making e-health work why would a clinician be interested in somantic interoperability?
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ICT expo Dublin 14 th April 2005. Making E-Health work Why would a clinician be interested in Somantic Interoperability?. Jeremy R L Nettle European Healthcare Director Oracle Corporation UK Ltd [email protected]. April 2005. The Interoperability Consortium. - PowerPoint PPT PresentationTRANSCRIPT
Making E-Health workWhy would a clinician be interested in Somantic Interoperability?
Jeremy R L NettleEuropean Healthcare Director Oracle Corporation UK [email protected]
April 2005
ICT expo Dublin 14th April 2005
The Interoperability Consortium
In November 2004, Oracle Corporation one of the eight leading services and technology companies came together as the Interoperability Consortium to respond to a request from the newly-formed office of the National Coordinator for Health Information Technology (ONCHIT) to submit information on how the National Health Information Network (NHIN) could be designed and deployed.
The Interoperability Consortium outlined an initial plan for patient-centered health care delivery systems, secure and private communications, open information exchange standards and public-private financing
Agenda
Why deliver Integrated Healthcare
The proliferation of non Integrated systems
What do we mean by Integrated healthcare
Understanding the architecture and standards to deliver interoperability
A normalised clinical data repository model
Why has Oracle entered this market?
Making e-Health Work
PatientsProviders
Suppliers Payers / Regulators
The healthcare marketplaceEnabling the healthcare enterprise…
Pharmaceutical
Medical Eqpt
Integrated
Networks
Hospitals
PrimaryCare
Outpatient
Other
Biotech
Distributor/Wholesaler
RegulatoryAgency
Physicians
Payer
Employer
Reducing Medical Errors Between 50,000 and 100,000 deaths each year are attributable to
adverse drug events (ADEs).1
Computerised Physician Order Entry can play a significant role decreasing the number of ADEs.2
“The report (Audit Commission, Spoonful of Sugar) estimates that adverse drug events might cost the NHS in the UK £1.1 billion per year. It also cites evidence to suggest that improved information systems could avoid 78% of transcription errors that lead to such adverse drug events.”
1 “To Err is Human”, Institute of Medicine, 19992 “Crossing the Quality Chasm”, Institute of Medicine, 2001
Why deliver integrated healthcare?
A Patient is at a higher risk of an ADE than of loosing their luggage when travelling!
A Simple Case
SP, a 38 year old businessman 14/08 – donates blood; hematocrit 45 21/08 – visits GP; obtains prescription for sulindac, an anti-inflammatory
agent 10/10 – in traffic accident
– Visits emergency room
– hematocrit is 40
10% drop in Hematocrit could indicate gastro-intestinal bleeding….
Beginning a Transaction Chain
As clinicians speak with and examine patients, they also begin to develop plans of care.
?
I need a chestX ray for Mr Smith.
.
Following a Transaction Chain
A clinical thought can spawn a series of clinical activities.
I need a chestx ray for Mr Smith.
Schedule chest x ray
Check room,equipmentavailability
Check technicianavailability
Perform procedure
Interpretstudy
Reportresult
Orderchest x ray
Place image in radiologist work queue
Fulfill
Following a transaction chain A clinical thought can spawn a series of clinical and business activities.
I need a chestx ray for Mr Smith.
Schedule chest x ray
Verify insurancecoverage forchest x ray
Check room,equipmentavailability
Check technicianavailability
Perform procedure Interpret
study
Reportresult
Submitprofessional
fee
Submitfacilities charge
Orderchest x ray
Reimburseproviders
Creating an Transaction Entity
When a clinical thought is entered in an EHR application as a part of a clinical plan, a medical entity-attribute complex should be created.
I need a chestx ray for Mr Smith.
X-ray, chestrt 3766207
Ordered byJames Miller, MD
prv 56647-9
Ordered for Marshall Smithmpi 885757439
12/04/050900.34.33
tr 334678898373
Order forchest x ray
Standardising Transactions
All clinical and business events need to reference all or part of the complex.
I need a chestx ray for Mr Smith.
