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Trillium Bridge: Bridging Patient Summaries across the Atlantic
EU and US Providers Exchanging Patient Summaries The case of Martha, a US Citizen and Paolo, an Italian from Lombardy
technical feasibility, live demo
Zachary Gillen, Kaiser Permanente
Giorgio Cangioli, HL7 Foundation
Ana Estelrich, Phast
Catherine Chronaki, HL7 Foundation
2
Trillium Bridge Project: a builder perspective…
The problem The Solution
What can we do to lower the
cost of transatlantic business
engagement in eHealth?
Reduce barriers for transatlantic
coordination, health care, trade
Decrease standards development
and implementation costs
Accelerate convergence towards
global standards
Support right of citizens to their
health data and safety
Well, perhaps we could try
building..
…a Transantlantic Bridge for
EHR summaries!
• Pragmatic Feasibility study on the
exchange of Patient Summaries
across the Atlantic
• Compare, analyze, and map EU/US
patient summaries starting with
Meaningful Use 2 C-CDA/CCD and
EU patient summaries (epSOS)
• July 2013 to February 2015
• Stellar consortium of EU member
state provider networks,
associations, SDOs US Health Care
Providers
Innovative Entrepreneurs
3
Trillium Bridge: status and work aheadBuilding the Transatlantic bridge for EHR patient summaries
Completed Gap analysis
D2.2. user stories, use cases, business architecture
Identified interoperability Assets
Established STS terminology
service associating EU/US terms, D3.1
proof of concept transformer of EHR structures
and semantics
Inform and support standardization efforts
ground work of an Intl EHR patient summary
Aligning infrastructure
Refine assets, work on the puzzle through validation
Test with EU countries and US providers
Set the tone and pace for interoperability
in the global eHealth ecosystem.
Attain the vision and aims of EU-US of the
eHealth MoU and roadmap!
Selecting Grounds
Building the Bridge
Testing the Bridge
Policy Alignment
We are here
CTS-2
Trillium transformer
4
Trillium Bridge Use CasesOne Value proposition:
When patient needs unplanned care overseas, a EHR summary fit for the
purpose of safe and efficient health care is available.
After the health care encounter, patient receives encounter report in a
format and language that can be understood back home.
Two use cases:
Provider mediated (citizen controlled, provider initiated)
Patient mediated (citizen initiated, citizen controlled)
Blazing the transatlantic path – constraints and assumptions
Translation of narrative unstructured content (not in scope)
Incorporate patient summary elements in EHR or PHR (not in scope)
Preconditions: citizen empowerment
EU Citizens have access to their EU Patient Summary (e.g. epSOS PAC, HECR)
US Citizens have access to their Clinical Summary in
C-CDA/ CCD
5
September 30th, 2014 Trillium Bridge ATR5
Portuguese Portal
(epSOS Patient Access)
Italian (Lombardy)
Portal (epSOSPatient Access)
Spanish Portal(epSOS Patient Access Service)
EU MS National Portal(epSOS Patient
Access)
Trilliu
m
Ga
tewa
y
Tethered Personal Health Record, Health App orBlueButton+
CTS-2
Terminology Services• EU epSOS master values (MVC/MTC)• US core value sets (NLM)
Doctor visualizespatient summaryIn local language prepares report (HCER)
Get EU patientsummary Request
transform..
Martha getsher CCDVia bluebutton
Provide clinical summary
Paolo receives encounterreport in CCDA/CCD
Request transform..
Reference OpenNCP
Portal
1 2 3
4
5
6
7
Paolo has his EU Patient Summary epSOS pivot (EN)
12
Request transform..
3 4
6
Provider Mediated Case: Technical Architecture Overview
National Contact Point
(Italy)
National Contact Point
(Spain)
National Contact Point
(Portugal)
Trillium Bridge
Gateway(based on the epSOS Open
NCP)
IHE XCAIHE XCPDIHE ATNA
(epSOS)
Local Connector & eHealth Exchange
Gateway
Transformer
CTS-2
IHE XCAIHE XCPDIHE ATNA(eHealth Exchange)
National Contact Points
otherinterested MS
Lux, Finland, Greece, Slovenia..
