The Medication Supply Registry The Medication Supply Registry Project & DemonstrationProject & Demonstration

in The Netherlandsin The Netherlands

The Medication Supply Registry The Medication Supply Registry Project & DemonstrationProject & Demonstration

in The Netherlandsin The Netherlands

A co-production byNICTIZ – HL7 the Netherlands – IT industry

Tom de JongHL7 the Netherlands

What is NICTIZ?

• Not-for-profit organisation• Founded by healthcare stakeholders:

– Ministry of Healthcare– Organization of IT Vendors in HC– Dutch HC Insurers Organisation– Organisation of HC Providers– Patient representation groups

• Funding by Ministry of Health (for a 5-year ‘trial’ period)

Current developments in Dutch healthcare

• Shift from administration and billing processes to clinical care itself.

• Very little central coordination in the creation and application of standards

• Restructuring of healthcare (mergers).• Shift from intra-institutional to

inter-institutional cooperation and a resulting need to share information throughout the ‘chain of care’.

Care regions

Ermelo

Harderwijk

Lelystad

Amersfoort

Almere

Mental hospital

Riagg

MFE

Ribw

Riagg

One solution: Service Centres

(e.g. in a hospital)

Hospital

Dependance

Pharmacy

GP

GP

GP centre

Hospital

Pharmacy

Dentist

Ophthamologist

GP

Laboratory

GP centre

Hospital

Dependance

Pharmacy

GP

GP

GP centre

Centrum voorRevalidatie

Mental hospital

Riagg

MFE

Ribw

Riagg

Regional Care Networks

Solutions

• One big EHR database with healthcare info for 16 million people

• Leave data at the source, but register a reference to it in a central repository (‘Act Registry’ in HL7 speak)

• A hybrid solution?

Features of the Care Information Broker (ZIM)

• Data itself it not copied in the registry• Interested parties use a pull mechanism (query) instead of

a proliferation of notification messages between systems.• Advantages

– Always the most recent data from the ‘virtual’ DB– No risk of inconsistencies due to duplication– No exponential growth in # of interactions

• Drawbacks– All interactions have to be standardised, which results in demands

to vendors, providers, etc.– The ZIM itself will have to be built and maintained by either a

central authority or a third party vendor

Care Information Broker functions

• Maintaining the Act Registry:– Process updates from HC systems– Process queries from HC systems

• Identification, Authentication(infrastructure & safe data transport are a requirement)

• Authorisation• Logging

Virtual data warehouse

Linking ZIMs together…

UZI ZIN

ZIMSCH

Lokaal

Regionaal

Nationaal

I&A

VWI

LOG

ZIR

AUF ZRAB PR

AUT

GBZ

ZA PD

GP

ZS

AUF

ZIMSCH

I&AMI

Identification Schemes

• ZIN: Care Identification Number

• UZI: Unique Care Provider ID

• UZOVI: Unique Care Insurer ID

The first ‘ZIM-based’ project

• Obtain ‘proof of concept’ for:– Query and response for Medication Supply,

based on HL7 version 3 models and messages– Use of an Act Registry (Care Information Broker)

to share medication supply information transparently

• Demo at Dutch Medical IT Conference:– Representative selection of IT vendors– Implementation of abovementioned concepts– Near-complete, realistic and ‘live’ operation of V3

interfaces within infrastructure of conference network

• Some limitations were agreed upon:– No authentication, authorisation etc.– XML based on ‘simple’ TCP/IP protocol– All unique identifiers are assumed to be in place– Single vendor selected for implementation of Act Registry

Act Registry

• Notification (upload) of a medication supply to theAct Registry

• Two versions:– Light version– Extended version

R-MIM Act Registry

Information concerning the ‘Act’

that is being ‘uploaded’ to the

Act Registry

1st participation is the patient.

2nd participation is the care provider that is

the source of the medication supply

A common element (CMET)

is used for the patient.

A common element (CMET) is used for the care provider.

R-MIM Act Registry (Lite)

CMET R_PatientLite

Zorg Identificatie nummer

Patiënt naam

CMET R_AssignedEntity

Unique Care Provider ID (UZI)

Care provider can be a person or an organisation

Interaction scheme Act Registry

• Application roles – – Sender: Act Reference Notification Informer– Receiver: Act Reference Notification Tracker

• Set of related messages

MFMT_AR100001NL: Act Reference Notification Informer – Active Only

MFMT_AR100002NL: Act Reference Notification Tracker – Active Only

Add Act to RegistryMFMT_ST000011NL

MFMT_IN100010NL Act Reference Registry Entry Created

MCCI_IN000002 Accept Acknowledgement

Interaction

Act Reference Lite Registry Entry Created (MFMT_IN100050NL)

Sending Role Act Reference Lite Notification Informer MFMT_AR100007NL

Receiving Role Act Reference Lite Notification Tracker MFMT_AR100008NL

Trigger Event Activate Act Reference Lite MFMT_TE100050NL

Message Type Act Reference Lite – Add MFMT_MT100300NL

Wrapper Type Registry Act Wrapper MFMI_RM700700

Query and responseMedication Supply

• What should the query result set be?– All medication supplies/dispenses (definition?)

for/to a specific patient (within a certain interval).– Both a specific pharmacy and the Act Registry (as

an information broker for a group of pharmacies and care providers) can be queried.