Schedule chest x ray
Check room,equipmentavailability
Check technicianavailability
Perform procedure
Interpretstudy
Reportresult
Orderchest x ray
Place image in radiologist work queue
Fulfill
Work vs medical entities
OrderFBC
RBC
WBC
Hg
Draw
SendOrder to
Lab
Specimento Lab
ScheduleDraw
ReceiveLab result
Done
Work Activities
Medical Entities
ProcessSpecimen
Constructing the System
Ancillary results
u
Clinician orders and observations
v
v o
o c
c a
a b
b u
l
l a
a r
r y
yu
A pervasive information model allows many parties to contribute to the EHR.
Devices
Patientinput
Interoperability is more than exchange
HL7 Mission Statement:
“Develop specifications for and that support interoperability in healthcare, i.e. “computer systems exchanging information in the healthcare space will predictably compute on the exchanged information based on an agreed upon set of specifications defining the structure and meaning of the exchanged information.”
Semanticinteroperability
Functionalinteroperability
Enforcing interoperability
Interoperability “Ability of two or more systems or
components to exchange information and to use the information that has been exchanged”
IEE Standard Computer Dictionary, IEE, 1990
Syntax and Semantics
– Syntax vs Semantics• Syntax structure• Semantics meaning
– Time flies like an arrow.– Fruit flies like a banana. (no meaning)– Give pain medication. – Give medication for pain.
different syntaxes can have same meaningdifferent syntaxes can have same meaning
What is Interoperability?
– Interoperability:• “The ability of one or more systems to exchange
data/information and to be able to utilise the exchanged information. ” (IEEE, 1990)
– Exchange information syntactic interoperability• Systems recognize the structure of the data
– Utilise information semantic interoperability• Systems understand the meaning of the information
– “Healthcare is a business in which information exchange is the norm, not the exception.”(Bob Herbold, Microsoft COO)
What is the HL7 RIM?
The RIM (Reference Information Model) is documentation of information from the healthcare domain.
It is used as a common reference for the data content of all HL7 version 3 standards.
The RIM has graphical expression and an accompanying data dictionary.
It is expressed using the Unified Modeling Language notation.
Why Build a Reference Information Model?
Healthcare Interoperability The Electronic Health Record• ‘A cradle-to-grave collection of all of a person’s
healthcare transactions’• ‘The integration of clinical, administrative, and financial
information’• ‘Converting from sickness care to health maintenance’• ‘Evidence-based healthcare’• ‘Outcomes-based healthcare’• ‘Providers assuming the risk for healthcare’• ‘Patients receive healthcare services at a number of
points in time and space’s
Why Build a Reference Information Model?
– To achieve any / all of these goals, we must have a set of standards that enable healthcare system interoperability at both the functional (syntactic) and operational (semantic) level.
– The RIM is a structural standard• Defines Concepts• Defines Attributes of Concepts • Defines Relationships between Concepts
– Semantic interoperability ?• V2.x: In principle but not in fact
• No standard structures to facilitate reuse across multiple healthcare domains
• No formal interface to external terminologies• ‘Bottom-up’ message development process
The RIM’s Value Proposition
The RIM is ‘more than just the basis for a messaging model’
It is also a knowledge repository containing Concepts Relationships Cross-domain knowledge World-wide depth and breath of input
An emerging ANSI and ISO standard in and of itself (i.e. separate from the V3 messaging standard per se)
The RIM is increasingly being used as a source set of abstractions and relationships around which to build logical data models which can, in turn, support real-work healthcare information systems from both a clinical and/or an administrative/financial perspective.
Core concepts of RIM
Every happening is an Act• Procedures, observations, medications, supply, registration,
etc. Acts are related through an Act_relationship
• composition, preconditions, revisions, support, etc. Participation defines the context for an Act
• author, performer, subject, location, etc. The participants are Roles
• patient, provider, practitioner, specimen, healthcare facility etc.
Roles are played by Entities• persons, organizations, material, places, devices, etc.