MU2 C-CDA/ CCDEU Patient
Summary epSOS pivot document (EN)
Terminology Services• EU epSOS master values (MVC/MTC)• US core value sets (NLM)
7
Provider Demonstration Scenarios
Martha KP patient in Italy (cancer survivor)
Martha Faces health Emergency
Italian doctor retrieves her patient summary from US
Italian doctor sends her encounter report to the US
Paolo, an Italian in San Fransisco
Paolo looses his *new* hypertension medication
KP doctor retrieves his patient summary from Lombardy
Context
Feasibility study
Evidence-based policy development
Scope
Trillium Bridge Demonstration 8Tuesday, October 28, 2014
• Demonstrate the Provider Mediated Use Case
• Show with real systems (test environment) how the
European epSOS and the US eHealth Exchange networks
now may technically cooperate for the purpose of
– Discovering Patients
– Exchanging Patient Summaries
Who
Provider Mediated Logical View
Trillium Bridge Demonstration 9Tuesday, October 28, 2014
U
S
-
K
P
THE
TRILLIUM GATEWAY
Architectural Overview
Trillium Bridge Demonstration 10Tuesday, October 28, 2014
cmp Prov ider Mediated Ov erv iew
CTS2 based Terminology Serv er
Name: Provider Mediated OverviewAuthor: GiorgioVersion: 1.1Created: 18/10/2014 07:20:56Updated: 18/10/2014 07:22:36
EU Terminology Serv er
KP
Infrastructure
EU National Infrastructure
(Country X)
KP::KP
gateway
epSOS Portal
Trillium GatewayepSOS::NCP
eHealth Exchange Circle of Trust epSOS Circle of TrustKP Circle of Trust EU Country X Circle of Trust
EU PS, EU HCER
C-CDA CCD
C-CDA (Transformed)
EU PS (Transformed)
The «Magic» Team
11Tuesday, October 28, 2014
Trillium Gateway(*)
with the support of
(*) EU Reference implementation funded from the
project - Gnomon
Trillium Bridge Demonstration 12Tuesday, October 28, 2014
MARTHA TOKEN
A KAISER PERMANENTE PATIENT
TRAVELING TO EUROPE
PAOLO CERRUTI
AN ITALIAN CITIZEN TRAVELING
TO THE USA
Trillium Bridge:
Behind the scenes:WP3 - Assembling Interoperability Assets
Ana ESTELRICH
ana.estelrich@phast.fr
Transcoding
Wednesday Oct 22, 2014 14
Transcode – Transcoding involves finding the closest equivalent
of a concept belonging to one code system in another code
system. The significance of the target concepts is desired to be
as identical as possible to the source concept.
Concept A Concept B
Code System SNOMED CT Code System ICD-10
OID 2.16.840.1.113883.6.96 OID 2.16.840.1.113883.6.3
version 20130901 version 20100101
Concept code 254837009 Concept code C50
Designation Malignant tumor of breast (disorder) Designation Malignant neoplasm of breast
Maps available in terminology server
(http://extension.phast.fr/STS_UI) part of Trillium Gateway
connection
• Transcoding (mapping) – Part of a larger activity of the
Trillium Bridge WP3: Assembling Interoperability Assets
• Compared clinically, syntactically and semantically the
European PS and CCD
Section Comparison
15
epSOS/EU DirectiveEU Patient
Guidelines epSOS PS CCDSection Optionality Optionality Optionality OptionalityAllergy R R Allergies R
List of current medicines R R Medications RList of current problems / diagnoses R R Problem RSurgical Procedures prior to the past six months R O Procedures
O (R only for inpatients)
Major Surgical Procedures in the past six months R R Procedures
O (R only for inpatients)
Medical Devices and implants R R Medical Equipment O
Vaccinations O O Immunizations O
Social History Observations O O Social History OPregnancy history (Expected date of delivery) O O Social History (Pregnancy Observation) O
Physical findings (Vital Signs Observations) O O Vital Signs ODiagnostic tests (Blood group) O O Results Section R
Treatment Recommendations R O Plan of Care O
Autonomy / Invalidity R O Functional Status OList of resolved, closed or inactive problems Advance Directives O
Family History O
Payer O
Encounters O
Using same template OID,
can be grouped together,
only difference is the date
Text only
Not equivalent in regular
specification CCD, can add
as an open template, not
included 4 sections not present in
epSOS PS
Wednesday Oct 22, 2014
Common Denominator
16
Allergies
Medications
Problems
Pregnancy History Expected date of delivery
Vaccinations
Social History
Medical Devices
Vital Signs
Blood group
Procedures
Wednesday Oct 22, 2014
Mapped data elements
100s of data elements, 2 types:
• Structural data elements– they come across as they are: moodCode, classCode, typeCode
• Value data elements (bound to specific value sets)*
17Wednesday Oct 22, 2014
Syntactic Mapping
• XSLT transformation for the value data elements
• Can range from very simple (only changing the template ID) to complex (change template ID, change structure, map from two possible ways of expressing a data element to one or vice versa).
18Wednesday Oct 22, 2014
Value Sets Mapping (1)
• Incorrect, we never map the value sets, we see if the value sets are equivalent in
their significance, then we see if the concepts they contain can be mapped
between themselves.
