Integration projects and HL7 implementation
atWrightington, Wigan & Leigh
NHS TrustPhilip Firth
IM&T Strategy Implementation ManagerWrightington, Wigan & Leigh NHS Trust
Introduction
Background to projects in Wigan Acute
Look at some of the integration issues that Acute Hospital NHS Trusts typically need to address
Look at an example project with complex integration needs – Accident & Emergency
Look at requirements for linking Acute Hospital NHS Trust systems to LSP solutions and the Spine
Existing Systems Integration
- Maximizing local IT investment
- Delivering functionality which meets local requirements
- Delivering functionality which maybe out of scope for NPfIT
Current integration architecture at WWL
Acute Systems Integration
Typical Issues
Standards - what standards???
Interface standards/output formats in Wigan– HL7 v2 (various implementations of)– EDIFACT– ASTM– System specific output – eg. Torex PAS
openlink
Acute Trusts need to learn to work with what’s available !!!
Implementation issues - PAS
PAS ‘real-time’ interface
No guarantee that messages would be delivered in the right order – Could get an Admission message prior to a Patient
Registration
Had to introduce a 15 minute time delay
Result: bed-status in EPR system slightly out of sink
Implementation issues - Pathology Handling previous results – append or overwrite?
– Microbiology – overwrite– Haematology, Chemistry – currently append
Collection date and time not always supplied Reference ranges can change
– Implication for graphing
Sensitive tests– What is the best way to deal with HIV, GUM, pregnancy
tests etc?
Implementation issues - Pathology Multiple patient IDs (NHS number, Hospital number) Multiple casenote numbers (Trust mergers)
– Need to establish systems for cross referencing patient IDs
Missing patient ID Pathology system sending internal patient ID Missing key patient data – DOB, Gender
– Unable to guarantee a match – need to Dump message
Data Quality Biggest issue by far is unique person referencing
Major education / change mgmt task to
– Get patient administration staff to register patient details accurately and avoid duplicates
– Get clinicians to use the Hospital / NHS Number
Problem especially big in emergency care
Issue has a huge knock on effect for the remainder of each episode care
Example: A consultant asked me to investigate why a particular chemistry result did not appear in the patient’s EPR record
In this instance the patient ID recorded in the Hospital Number field turned out to be the patient’s telephone numberMSH|^~\&|MLAB||||20040519113446||ORU^R01|X99156|P|2.3
PID|1||217779^^^^PAS~773702^^^^DEP||SURNAME^FORENAME^^^||19371113|M|||999 ACACIA AVENUE^ORRELL^WIGAN^^WN9 9XX|||||
ZMP|G3417810^^NAT^SS^^L|^^L
ZPV|AE|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|ACC|CC|CH|20177803|20040519|200405191026||FITS.|U||P
OBR|1||20177803^CCMLAB|CC_RUEGK^Urea, Elects. Gluc (urgent)^L^^^L|||20040519||||||FITS.|200405191026||&AP^PINTO^A.^^^Mr.||||||||CH|F||^^^20040519^S|
OBX|1|ST|CC_TONA^Sodium^L^44I5.^^RC||140|mmol/L|135-145|N|||F
Data Quality
Lesson: CANNOT use patient ID as the sole identifier – also need to cross reference with patient’s DOB, Gender, Surname …
Addressing data quality issues in Casualty
Solution Integrated emergency floor system
New emergency floor system is integrated with PAS to enable staff to retrieve up-to-date patient demograhics, including NHS Number
New emergency floor Pathology / X-ray requests automatically include patient ID - improvement departmental system data quality
New emergency floor system will be able to automatically register new patients on PAS - improvement 24 hour bed status
Patient ID data quality
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IDIntegrated
emergency system live
Addressing data quality issues in Casualty
Issues that are not so easy to address …
Real-time data capture – Not easy when an A&E receptionist is face to face with a patient
who is either • Confused• Uncooperative• Abusive• Unconscious
– Addressing these issues is proving to be a much more challenging task!!!
Addressing data quality issues in Casualty
Rapid application development approach :
(1) Present the HL7 results in the EPR test system environment via a stylesheet, and ask the domain experts for comments
(2) Amend stylesheet, and repeat (1) until domain experts are happy to sign off stylesheet design
(3) Implement stylesheet in live EPR system
Addressing presentation issues using XSL Stylesheets
Microbiology example - Legacy Pathology System view
Sensitivities in a fairly non user-friendly cross tabulation format
HL7v2 messages
A Culture and Sensitivity result is reported using multiple OBX segments.
A single organism result comprises an Organism OBX segment with subID N followed by an Organism Growth OBX segment with subID N followed by zero, one or more Organism Sensitivity OBX segments also with a subID value of N.
Microbiology
The final stylesheet design was deemed an improvement to the legacy system text based screen
More user-friendly cross tab for Organism vs Sensitivities
Critical issue - TIME Building interfaces is not a 5 minute job
Tasks TIME– Find funding to initiate project ? (show-stopper?)– Design interface, agree end-to-end requirements 1-3 months ?– Supplier set-up / configure interface 1-3 months ?– NHS Trust set-up / configure interface 1-3 months ?– End-to-end testing 1-3 months ?– On-going Stylesheet development ?