Referral
authorized_visits_qty : REAL
Observation
value : ANYinterpretation_cd : SET<CE>method_cd : SET<CE>target_site_cd : SET<CD>derivation_expr : ST
Substance_administration
route_cd : CEapproach_site_cd : SET<CD>dose_qty : IVL<PQ>rate_qty : IVL<PQ>dose_check_qty : SET<RTO>max_dose_qty : SET<RTO>potency_qty : PQsubstitution_cd : CE
Procedure
method_cd : SET<CE>approach_site_cd : SET<CD>target_site_cd : SET<CD>
Supply
qty : PQexpected_use_time : IVL<TS>
Diet
energy_qty : PQcarbohydrate_qty : PQ
Clinical_document
set_id : IIversion_nbr : INTcompletion_cd : CEstorage_cd : CEcopy_time : TS
Container
capacity_qty : PQheight_qty : PQdiameter_qty : PQcap_type_cd : CEseparator_type_cd : CEbarrier_delta_qty : PQbottom_delta_qty : PQ
Access
approach_site_cd : CDtarget_site_cd : CDgauge_qty : PQ
Device
manufacturer_model_nm : STsoftware_nm : STlocal_remote_control_state_cd : CEalert_level_cd : CElast_calibration_time : TS
Employee
job_cd : CEjob_title_nm : STjob_class_cd : CEsalary_type_cd : CEsalary_qty : MOhazard_exposure_txt : EDprotective_equipment_txt : ED
Living_subject
administrative_gender_cd : CEbirth_time : TSdeceased_ind : BLdeceased_time : TSmultiple_birth_ind : BLbirth_order_nbr : INTorgan_donor_ind : BL
Material
form_cd : CE
Assigned_entity
position_cd : CEprimary_care_ind : BL
Certified_entity
recertification_time : TS
Place
mobile_ind : BLaddr : ADdirections_txt : EDposition_txt : EDgps_txt : ST
Manufactured_material
lot_nm : STexpiration_time : TSstability_time : IVL<TS>
Non_Person_living_subject
taxonomic_classification_cd : CEbreed_cd : CEstrain_txt : EDgender_status_cd : CEeuthanasia_ind : BL
Patient
confidentiality_cd : CEvery_important_person_cd : CE
Organization
addr : BAG<AD>standard_industry_class_cd : CE
Account
nm : STcurrency_cd : CEinterest_rate_qty : RTO<MO,PQ>allowed_balance_qty : IVL<MO>
Financial_act
net_amt : MO
Person
addr : BAG<AD>marital_status_cd : CEeducation_level_cd : CEambulatory_status_cd : CEdisability_cd : CEliving_arrangement_cd : CEreligious_affiliation_cd : CEspecial_accommodation_cd : SET<CE>race_cd : SET<CE>ethnic_group_cd : SET<CE>
Working_list
ownership_level_cd : CE
Public_health_case
detection_method_cd : CEtransmission_mode_cd : CEdisease_imported_cd : CE
Patient_encounter
acuity_level_cd : CEadmission_source_cd : CEbirth_encounter_ind : BLdischarge_disposition_cd : CElength_of_stay_qty : PQpre_admit_test_ind : BLreferral_source_cd : CEspecial_courtesies_cd : SET<CE>urgency_cd : CEvaluables_desc : EDvaluables_location_desc : ED
Schedulable_resource
slot_size_increment_qty : PQ
Acts (Financial)
Acts (Clinical)
Infrastructure (Structured documents)
HEALTH LEVEL 7 REFERENCE INFORMATION MODEL VERSION 1.15 (RIM_0115)
Version reflects RIM changes through Harmonization on 03/07/2002 that were approved for implementation following the release of the second committee-level ballot of Version 3.