• We will only focus on value sets that can be “mapped”
• 2 situations present:
– Value sets based on the same code system
– Value sets based on different code systems
Value set based on the same code system:
1. Value sets are based on the same code system, they contain exactly the same concepts
19Wednesday Oct 22, 2014
Value Sets Mapping (2)
20
2. Value sets are based on the same code system, there is partial overlap
Wednesday Oct 22, 2014
Value Sets Mapping (3)
Value Sets based on different code systems
1. Official mapping exists, however it is limited
• Mapping exists between
• SNOMED CT International –ICD-10 version 2010
• SNOMED CT US Extension – ICD-10 CM version 2013 (other ICD-10 CM
versions also available).
• NDF-RT – ATC
• RxNorm – ATC
21Wednesday Oct 22, 2014
Value Sets Mapping (4)
• Official mapping in uni-directional (SNOMED CT-ICD10), the reverse does not exist
• The official map was used in reverse to get the mapping ICD-10-SNOMED CT
• Initially we wanted to look at one-to-one, many-to-one and one-to-many mappings
• It quickly became evident that the one-to-many mappings must be excluded as it introduces ambiguity (which term to choose to send? All? If receiving 4 terms, which one is the correct one?)
• Synonyms were counted only once
• Stringent rules were chosen in the mapping of SNOMED CT
22Wednesday Oct 22, 2014
2. In-house mapping, done one concept by one concept, in both directions:
23
Value Sets Mapping (5)
ISCO-08 epSOSHealthcareProfessionalRoles ISCO_NUCC_epSOSHealthcareProfessionals_VS
NUCC CCD_Provider Type NUCC_ISCO_ProviderType_VS
SNOMED CT epSOSAllergenNoDrugs UNII_to_SNOMED CT_IngredientName_VS
UNII CCD_Ingredient Name SNOMED CT_UNII_epSOSAllergenNoDrugs_VS
EDQM Standard Terms epSOSRoutesofAdministration EDQM_NCI_epSOSRRouteofAdministration_VS
epSOSDoseForm EDQM_NCI_ epSOSDoseForm _VS
NCI Thesaurus CCD_Medication Route FDA NCI_EDQM_ Medication Route FDA _VS
CCD_Medication Product Form NCI_EDQM_ Medication Product Form _VS
SNOMED CT CCD_Problem CVX_SNOMED CT_ Vaccine Administered_VS
CVX CCD_Vaccine Administered SNOMED CT_CVX_ epSOSVaccine_VS
*Code system contains over 63, 000 concepts, only 5,300 were mapped due to limited resources
Wednesday Oct 22, 2014
Statistics (1)
24
ATC
CVX
EDQM Standard Terms
HL7 AddressUse
HL7 AdministrativeGender
HL7 Confidentiality
HL7 EntityNamePartQualifier
HL7 RoleClass
HL7 RoleCode
ICD-10
ICD-10-CM
ISCO-08
ISO 3166-1 Country Codes
ISO 639-1
LOINC
NCI Thesaurus
NDF-RT
NUCC
RxNorm
SNOMED CT
UCUM
UNII
22 Code Systems 25 CCD value set (out of 65) 26 epSOS value set (out of 46)
CCD_ HITSP Vital Sign Result Type
CCD_Administrative Gender (HL7)
CCD_AgePQ_UCUM
CCD_Allergy/Adverse Event Type
CCD_CountryValueSet
CCD_EntityNamePartQualifier
CCD_HealthStatus
CCD_HITSPProblemStatus
CCD_HL7 BasicConfidentialityKind
CCD_INDRoleclassCodes
CCD_Ingredient Name
CCD_Language
CCD_Medication Brand Name
CCD_Medication Clinical Drug
CCD_Medication Drug Class
CCD_Medication Product Form
CCD_Medication Route FDA
CCD_Personal Relationship Role Type
CCD_Problem
CCD_Problem Type
CCD_Provider Type
CCD_Social History Type Set Definition
CCD_Telecom Use (US Realm Header)
CCD_UCUM Units of Measure
CCD_Vaccine Administered
epSOSActiveIngredient
epSOSAdministrativeGender
epSOSAdverseEventType
epSOSAllergenNoDrugs
epSOSBloodGroup
epSOSBloodPressure
epSOSCodeProb
epSOSConfidentiality
epSOSCountry
epSOSDoseForm
epSOSEntityNamePartQualifier
epSOSHealthcareProfessionalRoles
epSOSLanguage
epSOSMedicalDevices
epSOSPersonalRelationship
epSOSPregnancyInformation
epSOSProcedures
epSOSReactionAllergy
epSOSResolutionOutcome
epSOSRoleClass
epSOSRoutesofAdministration
epSOSSocialHistory
epSOSStatusCode
epSOSTelecomAddress
epSOSUnits
epSOSVaccine
Wednesday Oct 22, 2014
Statistics (2)
25
ATC_NDF-RT_epSOSActiveIngredient_VS
ATC_RxNorm_epSOSActiveIngredient_VS
CVX_SNOMED CT_ Vaccine Administered_VS