In summary, even a bog-standard unidirectional HL7 interface could take anything from 3 to 15 months, from start to finish
Key benefit of basing your integration architecture
around XML
EXCHANGE OF BOTH DATA AND
PRESENTATION
Data and Presentation Web technology is enabling the Trust to
benefit from both
Data exchange: development of interfaces which move XML patient data between an EPR (an XML clinical repository) and other departmental systems
Presentation: development and sharing of stylesheets which present a common view of departmental system data across multiple applications
ExampleBi-directional transfer of data and presentation between EPR and A&E EPR
Electronic Patient Records
Emergency FloorElectronic Patient
Records
Discharge Letters, Emergency Care summary
Pathology results, Patient demographics
Data and Presentation
JOIN
Shared XML data and stylesheets
Haematology result in the EPR system
Haematology result in the A&E system
Addressing data quality and change issues
Planning ahead for NPfIT / LSP integration
The clinician's perspective on electronic health records and how they can affect patient care. BMJ 2004;328:1184-1187 (15 May)
Many attempts to get clinicians to use electronic health records have failed, often because of difficulties with data entry.
Kay and Purves maintain that narratives are at the heart of clinical decision making and refers to this concept as "narrative reasoning
Van Ginneken states that many computerised medical record systems are rejected by clinicians because they are not based on a story metaphor
Challenge: How to get clinicians to enter ‘coded’ information into a computer when they would prefer to hand write on paper or type essays into a free text box?
Emergency Floor system design Change management issues
– A&E clinicians had never previously entered clinical data into a computer – all notes were recorded on a paper cascard
– Solution had to be QUICK and USER-FRIENDLY !!!
Single screen to record all discharge information
Order comms – all requests for investigations recorded
Treatment given – point and click
Drugs administered – point and click
Diagnosis – point and click
Clinician notes – free text
Emergency Care System
Emergency Floor system designSimple / Quick point and click data capture
Emergency floor system
Discharge screen auto generates an XML discharge summary message
Stylesheets to produce 2 documents on discharge:
(a) Patient letter
(b) GP letter
Emergency floor discharge summaries
Discharge summaries are currently stored in XML format and presented on screen using an XSL stylesheet (A&E and EPR systems)
Diagnosis values are coded ICD10, but can easily be coded in SNOMEDCT as well
XML data could be transformed into valid HL7v3 Provision of care messages using XSLT prior to routing to the Spine
NPfIT Integration Challenges
Scope - NPfIT clinical messaging
The scope of Phase 1 clinical messaging is very big and complex
It is HL7 version 3 which is new to the majority of people in health informatics
Primary CareLSP / Existing
EBS Slots (provide and fill)Referral
OOH Encounter **
NHSDEncounter **
Phase 1 Clinical Messaging Flow Summary
Any PSIS / NCRSAccredited
System
PSIS Query
Secondary CareLSP / Existing
PoCDischarge Report
(Inpatients)or
PoCCare Event
Report(Out Patients)
PoC Disch or Care Event Report
ETP
Pharmacy
PrescribeCancel
Full / PartialDispense
PSIS
Medication Updates
SAP
SAP Encounter(PoC Care
Event Report)
GP2GP
DiagnosticImaging
DIReport
DI Report
DIEncounter
DI Requestor
Care EventReport
(Primary Care)
PoC
Emergency Admission Notification **
A&EA&E Report **
Mental Health
AdmDisch
CPA Summary
Adm / Disch /CPA SummaryNotifications
NOTE: Flows marked with ** are also sent to PSIS but not shown on this diagram for ease of reading
Existing Systems Integration
Replacement of NHS IT systems will not happen overnight in Acute Hospital Trusts
Key department systems may not be replaced before 2010
Existing systems integration is therefore a key issue for Acute Hospital Trusts
Potential LSP Interfaces
LSP Interface Engine
NCRS Spine
Trust Interface Engine
LSP enables interface and publishes specifications and updates (ongoing process)
Appropriate interfaces developed and implemented for existing trust systems
Specialist orDepartmental
Systems
LSP Core Solution
Specialist orDepartmental
Systems
Trust
LSP
Other systems(not connected)
Existing specialist or departmental systems will interface to the
LSP core solution NOT directly to the Spine
Spine compliance
LSP compliance
LSP Existing Systems Integration Single logical link between LSP data centre
and the Authority Service Recipient via N3
Messages HL7 V2.4 and encrypted
Integration engine required (Seebeyond license is free for CSC TIE use only)
Inbound messages must be agreed with NPfIT(conforming to the rules referenced in CRS Interactions with Existing System (NPFIT-FNT-TO-TAR-0004) and Principles for CRS Clinical Data Access by Local NHS Systems (NPFIT-FNT-TO-TAR-0006.01))
WWL / CSC NPfIT integration approach