Underpinnings of the Interoperability Reference

Architecture(HISO 10040)

Koray Atalag1, Alastair Kenworthy2, David Hay3 1.NIHI – University of Auckland2.Ministry of Health3.Orion Health

The Problem• Patient centred integrated/shared care paradigms hinge

on more interconnectivity • We all know about silos: 1+1 >2 when shared• It’s all about People, processes and technology• Standards crucial – but need an overarching framework

– No one size fits all! depends on needs, resources– Myriad of standards, methods etc.– Not so much success so far worldwide

• Narrow opportunity window in NZ to enable sector-wide consistency & interoperability(too many projects in-early flight or kicking off)

State of the world

• US: advanced provider-centric systems but little inter-connectivity (HL7 v2/CDA)

• Canada: CHI providing leadership & standards (v2/v3/CDA)

• UK: bootstrapping from CfH disaster, focus on high value/established systems (HL7/13606)

• Nordic: well established, (↑13606 / HL7 v2/CDA)

• EU: very patchy – HL7/↑13606/openEHR

• Asia: patchy -propriety / HL7 / little 13606/openEHR

• Brazil/Paraguay: mainly openEHR & HL7 v2/CDA

• Australia: Nehta/PCEHR, v2/v3/CDA & openEHR

State of the nation

• Core EHR by 2014 – are we getting there?• National planning, regional implementations• Shared Care and PrimarySecondary

– Shared care projects: long term conditions, maternity, well child etc.

• Clinical Data Repository (CDR) as enabler

– GP2GP, Transfer of Care, eMedications– Medicines reconciliation, specialist CIS– Others: NZULM, new NHI/HPI

• Good emphasis & support for standards

The Principles

1. Align to national strategy: as per national and regional plans

2. Invest in information: use a technology agnostic common content model, and use standard terminologies

3. Use single content model: information for exchange will be defined and represented in a single consistent way

4. Align to business needs: prioritise the Reference Architecture in line with regional and national programmes

5. Work with sector: respect the needs of all stakeholders

6. Use proven standards: adopt suitable and consistent national and international standards wherever they exist (in preference to inventing new specifications)

7. Use a services approach: move the sector from a messaging style of interaction to one based on web services

HISO 10040 Building Blocks

10040.1R-CDRs

XDS

10040.2 CCR

SNOMED CTopenEHR

10040.3CDA

Acknowledge Alastair Kenworthy

What is ECM?

• IT IS A REFERENCE LIBRARY - for enabling consistency in HIE Payload

• Superset of all clinical dataset definitions – normalised using a standard EHR record organisation (aka DCM)– Expressed as reusable and computable models – Archetypes

• Top level organisation follows CCR*• Further detail provided by:

– Existing relevant sources (CCDA, Nehta, epSoS, HL7 FHIR etc.)– Extensions (of above) and new Archetypes (NZ specific)

• Each HIE payload (CDA) will correspond to a subset (and conform)

* kind of – CCDA may be more appropriate

Creating Payload

?

Source System Recipient System

Source data Recipient data

Exchange Content Model

Conforms to

Map Source to

ECM

Map ECM to

Recipient

Message Payload (CDA)

Exchange Data

Object

Web Service

ECM Working Principle

Authoring & HISO process

• Initiated & funded by Health Sector Architects Group (SAG), an advisory group to the NHITB

• 4 co-authors – from Interoperability WG• Initial feedback from SAG then publish on HIVE• ABB produced - condensed version of IRA (2011)• Public comment and evaluation panel October 2011• Ballot round February 2012• Interim standard April 2012• Trial implementation with Northern DHBs, 2012/13

Archetypes• The way to go for defining clinical content

CIMI (led by S. Huff @ Intermountain & Mayo) In many nat’l programmes (eg. Sweden, Slovenia, Australia, Brazil)

• Smallest indivisible units of clinical information with clinical context• Brings together building blocks from Reference Model (eg. record

organisation, data structures, types)• Puts constraints on them:

– Structural constraints (List, table, tree, clusters)– What labels can be used– What data types can be used– What values are allowed for these data types– How many times a data item can exist?– Whether a particular data item is mandatory– Whether a selection is involved from a number of items/values

Logical building blocks of EHR

Compositions

EHR

Folders

Sections

Clusters

Elements

Data values

Entries

BP Measurement Archetype

Extending ECM• Addition of new concepts• Making existing concepts more specific

– powerful Archetype specialisation mechanism:– Lab result > HbA1C result, Lipid profiles etc.