EDQM_NCI_ epSOSDoseForm _VS
EDQM_NCI_epSOSRRouteofAdministration_VS
ICD 10 CM_SNOMED CT_epSOSIllnesses_VS
ICD 10_SNOMED CT_epSOSIllnesses_VS
ISCO_NUCC_epSOSHealthcareProfessionals_VS
NCI_EDQM_ Medication Product Form _VS
NCI_EDQM_ Medication Route FDA _VS
NDF-RT_ATC_Drug_Class_VS
NUCC_ISCO_ProviderType_VS
RxNorm_ATC_Clinical_Drug_VS
RxNorm_ATC_Medication_Brand_VS
SNOMED CT_CVX_ epSOSVaccine_VS
SNOMED CT_to_ICD 10 CM_CCD_Problem_VS
SNOMED CT_to_ICD 10_CCD_Problem_VS
SNOMED CT_UNII_epSOSAllergenNoDrugs_VS
UNII_to_SNOMED CT_IngredientName_VS
19 Association or Mappings
Terminology Assets present in the CTS2-based terminology server:
http://extension.phast.fr/STS_UI/
Wednesday Oct 22, 2014
Statistics (3)
26
Applicability of the maps to the value sets – examples:
Wednesday Oct 22, 2014
epSOS Value Set epSOS Code System
concepts with corresponence/concepts present/(% covered)
CCD Value Set CCD Code System
concepts with corresponence/concepts present/(% covered)
epSOSActiveIngredient ATC 606/5592 (6%) Medication Drug Class
NDF-RT 1365/10699 (13%)
epSOSActiveIngredient ATC 2836/5592 (51%) Medication Brand Name
RxNorm 3329/13885 (24%)
epSOSActiveIngredient ATC 2836/5592 (51%) Medication Clinical Drug
RxNorm 9642/31214 (31%)
epSOSAllergenNoDrugs SNOMED CT 79/112 (71%) Ingredient Name UNII 5315/63996 (8%)*
epSOSRoutesofAdministration
EDQM Standard Terms
55/73 (75%) Medication Route FDA
NCI Thesaurus 57/118 (48%)
epSOSDoseForm EDQM Standard Terms
28/457 (6%) Medication Product Form
NCI Thesaurus 99/153 (65%)
epSOSIllnessesandDisorders
ICD-10 1775/9525 (19%)IHTSDO maps
Problem SNOMED CT 7204/16443 (44%)IHTSDO maps
epSOSIllnessesandDisorders
ICD-10 1147/9525 (12%)NLM maps
Problem SNOMED CT 6914/16443 (42%)NLM maps
epSOSVaccine SNOMED CT 27/31 (87%) Vaccine Administered CVX 87/163 (53%)
Common Denominator has been established!
• Files exchanged with ONC, we need to plan a rigorous QA process, subject
matter experts needed in various areas
• Original code is always be sent for safety reasons
• The translated and transcoded Trillium document bears the indication that
it has undergone a transformation, the original document is always
available in its entirety
• Trillium Bridge WP3 performed an important Feasibility Study to prepare
the road for future projects and harmonization efforts
27Wednesday Oct 22, 2014
Lessons Learned
Trillium Bridge Demonstration 28Tuesday, October 28, 2014
• Alignment on vision and roadmap critical to demonstration success
• Same exchange standards (IHE XCPD and XCA) in use across networks. Different implementations of those standards observed.
– Detailed gap analysis of messages to identify processing issues
– Agreement on remediation (EU or KP) for purposes of demonstration
– Teamwork
– Developed message translation engine to bridge difference between eHealth and Epsos messages and gateway requirements
• Opportunity to provide feedback to standards bodies
• Demonstrated technical feasibility. Trust, Legal, Compliance and Governance questions a greater challenge.
What’s next?
• First and foremost it is about people – You have seen that it is technically feasible to exchange
EHR data and make EU and US citizens feel safe and secure.
– Business is ready to invest, states ready to pilot
• Trillium Bridge is a paradigm that scales globally– International Patient Summary
• It is about evidence that can help shape policy– Incentives, education, clinical research, business models,
security and privacy, standardization, cross-vendor integration
• Stay tuned for the Trillium Bridge policy workshop in the beginning of 2015.
Trillium Bridge Demonstration 29Tuesday, October 28, 2014
The “Trillium” Team:believers, builders, enterpreneurs
30
EU Member StatesEntrepreneursUS Health Care Providers Standards Developing Organizations
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