• Query implementation based on the generic query framework from HL7 version 3– First (successful) practical application?

• Query response has similar (same?) payload as unsolicited Medication Supply message

The Medication Supply Message (I)

• Challenge: the Medication Information section of the V3 ballot was ‘frozen’; its status was unclear.

• Dutch work was based on parallel work in the UK (Hugh Glover et al), which was shared with us.

• Modified D-MIM (domain model) and message definition for Act Registry Upload and Medication Supply Query were developed within the task force.

• Feedback of results in the international standard is in progress and will lead to final harmonization.

• Minimal discussion with the IT vendors to ensure efficiency in preparing for the conference demo evaluation and extension with care provider organizations and IT vendors will continue in 2004.

The Medication Supply Message (I)

• Information contents of V3 messages were checked with EDIFACT message currently in use between Dutch community pharmacies.

• Result: first (partial) mapping of EDIFACT pharmacy messages to HL7 v3 models.

• Comparison and mapping to HL7 v2 messages (used within hospitals) will follow.

• But there are even more ‘competitive’ standards that will have to be ‘harmonized’.

Medication supply Query & Response

• Query with query parameters is sent to a ‘query responder’

• ‘Query responder’ collects medication supplies that answer to query parameters and sends the answer to ‘querying application’

• Act Registry may be used, but the interactions are the same for direct communication between querying application (e.g. EHR) and query responder (i.e. source pharmacy).

R-MIM Medication Query

Medication usage interval

Medication supply interval

Supply ID

Query definitionID, status: New

Preferred sort order

ZIN; mandatory

R-MIM Query response

Interaction scheme Query & query response

• Application role – – Requester: Substance Supply Event Query Placer – Fulfiller: Substance Supply Event Query Fulfiller

Interactions

Sending Role Substance Supply Event Query Fulfiller PORX_AR100020

Receiving Role Substance Supply Event Query Placer PORX_AR100010

Trigger Event Substance Supply Event Query Response PORX_TE100002

Message Type Substance Supply Query Response PORX_MT100400

Interaction Type Substance Supply Event Query Response QURX_IN100002

Wrapper Type Query response QUQI_RM120000

Substance Supply Event Query Response

Sending Role Substance Supply Event Query Placer QURX_AR100010

Receiving Role Substance Supply Event Query Fulfiller QURX_AR100020

Trigger Event Substance Supply Event Query QURX_TE100001

Message Type Substance Supply Query. QURX_MT100401

Interaction Type Substance Supply Event Query QURX_IN100001

Wrapper Type Query QUQI_RM020000

Substance Supply Event Query

Project context

• Start of project May 1 (announced late April).• Parallel paths:

– Creation of Implementation Guide for Act Registry Upload and Medication Supply Query & Response.

– Bringing together a representative group of IT vendors; convincing them to invest and participate in the demo.

• Implementation guide delivered first week of July.• After that, getting the interface specialists from the

vendors involved turned out to create an excellent environment for active cooperation in the project.

The ICT vendors (I)

• Participating companies:– Community pharmacy systems: MicroBais, EuroNed

(a special ‘OZIS gateway’ was developed to allow use of existing standards for querying the Act Registry; upload not yet possible)

– Hospital pharmacy systems: Falcon– HIS/EHR vendors:

ChipSoft, McKesson, 2Cure, Infocare– Act Registry was implemented by LifeLine

• Two GP systems were involved, but were allowed to send proprietary prescription messages to the ‘OZIS gateway’.

• Realization of interfaces between August and October: – HL7 Netherlands task force gave support where necessary– Intermediate communication was mainly handled by e-mail

• Interface realization was greatly expedited by use of XSLT scripts to transform from EDIFACT-XML to HL7 v3-XML.

The IT vendors (II)

• Integral test sessions on October 29/30 at NICTIZ (with all participating vendors & HL7 NL present).

• Atmosphere of energetic, enthusiastic cooperation (‘innovation can be fun’).

• NICTIZ took care of facilities and politics, HL7 task force handled message implementation

• Conclusions: – Implementation guide (almost) ensured plug-and-play– Quick-and-dirty coding could be done in one day– Act Registry concept and message interfaces worked!

The MIC demo

• NICTIZ had prepared all conference attendees as ‘patients’ (marketing instrument)

• Some ‘Murphy’s Law’ issues were corrected on the night before the conference started;-)

• Demo performed excellently at all vendor stands (visitors could follow a realistic route through the ‘simulated care chain’)

• Politicians and other ‘budget makers’ made this tour too and saw something that worked

Conclusions

• Great sense of enthusiasm (‘proof of concept’)• Unique synergy between competing vendors

(important to maintain and expand on this while it still exists)

• Breakthrough event for NICTIZ (important for its role as a catalyst in health IT innovation)

• Breakthrough event for HL7 NL and V3(important for its role as a catalyst in interface standardization)

• Follow-up projects to build on this foundation:– Working on a complete interface specification with all

parties involved (care providers and IT vendors)– Try to move from “I’ll join if you…” to “please, can I join”

• Important 1st step towards goal of having a national medication record online by 2006.

Questions