Problem

Diagnosis

Diabetesdiagnosis

Text or Coded TermClinical descriptionDate of onsetDate of resolutionNo of occurrences

Coded Term+GradingDiagnostic criteriaStage

+Diagnostic criteria Fasting > 6.1 GTT 2hr > 11.1 Random > 11.1

First level specialisation

Second level specialisation

ECM > HIE Payload

Case Study: Medication

• Essential to get it right – first in patient safety!• Single definition of Medication will be reused in many places,

including:– ePrescribing– My List of Medicines– Transfer of care– Health (status & event) summary– Specialist systems– Public Health / Research

• Currently no standard def in NZ(coming soon 10043 Connected Care)

• NZMT / NZULM & Formulary > bare essentials

Current state & projects

• PMS: each vendor own data model• GP2GP: great start for structure• NZePS: started with propriety model, now waiting

for standard CDA. – PMS vendors implementing Toolkit based Adapter

• Hospitals: some using CSC MedChart • Pharmacies?• Others? Actually we’re not doing too bad

Why bother?(with a standard structured Medication definition)

“If you think about the seemingly simple concept of communicating the timing of a medication, it readily becomes apparent that it is more complex than most expect…”

“Most systems can cater for recording ‘1 tablet 3 times a day after meals’, but not many of the rest of the following examples, ...yet these represent the way clinicians need to prescribe for patients...”

Dr. Sam Heard

Medication timingDose frequency Examplesevery time period …every 4 hours

n times per time period …three times per day

n per time period …2 per day…6 per week

every time period range …every 4-6 hours, …2-3 times per day

Maximum interval …not less than every 8 hours

Maximum per time period …to a maximum of 4 times per day

Acknowledgement: Sam Heard

Medication timing cont.Time specific ExamplesMorning and/or lunch and/or evening

…take after breakfast and lunch

Specific times of day 06:00, 12:00, 20:00

Dose durationTime period …via a syringe driver over 4

hours

Acknowledgement: Sam Heard

Medication timing cont.Event related ExamplesAfter/Before event …after meals

…before lying down…after each loose stool…after each nappy change

n time period before/after event

…3 days before travel

Duration n time period before/after event

…on days 5-10 after menstruation begins

Acknowledgement: Sam Heard

Medication timing – still cont.Treatment duration ExamplesDate/time to date/time 1-7 January 2005

Now and then repeat after n time period/s

…start, repeat in 14 days

n time period/s …for 5 days

n doses …Take every 2 hours for 5 doses

Acknowledgement: Sam Heard

Medication timing – even more!Triggers/Outcomes ExamplesIf condition is true …if pulse is greater than 80

…until bleeding stops

Start event …Start 3 days before travel

Finish event …Apply daily until day 21 of menstrual cycle

Acknowledgement: Sam Heard

Modelling Medication Definition

• NZePS data model (v1.9) & draft 10043 Connected Care CDA templates

• Start from Nehta ePrescribing model– Analyse models and match data elements– Extend where necessary as per NZ requirements

• Add new items or rename existing• Tighter constrains on existing items (e.g. cardinality,

code sets, data types)

Nehta Medication Model

Results & Outlook

• Extended model 100% covering NZePS (community ePrescribing)

• Must consider secondary care• Need to look in more detail:

– Consolidated CDA– epSoS (European framework)– Other nat’l programmes

• Generate Payload CDA using transforms

Value Proposition• Content is ‘clinician’s stuff’ – not techy; yet most existing standards are

meaningless for clinicians and vice versa for techies– Archetypes in ‘clinical’ space – easily understood & authored by them

• Single source of truth for entire sector– One agreed way of expressing clinical concepts – as opposed to

multiple ways of doing it with HL7 CDA (CCDA is a good first step)• Archetypes can be transformed into numerous formats – including CDA• Archetypes are ‘maximal datasets’

– Much easier to agree on• Scope not limited to HIE but whole EHR; workflow supported• ECM principle invest in information fulfilled completely

– future proof content today for tomorrow’s implementation technology (e.g. FHIR etc., distributed workflows etc.)

Thank you – Questions?

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