlocal & use-specific

base ontological commitments of domain, e.g.

“observation”, “subject-of-care”, “protocol”…

minimal ontological commitments – sufficient for “recording” and “sharing”, e.g.“composition”, “committer”, “attestation”…

atomic domain concepts, e.g. “lab result”, “patient”,

“apgar score”, “BP measurement”, …

use context-specific concepts, e.g. “asthma note”, “ante-natal exam”

Level 0 – foundationalObject meta-model (objects, attributes etc)

built-in data types,


…and corresponding models

Domain Base IM

Persistence IM

archetypes

Semantic templates

Terminology/ontology

100% bidir. mapping

Base ontology for

Re-usable pieces

Bind/mediate

Exchange IM

100% bidir mapping


Level 2 –invariantdomain concepts

Level 3 – variantre-usable domain concepts

Level 4 – domain-variantlocal & use-specific

Level 0 – foundational






• Standards

• Strategy


What is a “good” standard?• Based on the 3 principles• Componentised• Validated by implementation feedback


Are good standards being built?• Some are based on the 3 principles, and will lead to

modular software and interoperable platforms (CEN 13606, HISA, openEHR)

• Some are very mixed, e.g. HL7v3 RIM – contains Act, Observation, but also Medication, Invoice, RMIMs more focussed…

• HL7/OMG services project – updating Corbamed

• In Australia, archetypes being developed for standardisation

• But … still no good standard for clinical data types - Quantity, Coded_term, Ordinal, Text, etc

• Emergence is ad hoc, uncontrolled, and sometimes competitive….


Standards today


Level 2 – invariantDomain concepts

Level 3 – domain-variantre-usable concepts

Level 4 – domain-variantlocal & use-specific

ISO 11404 – general purpose data typesLevel 0 – foundational

ISO RM/ODPOMG MOF/UML

CEN 13606-1 – EHR communicationISO ???? – clinical data types

Corbamed – PIDS

Content-dependent Content-independent

HL7v2EDIFACT

HL7v3 RIMopenEHR – EHR IMUN/CEFACT – ebXML-8

W3C XML-schema

openEHR – common, DT, DS IMs

emerging – national archetypes

CEN 13606-2 – categorial structuresHL7v3 CDA

WHO ???? – basic archetypes

Denmark – G-EPJ

openEHR – ADL

CEN EN13940 – continuity of care

ISO 8601 – date/time

Corbamed – TQS


CEN 13606

Proposal: a new CEN standard (WG2-led)

Archetype Base IM

Exchange IM

archetypes

Semantic templates

Part 1

Part 2 – archetype

interoperability

CEN nnnnn

Archetype ontology

Base ontology IM

Information/ terminology

brokering

IM/IM mappingguidance

Archetype repository

service model+ examplearchetypes

Reduceddata types

Part 3 – ?????






• Standards

• Strategy


What should government do?• The market will not solve the problem - it is a

‘commons’ problem• Define & design national EHR infrastructure

based on standardised information, services and knowledge (like defining the internet)

• Centrally manage knowledge resources - data sets, archetypes, terminologies - but allow distributed development!

• Use economic encouragements and legislative pressure to get compliance

• Engage clinicians and consumers all the way


What should Standards Orgs do?

• Follow 3 principles of modularity

• Analyse todays standards and improve

• Improve development MO to more disciplined engineering, less ad hoc discussion

• Use constant implementation to provide validation – work with implementation orgs

• (these are the principles of openEHR)


What should vendors do?

• Get involved in standards development

• Choose standards judiciously

• Plan for the health computing platform

• Modularise your software using 3 principles

• Expect service-oriented computing environment, e.g. PIDS, CTS etc

• Be ready to use archetypes, templates, terminology


Final thoughts


Where we need to go


Where we can get in 5 years


Where most of us are today

interoperability in health informatics: saving data from obsolescence, and putting the patient first...

Documents

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