Billboard produced by:Rochester Outdoor Advertising
Roles
Guarantor
credit_rating_cd : CE
Diagnostic_image
subject_orientation_cd : CE
Imaging_modality
pixel_intensity_relationship_cd : CEspacial_resolution_qty : PQpixel_padding_qty : PQ
Query_ack
query_response_cd : CSmessage_query_cd : CEresult_total_qty : INTresult_current_qty : INTresult_remaining_qty : INT
Query_continuation
continuation_qty : INTstart_result_nbr : INT
Table
rules : CScellspacing : STcellpadding : STsummary : STwidth : STborder : INTframe : CS
Table_structure
halign : CSchar : STcharoff : STvalign : CSlocal_id : ST
Table_column_structure
span : INTwidth : ST
Table_cell
rowspan : INTcolspan : INTabbr : STaxis : STheaders : SET<ED>scope : CS
Local_attr
name : STvalue : ST
Local_markup
ignore_cd : CSdescriptor : STrender : ST
Link_html
title : STname : SThref : EDrel : SET<CE>rev : SET<CE>
Context_structure
local_id : ST
Infrastructure (Structured documents)
Infrastructure (Message control)
Enitites
Message Control
Financial_transaction
credit_exchange_rate_qty : REALdebit_exchange_rate_qty : REALinterest_rate_qty : RTO
Invoice_element
modifier_cd : CEunit_qty : PQunit_price_amt : RTO<MO,PQ>factor_nbr : REALpoints_nbr : REALcoverage_source_cd : CEnotify_subject_ind : BL
Financial_contract
payment_terms_cd : CE
Role_heirEntity_heir
Sort_control
element_nm : STsequence_nbr : INTdirection_cd : CS
Query_spec
execution_and_delivery_time : TSinitial_qty : INTinitial_qty_cd : CEmessage_query_cd : CEmodify_cd : CSresponse_modality_cd : CSresponse_priority_cd : CSresponse_element_group_id : SET<II>
0..n 1
is_for
0..n
has
1
Relational_expression
element_nm : STvalue : STrelational_operator_cd : CS
Query_by_selection Selection_expression0..n1is_for
0..n
has_ex pression
1
Logical_expression
relational_conjunction_cd : CS
1
0..n
has_left_side1
is_lhs_for0..n
1
0..n
has_right_side
1
is_rhs_for0..n
Query_by_parameter
Parameter_list
Parameter
nm : STid : II 0..n 0...
is_parameter_of0..n
has
0...
0..1
0..n
may_contain 0..1
is_part_of
0..n
Parameter_item
value : ANYsemantics_txt : ST
Device_task
parameter_value : LIST<ANY>
Acknowledgement
type_cd : CSnote_txt : EDerror_detail_cd : CEexpected_sequence_nbr : INT
Message
accept_ack_cd : CSapplication_ack_cd : CSattachment_txt : EDinteraction_id : IIprocessing_cd : CSprocessing_mode_cd : CSprofile_id : SET<II>sequence_nbr : INTversion_id : ST
0..*
1
acknowledges0..*
is_acknowledged_by1
0..1
1
occurs_wi th0..1
has 1
Query_event
query_id : II
Control_event
structure_type_id : IIresponse_cd : CS
0..1
0..n
is_communicated_as
0..1
has_payload
0..n
0..1
1
occurs_with
0..1
may_have 1
Act_relationship
type_cd : CSinversion_ind : BLcontext_control_cd : CSsequence_nbr : INTpriority_nbr : INTpause_qty : PQcheckpoint_cd : CSsplit_cd : CSjoin_cd : CSnegation_ind : BLconjunction_cd : CS
Act_context
level_cd : CE
Act
class_cd : CSmood_cd : CSid : SET<II>cd : CDnegation_ind : BLtxt : EDstatus_cd : SET<CS>effective_time : GTSactivity_time : GTSavailability_time : TSpriority_cd : SET<CE>confidentiality_cd : SET<CE>repeat_nbr : IVL<INT>interruptible_ind : BLcontext_lock_ind : BLindependent_ind : BLreason_cd : SET<CE>language_cd : CE
0..n1
has_target
0..n
is_target_for
1
0..n1
has_source
0..n
is_source_for
1
1..*
0..*
originates_in_context_of
1..*
provides_context_for
0..*
Participation
type_cd : CSfunction_cd : CDcontext_control_cd : CSsequence_nbr : INTnote_txt : EDtime : IVL<TS>mode_cd : CEawareness_cd : CEsignature_cd : CSsignature_txt : ED
0..n 1
for
0..n
has
1
Role_link
type_cd : CSeffective_time : IVL<TS>
Role
class_cd : CSid : SET<II>cd : CEnegation_ind : BLaddr : BAG<AD>telecom : BAG<TEL>status_cd : SET<CS>effective_time : IVL<TS>certificate_txt : EDqty : RTOposition_nbr : LIST<INT>
0..n1
has_as_participant
0..n
participates_in
1
0..n1
has_source
0..n
is_source_for
1
0..n1
has_target
0..n
is_target_for
1
Language_communication
language_cd : CEmode_cd : CEproficiency_level_cd : CEpreference_ind : BL
Attention_line
key_word_txt : STvalue : ST
Batch
nm : STreference_control_id : IIbatch_total_nbr : SET<INT>batch_comment : SET<ST>transmission_qty : INT
Entity
class_cd : CSdeterminer_cd : CSid : SET<II>cd : CEqty : SET<PQ>nm : BAG<EN>desc : EDstatus_cd : SET<CS>existence_time : IVL<TS>telecom : BAG<TEL>risk_cd : CEhandling_cd : CEimportance_status_txt : ED
0..n0..1
is_played_by
0..n
plays
0..1
0..n0..1
is_scoped_by
0..n
scopes
0..1
10..n
communicates_with
1
used_by
0..n
Transmission
creation_time : TSid : IIsecurity_txt : ST
0..n1
can_accompany
0..n
can_include
1
0..1
0..n
contains 0..1
is_contained_by
0..n
Communication_function
type_cd : CStelecom : TEL
1..n
0..*
serves
1..n
served_by
0..*
1..*0..*
executed_by
1..*
executes
0..*
Managed_participation
id : SET<II>status_cd : SET<CS>
Act_heir
Reference Information ModelClass Diagram
Entity
•Entities play roles –persons–organizations–material–places–devices –Etc.
