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I gave this prezo to Auckland Regional Clinical IS Leadership Group on Feb 21, 2014. It shows how difficult it can be to deal with certain kinds of health information when developing systems by an impressive example (originally from Dr. Sam Heard). Therefore we need rigorous and scientific methods to tackle this - in this case using openEHR's multi-level modelling approach to create a single content model from which all health information exchange payload definitions will be derived. New Zealand's Interoperability Reference Architecture (HISO 10040) is underpinned by openEHR Archetypes to create this content model. The bottom line of the prezo is that almost every national programme starts health information standardisation from the wrong place; most of them are complex technical speficifications, like CDA, which are almost impossible for clinicians to comprehend and provide feedback. The process is flawed! Instead it should start from simple to understand representations, such as simple diagrams, mindmaps etc.and then handed over to techies once clinical validity and utility is agreed upon.That's the beauty of Archetype approach - great tooling and the Clinical Knowledge Manager (CKM) enable clinicians and other domain experts to collaborate and develop clinical models easily.
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The National Institutefor Health Innovation
Getting Clinical Information
Right
Emerging Medication Standards
Koray Atalag, MD, PhD, [email protected]
HISO MemberHL7 New Zealand Vice-ChairopenEHR Programme Lead
Agenda
• The problem
• What’s out there?
• Medication Example
• Methods & Standards
• Recommendations & Discussion
What’s the problem?
• Healthcare is hard!– Breadth, depth, complexity, variability etc.
• So is dealing with health information...– What is a Heart Attack?– Is there such a disease as hypertension?– Is Diabetes a single disease?
• Burning issue: getting a core dataset ASAP– Who will be responsible to govern definitions?– How to coordinate and support dataset teams?– How to get clinicians/experts on the same page?
• An obvious gap in current approach• Start with Medication (+ Allergies & ADR)
So what’s actually out there?
• PMS: each vendor has own data model• GP2GP: great start for structure• NZePS: started with a propriety XML payload, now
waiting for standard CDA – PMS vendors implementing Toolkit based Adapter
• Shared Care / Maternity / St John?• Hospitals?• Labs & Pharmacies?• Others?
Can you really trust incoming data?(without human control)
Unified Medication Definition
• Essential to get it right – first in patient safety!– Needs to be clinically valid, computable and support multiple use
• Reused in many places, including:– ePrescribing, eReferrals– My List of Medicines– Shared Care systems– Patient and clinician portals– Health (status & event) summary– Public Health / Research
• New HISO Connected Care suite of standards– HISO 10043 CDA Common Templates – 10041.1 CDA Templates for Medications, Allergies and Adverse
Reactions just passed public consultation – coming soon
• NZMT / NZULM & Formulary > great start!
Why bother?(with a standard structured Medication model)
“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
Example: Medication timing
Acknowledgement: Sam Heard
Medication timing – and more!!
Acknowledgement: Sam Heard
Medication timing cont.
Acknowledgement: Sam Heard
Medication timing – cont.
Acknowledgement: Sam Heard
Medication timing – even more!
Acknowledgement: Sam Heard
HISO 10040 Interoperability Reference Architecture
10040.1R-CDRs
XDS
10040.2 CCR
SNOMED CT
openEHR
10040.3CDA
Acknowledge Alastair Kenworthy
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
It’s REFERENCE LIBRARY (of reusable clinical information models)
Data & meta-data definitions (data dictionary)Relationships & clinical terminology
Usage of the Content Model
Health Information Exchange & More
Single Content Model
CDA
FHIR
HL7 v2/3
EHR Extract
UML
XSD/XMI
Mindmap
PAYLOAD
System A
Data Source A
MapTo
Content Model
System B
Data Source B
Native CDR / Datamart
Secondary Use
MapTo
Content Model
Automated Transforms
No Mapping
Creating CDA Payload
Draft HISO Medication Standard
Peer review of models
Resulting Models (using CKM Tool)
Who else is doing it?
Other upcoming HISO standards
• 10041.4 CDA Templates for Referral Requests• 10040.4 Clinical Document Metadata Standard• 10050.1 Maternity Data Set Standard• 10050.2 CDA Templates for Maternity Care
Summary• 10052 Ambulance Data Set StandardThey all share common clinical concepts; certainly the
Medication Definition– Who’s responsible for making sure they are aligned?– What mechanism exist to assist dataset developers / clinical
domain experts?– How do you keep them aligned over time / governance?
Options / Recommendations
Who can be responsible for making sure datasets are aligned and interoperable?MoH, NHITB, HISO, HIGEAG, NICLG, other?
What mechanisms to assist dataset developers / clinical domain experts?Policy, principles, guides, examplesHISO 10040.2 Exchange Content ModelTools? CKM but also Word, Excel, mindmaps, UML
How do you keep them aligned over time / support governance?CKM – Not Data dictionary, meta-data registry, Excel
Bottom line
• Content is ‘clinician’s stuff’ – not techy; – yet most standards are meaningless for clinicians
• We need to invest in information– Whatever technology will be
• Method defined in HISO standard– Worked well for Medications
• Let’s build rest of it as we go!– NIHI is keen to facilitate clinical
content development and governance + tooling support
– This will also fulfil MoH “Data Dictionary” need
