Making E-Health workWhy would a clinician be interested in Somantic Interoperability?

Jeremy R L NettleEuropean Healthcare Director Oracle Corporation UK LtdJeremy.nettle@oracle.com

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 LtdJeremy.nettle@oracle.com

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