IDH Seminar – Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Connected Health: The Challenge of Interoperability

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Connected Health: The Challenge of Interoperability Slide 1 Theodoros N. Arvanitis, RT, DPhil, CEng, MIET, AMIA, NYAS, FRSM Professor of e-Health Innovation and Head of Research, Institute of Digital Healthcare, WMG, University of Warwick Affiliate Professor of Health Sciences, Warwick Medical School, University of Warwick Honorary Clinical Scientist, Birmingham Childrens Hospital NHS Foundation Trust Digital Theme co-Director, NHS West Midlands AHSN

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Power of information The improved understanding of the whole healthcare and wellbeing pathway for individuals depends on the power of healthcare information, being made readily available and easily interpretable by both humans and machines. Slide 2

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Community Care Hospital Care Primary Care Social Care Motivation for interoperability Slide 3 towards an enhanced integrated care approach

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Health Information Exchange Source: https://himsshie.pbworks.com/w/page/4775490/HIEDefinition The challenge of interoperability Slide 4

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Representing healthcare knowledge The foundation of interoperability lies with a shared understanding of data representation and concepts between systems: syntactic (messaging/model- based) semantic interoperability it is necessary to establish syntactic (messaging/model- based) and semantic interoperability to represent knowledge in a computable form Slide 5

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Connected Health Interoperability Challenge Slide 6

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Main Entry: interoperability : ability of a system... to use the parts or equipment of another system Source: Merriam-Webster web site interoperability : ability of two or more systems or components to exchange information and to predictably use the information that has been exchanged. Source: IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries, IEEE, 1990] The concept of interoperability II Semantic interoperability Syntactic interoperability (interchange) Source: Charles Mead, CaBIG Slide 7

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Importance of interoperability The Goal: healthcare and patient-related information enrichment The Challenge: Developing a user understandable, computable and extensible knowledge representation scheme for capturing healthcare concepts and information (knowledge) Patient-Centric World: From EHR to PHR Slide 8

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis 9 Continuous Pathway of Care Application level Logical level Technical level presentation clinical content model format & storage transmission Semantic interoperability Technical interoperability terminology functionality presentation clinical content model format & storage transmission terminology functionality Integrated Care Interoperability Adapted from the Antilope Project ALT model Interoperability at different levels EHR PHR Slide 9

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis 10 Technical (syntactic) interoperability Source: http://www.altova.com/HL7_technology_primer.html

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Standards Development Organizations and associated groups are engaged in activities to develop and implement standards for elements of both syntactic and semantic interoperability, e.g. Health Level Seven International (HL7) clinical information systems standards and others such as DICOM, ISO, W3C, etc. Integrating the Healthcare Enterprise (IHE) shaping the integration of standards by facilitating the concept of sharing information in the healthcare enterprise. Clinical Data Interchange Standards Consortium (CDISC) providing standards to support the acquisition, exchange, submission and archive of clinical research data and metadata The Role of Standards Slide 11

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis An example from the clinical care perspective The screening for hearing loss in newborns before hospital discharge is now considered a standard of health care in the United States and is referred to as Early Hearing Detection and Intervention (EHDI) Sponsored by CDC - an ambitious program that can potentially capture the whole of the newborn population Establishes bi-directional information exchange between clinical care and public health in a relatively simple and feasible way by using HL7 standards and IHE implementation approaches Slide 12

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis EHDI Standards-based Information exchange IHE Newborn Admission Notification Information (NANI) HL7 EHDI Messaging Data Standard Trial Use (DSTU) IHE Early Hearing Care Plan (EHCP) CQM EHDI Clinical Quality Measure (CMS 31v1/NQF 1354) IHE Quality Measure Execution (QME-EH) IHE EHDI Cross-enterprise Workflow Document Labor & Delivery Newborn Screening State EHDI Program Federal Reporting Care Tasks & States e-Measure Definition Specialist HL7 v2 HL7 CDA R2 HL7 HQMF HL7 QRDA Medical Home Source: John Eichwald, Team Lead of CDC EHDI Slide 13

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Slide 14 of 21 Semantic interoperability

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Towards Semantics: Models Containers of clinical content dialect and meaning is needed Source: HL7 Slide 15

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Informatics tower of Babel: the grand challenge Common Semantics? Each part of the health community speaks its own scientific dialect (e.g. lab values, genetic profile, clinical data) Lack of consensus on common standards and terms Recently, convergence of terminology-base standardisation efforts Enterprise vocabulary services: ontology-based to drive mappings between various terminologies Avoiding the informatics Tower of Babel problem (coined by caBIG project) Slide 16

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Aspects of terminological systems Enterprise-level Vocabulary Services Efforts Terminology-based standardisation efforts Practitioner-based technologies Language independenceLanguage Dependence OntologyTerminologyNatural Language/ structured language (epistemology based) Model of the domain: Taxonomy, relationships & constraints Expert domain Representation Unique preferred terms Well defined of terms Pragmatic Representation of domain Clinical use and dissemination The Tower of Babel effect Slide 17

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Terminological systems components ComponentDefinition TerminologyList of terms, domain dependant language dependence ?? ThesaurusList of ordered terms + synonyms ClassificationOrdered system of concepts (implicit or explicit rules) DictionaryStructured collection of lexical units, with linguist information about each of them VocabularyDictionary of specific terminology (definitions) language dependence ?? NomenclatureSystem of terms composition rules Coding systemCodes as designators to terms Slide 18

