Through functional harmonisation to Interoperability of EHR systems

ISHEPZagreb, September 16, 2010

Dr. Jos Devlies, EuroRec

Topics addressed

• The EuroRec Institute• Interoperability and Quality….• Functionality as prerequisite for

Quality• EuroRec Functional Criteria• EuroRec Seal• HITCH project• Conclusions

The EuroRec Institute• Not-for-profit• Federation of

National Centres• To promote the use of

high quality EHR systems

• Main activities:– Research– Product Conformance

Why do we need interoperability?• Efficiency in care:

– sharing available patient information with authorised ‘users’

– knowledge explosion more decentralised care decisions on more centralised data

• Patient-focused information management– complete record = patient lifetime (at least)- beyond life the HC Professionals- applications ‘disappear’

What is Interoperability?

• So many definitions: just one of IEEE“The ability of two or more systems or components to exchange information and to use the information that has been exchanged”

• Focus on the “use” • More than exchangeability

More than being “human understandable”

exchangeability is a “low level of interoperability”.

• Remark: We are only addressing “clinical systems”

(Re)use is the issue

• Interoperability means the ability to (re)use content – by different applications– outside the context of origin– without new / complementary encoding

• Is exchangeability / understandability enough for (re)use?

• Everything depends on the quality…

Garbage in... Garbage out

Exchangeable Garbage

is still

Garbage

Health data need to be

• Correct at “conception”• Comprehensive regarding context:

– Who, when, circumstances and role of the author regarding the patient (on duty service, regular GP consult, multidisciplinary conclusion of a hospital stay)…

– Co-morbidity / absence of co-morbidity

• Precise and granular– “Other disease of genito-urinary tractus”– Staging and severity– Certainty

Quality problems ?• Enormous “quality” gap at data entry

– professional inconsistency in labelling clinical conditions using “standards” (if used…)

– functionalities of systems insufficiently used– systems with poor functionality

• Lack of domain-validated “info-structure”: – what are now the correct attributes in order to capture a

complete description of a type II diabetes, of blood pressure, a medication administration?

– where are the standard expressions for some of these attributes?

• Even more regarding environmental, behavioural, hereditary and professional context

Also at application levelSystems need to be able to produce / to collect and to share those “high quality data” with authorised Healthcare Professionals.

Examples:– Staging of diseases– Complex dosing schemes for medicinal products– Distinguish a confirmed diagnosis from a nursing diagnosis or from

a hypothesis– Monitor real-time alerts for allergies or specific health conditions– Manage prevention and immunisations– Implement Good Practice Guidelines and specialised Care

Protocols– Device connectivity…

Defining the needs is defining EHR functional requirements.

Functional Requirements

• Without functionalities no content, nothing to exchange…

• Systems with the same / similar functionalities will produce

roughly the same data (more specifically when using the same

standards or based on the same requirements).

• There are hundreds, thousands of requirements to be met

– Some by all the systems

– Some (domain specific) only by some applications

• The actual EuroRec repository of functional descriptive

statements contains over 1.600 statements / criteria.

• Partially translated in 19 languages.

The EuroRec Functional Requirements

Countries of origin

• Belgium (1999-2006-2010)• CCHIT (USA)• Alberta (Canada)• Ireland• France (LAP)• Denmark• Meaningful use (USA)• Clinical research (eClinical Forum)• Austria (Lab results)

Medicinal decision support related statements….

In Croatian

How to reach functional quality?

• Someone defines an agreed “quality” level. What and how a system should behave. Who?– The users… surely, ideally a professional consensus

– Also the authorities, as they:

• have different / additional priorities

• want consistency between the systems

• Translated in system / functional requirements

• Issuing requirements is not enough, they should be “verified” conformance testing

• Will result in systems with similar (not identical!) functionality harmonisation

Two ways to favour functional harmonisation?

• National / Regulatory way:– Can be very detailed / comprehensive.– May address one specific user group.

• Cross-Border: needs to be more generic• EuroRec issued two “Seals”

– Seal Level 1 : 20 mainly generic statements– Seal Level 2 : 50 criteria also addressing security

and confidentiality management.• http://www.eurorec.org/consortium_intern/seal/index.

cfm

• Available in all the languages

Composition of the sealNumber Index Index Title

12 A00 EHR Data Entry related

9 A02 EHR Content related

8 A03 EHR Structuring Data

22 A04 EHR Display

1 A05 EHR Data Exchange Services and Record Interfaces

14 A09 EHR Generic Data Properties

7 A10 Medication Management

3 A11 Clinical Statements Management

3 A14 Shared Care

2 A15 Clinical Decision Support: alerts, reminders

7 A22 Demographic Services

1 A32 Laboratory Services

4 A6 Health Information System management

23 A7 Privacy and Accountability Services

6 A8 Technical Security Services

Is that enough to guarantee quality?

• Having good systems is one step.This includes the function of sharing / exchanging patient information.

• Getting them used properly is another issue– Using the rod or whip does not work– Let the market do his job…– Incentives….for using those systems (meaningful use

in the USA)– Education and training are essential as well… 25

years after the first PCs still…

How to match Functional Testing (EuroRec,…)

andInteroperability Testing (IHE

Europe) ?

• Support Action within 7Th Framework.• Aim of the project is to define “A

roadmap to establish a foundation for the Interoperability Conformance Testing of information systems in Healthcare”

• Partners: INRIA, IHE Europe, OFFIS, ETSI, MEDCOM and EuroRec.

Overlap functionality and interoperability testing

Conclusions• Quality of the content is a prerequisite to

interoperability.• Quality of the content depends on functional

ability of the system to produce those data and on the effective use by the HC Professional.

• Systems meeting the same / similar functional criteria evolve to a degree of functional harmonisation, favouring interoperability.

• Conformance testing is an important step to realise quality as well as interoperability.

Thank you

www.eurorec.orgjos.devlies@eurorec.org