Role
•Roles participate in Acts –patient–provider –Practitioner–Specimen–Etc.
Participation
•Participation defines
the context of an Act–Author–Performer–Subject–Location–Etc.
FinancialActs
Clinical Acts
•Acts are everything that happens
–Procedures–Observations–Medications–Registration–Etc.
Deriving the RIM BackboneThe Essential Structures of Healthcare
• A Healthcare Action can be the source of zero-to-many Healthcare Relationships, each of which relate the source Healthcare Action to one-and-only one other Healthcare Action (the target action).
• A Healthcare Action can be the source of zero-to-many Healthcare Relationships, each of which relate the source Healthcare Action to one-and-only one other Healthcare Action (the target action).
ACT:Temp 101F
ACT:Abnormal
CXR
ACT:Elevated
WBC
AR:“is supported
by”
AR:“is supported
by”
AR:“is supported
by”
has target has target
has targethas target
has targethas target
ACT:Dx Pneumonia
is source foris source for
is source for
is source for
is source for
is source for
A Simple Case
SP, a 38 year old businessman 14/08 – donates blood; hematocrit 45 21/08 – visits GP; obtains prescription for sulindac, an anti-inflammatory
agent 10/10 – in traffic accident
– Visits emergency room
– hematocrit is 40
10% drop in Hematocrit could indicate gastro-intestinal bleeding….
ViewingApplication
Any clinician, with appropriate authorization from the patient and permissions from the system, can view clinical data
LocalSystems
Blood bank GP office ER Pharmacy Radiology
A normalised clinical data repository model
Lab
14/08
21/08 21/08 10/10 10/10
10/10
CentralizedDataRepository CDR
• Message Processing• Person Management• Terminology Management• Security, authentication
R E A L D A T A Rules Engine
??
Notification
ViewingApplication
LocalSystems
Blood bank GP office ER Pharmacy Radiology Lab
CentralizedDataRepository CDR
• Message Processing• Person Management• Terminology Management• Security, authentication
R E A L D A T A
Notification
SecurityCheck
Consent
Any clinician, with appropriate authorization from the patient and permissions from the system, can view clinical data
A normalised clinical data repository model
Why has Oracle entered this market?
Oracle has the fundamental infrastructure Growing need for electronic health records (EHR) Regulations for data standards, security, confidentiality Growing awareness of the need to re-use clinical data HL7 standards movement The other guys cannot do it
The implications of our approach: Evolve Oracle’s database functionality into a health care platform Deploy the ideal model for multi-centered systems, including those with
regional, and national responsibilities Occupy the center of the clinical data re-use, data exchange and
warehouse business Offer the most efficient solutions for dealing with legacy systems
A foundation for healthcare
Enables interoperability and meaningful data integration
Built to support large, complex healthcare communities as well as single hospitals
Standards-based, open architectureAdaptive development, integration and operation
platform Leverages Oracle’s core expertise and productsGlobal platform
Scalability and performance
Healthcare Transaction Base (HTB)
Jeremy R L NettleEuropean Healthcare Director Oracle Corporation UK [email protected]
April 2005
Making E-Health work
“Knowledge of what is possible is the
beginning of happiness”George Santayana (1863 - 1952) US (Spanish-born) philosopher
The Healthcare Transaction Base
AQ&Q U E S T I O N SQ U E S T I O N S
A N S W E R SA N S W E R S