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Example of terminological systems SNOMED-CT: Terminology, Thesaurus, Classification, Vocabulary, Nomenclature, Coding System ICD-10: Terminology, Thesaurus, Classification, Vocabulary, Nomenclature, Coding System ICPC2: Terminology, Thesaurus, Classification, Vocabulary, Nomenclature, Coding System Complete Terminological Systems Slide 19

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Desiderata for terminological systems Comprehensiveness - Completeness Do we need to cover all aspects of Healthcare re-inventing the wheel? Fit for Purpose - Utility Multiple purposes (trials, safety, decision support, workflow, clinical care,etc.) How do we measure its utility to different stakeholders Does a good information model and ontology exist? Are these two aspects needed? Multilingual applicability Do we need a language independent formal concept representation? Representation in multiple languages that goes beyond the direct translation and uses conceptual context? Reliability Do we get the same results across different users Validity Clinical validity - evidence Interoperability Do we achieve syntactic and semantic interoperability? Sustainability Commitment to stability with earlier versions - dependence on other organizations? Slide 20

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Example project: TRANSFoRm I Translational Research and Patient Safety in Europe 5-year project (2010-2015) EU funding 21 partners 10 EU member states Aims to deliver a digital infrastructure that facilitates the reuse of primary care electronic Health Records (eHR) data to improve both patient safety and the conduct and volume of clinical research in Europe Slide 21

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Slide 22 Example project: TRANSFoRm II

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis TRANSFoRm Itegrated VS The TRANSFoRm Integrated Vocabulary Service is designed to allow end users to search and retrieve clinical vocabulary concepts and associated content a web interface and a web service API the service uses the LexEVS (version 5.1 and 6.0) technology to access a backend UMLS vocabulary database the service uses direct Java Database Connectivity (JDBC) to access other vocabulary databases (e.g. Read Codes V2, ICPC2) Slide 23

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis UMLS as the basis of terminology cross mappings Slide 24 Approach

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Example terminological mappings Read Codes (RCDv2) and International Classification of Primary Care (ICPC2) corpus of terms and their associated mappings created to cater for the initial need of the existence of specific primary care oriented terminologies. The UK NHS Connecting for Health Terminology Centre - mappings from Read Codes version 2 to SNOMED CT. The Read Codes v2 database in Transform VS is set up based on this mapping so that Read Codes 2 concepts can be linked to a UMLS search. Similar approach for ICPC2. ICPC2-ICD10 Thesaurus and mappings - Transition Project @ University of Amsterdam The TRANSFoRm team has updating the ICPC2-ICD 10 mapping and Thesaurus UMLS Metathesaurus Read Codes v2 Codes SNOMED CT Codes ICPC2 Codes ICD-10 Thesaurus/Codes UMLS Metathesaurus

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis A screenshot of the vocabulary service web-based interface Slide 26

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Example: Selecting an event type

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Select diagnosis codes

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Add concept to diagnosis

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Thing Entity Continuant IndependentDependent Material Chemical -> Form -> Product Molecular -> DNA -> SNP Object -> Human -> Patient Information Content Document -> Rx Directive -> Act -> Rx item Directive -> Condition -> Rule Label -> Measurement unit -> Unit label Data item Measurement datum Systolic measurement Lab measurement Pulse rate measurement Clinical finding -> Phys Exam Clinical finding -> Lab finding Diagnosis Prognosis length -> human height Mass -> dose phenotype -> gender pressure -> diastolic pressure Quality Models of how clinical content is organised Slide 30 The Clinical Data Information Model (CDIM) of the EU FP7 TRANSFoRm project

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Current Challenges Language terminological systems might reflect local Politics Ethics Tradition specialty specific Social organization e.g. NHS/Primary-care Standardization Different use of data at the national Clinical care, secondary use, research, etc. Slide 31

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Desiradata for TRANSFoRm Vocabulary Services: High-level Open Questions International or European terminological systems Challenge of multilingual systems in Europe Importance of appropriate existing terminological systems Issues of implementation Issues of user acceptance Can these be used in patient-centric integrated care paradigm? Food for thought

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Towards an integrated care Slide 33

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Challenges for PHR: the UK experience NHS Connecting for Health: 20bn programme to develop and run NHS IT systems Patient Summary Care Records stored on centralised database (Spine) with pointers to Detailed Care Records in regional databases Electronic prescriptions Choose and book Barriers: 50% of GPs will refuse to upload medical records to central "Spine" without patients' permission 80% think Spine puts patient confidentiality at risk 79% think new system will be less secure Challenges for an integrated PHR approach: the UK Example

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Digital Health Vision : to deliver the first UK Regional Digital Health ecosystem Co-Production of integrated solutions Interoperability & Integration Wide Health and Wealth Improvement Semantic Interoperability: Central to Healthcare

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Looking into the future Slide 36 The only way you can predict the future is to invent it. Alan Curtis Kay Pioneer Computer Scientist Jazz Guitarist, Composer and Theatrical Designer The challenge of interoperability brings the opportunity of connected health with the patient at the centre

IDH Seminar Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Thank You [email protected] Slide 37

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IDH Seminar – Connected Health: The Challenge of Interoperability - 23 October 2014 Professor T.N. Arvanitis Connected Health: The Challenge of Interoperability