A document oriented approach to building a national EHR - applying CDA R2 in Finland

Transcription

1 International HL7 Interoperability Conference IHIC 2006 A document oriented approach to building a national EHR - applying CDA R2 in Finland Jari Porrasmaa & Vesa Pakarinen (VTT ) University of Kuopio, HIS R&D, SerAPI project Association of Finnish Local and Regional Authorities,Core dataset project HL7 Finland, technical committee member HL7 Service Oriented Architecture SIG co-chair (HL7-OMG HSSP)

2 Agenda Background and situation in Finland CDA R2 Other ongoing development Summary

3 "Terveyshanke", health project building national EHR Before the national healthproject IT strategy for healthcare 1997 Regional Information systems, Makropilotti project, regional information systems for sharing patient records CDA R1 implementations (starting from late 90's) Regional systems geographic coverage 50% of Finland Council of state decision principle: "A national EHR by the end of 2007" interpreted as improving the interoperability of existing EPR software 200 M program for for achieving this, municipalities provide additional funding

4 History: The unified paper based continuing record system for specialized care ("the green book") late Primary care has a similar standard HENKILÖ- PERSON TIEDOT DEMO- GRAPHICS YHDIS- HEALTH TELMÄ HISTORY YLE SIS KIR PSY Overview level LPSY Summary level, medical specialities SOS LAB RAD OPER VEREN BLOOD - SIIRTO LÄÄ MEDS PSY ANS RR DIA KUUMEKU FEVER LÄHETE REFER PSYC HOSU PLAN HOSU CARE TAUDIN- KULKU JA HOITO detailed level forms Service specific forms (blood trans, radiology, lab,..) Program specific (diabetes, meds,...) Care episode specific, daily notes, nursing plan

5 Example: overview, health history Risk information Problems, diagnosis, complications Other significant information Episode: date and care facility

6 Example: summary level Structure: main heading sub headings text blocks and data elements Example is a summary of a 16 day care episode of a cardiac patient, summary contains overview of treatment and plan for continuity of care Heading vocabulary Medical speciality or other summary code

7 National person identifier Everyone has one, you get it 1-2 days after birth, foreigners registered on request National person registry, basic person demographics updated centrally and spread around the society (banking, postal service, healthcare, municipalities,...) Established in 1969, computerized in 1971 Batch updates and real-time queries Simplifies things quite dramatically! Still need person identification service to handle that 0,1% of patients

8 Cluster projects for implementing structured record and CDA implementation TietoEnator + "100" primary care installations MediciData Esko Lappi Länsi-Pohja Pohjois- Pohjanmaa Vaasa WMData "100" primary care installations Helsinki-Uusimaa Pirkanmaa Pohjois-Savo Varsinais-Suomi Etelä-Karjala Etelä-Pohjanmaa Etelä-Savo Itä-Savo Kanta-Häme Keski-Pohjanmaa Keski-Suomi Kymenlaakso Pohjois-Karjala Päijät-Häme Helsinki Turku Kuopio Tampere Effica Esko Miranda Effica Miranda Esko Esko Effica Miranda Effica Effica Effica Effica Effica Esko Miranda Effica Effica Useita muita (Kalvo STM 2005)

9 National Actor for healthcare IT: The Social Insurance Institution of Finland Job: organize, setup and maintain national services for healthcare IT Decision reached

10 Legislation Lex Makropilotti, Draft Law for Trial Use enabled regional information sharing Kainuu region DLTU Legislation for digital signatures New: Principles of processing electronic information in socialcare and healthcare New: legislation of electronic prescriptions New laws come to effect on ? national services, mandate for Kela, obligations for using national services,...

11 Structuring records and using HL7 CDA R2 in Finland The core data set and CDA

12 Definition of the core data set data elements that must be structured in all EHRs, they can be shared and used in different systems collaboration of domain experts doctors, nurses, computing specialists, statistics, administration, researchers, etc. need a method of describing data that is understandable for all parties, also allow easy editing of the definition in working meetings the definition is an excel spreadsheet with grouping elements, individual dataelements and their associated codesets definition created in an open process during 2003 (some refinement in 2004 and 2005)

13 The core structured data set (2003) Identifiers ISO OID patient encounter episode care chains problems & diagnoses medication laboratory Care related procedures risks summaries nursing functionality health behaviour organisation department imaging care plan physiological measurements Independent forms & documents: statements & certificates, Care will, A, B1, B2, Driver's licence,... required by the ministry for EPR software by the end of 2007

14 Basis for CDA R2 implementation Paper based unified record Regional information system implemention guidelines (CDA R1) and the real implementations The core structured data set

15 Core dataset fragment Dg Problems and diagnosis Classifications, codesets and unique identifiers Dg Dg Dia gnosis Primary and secondary diagnosis ISO OID ( ) Dg Dg Diagnosis name Code and classification ICD-10 / ICPC Dg Dg Diagnosis state Code, diagnosis certainty ISO-OID ( ) Dg Code, diagnosis permanency ISO-OID ( ) Dg Diagnosis episode identifier ISO-OID ( ) Dg Diagnoosin episodikoodi ISO-OID ( xxx.14) Dg Information of the healthcare providerl and organisation See detailed data description Dg Date for entry of diagnosis yyyymmdd Dg Date for removal of diagnosis yyyymmdd HL7 RIM Defining technical artifacts for vendors: (D-MIM) CDA R2 R-MIM CDA R2 HMD CDA R2 ANSI standard CDA R2 XML Schema domain experts HL7 Finland expert(s) Implementation guideline for CDA R2 diagnosis list

16 CDA R2 implementation guides Header General structure for records and forms, including the core structured data set Referral-discharge summary Medication list Diagnosis list Lab results The guidelines rely on the CDA R2 schema Constraints to the schema expressed as textual descriptions in the guides, guides pages Outside of CDA: transport, V3 basics, statistics message

17 Two "styles" of documents General patient record structure used for 39 types of medical specialty, service or program specific information possibly system or organization specific types following CDA R2 very closely, some national extensions Forms independent documents that professionals and patients use for several purposes 17 defined + 10 more this year "A Finnish methology"

18 Example forms

19 Fields Sections grouping fields

20 Characteristics of forms Usually a number of named fields, with text, coded values, check boxes etc. Highly structured, datatypeable information, very little narrative Most EPR software already have electronic versions which are filled and printed Need to enable electronic processing and transfer of the forms exchange between healthcare, patient, insurance, etc. V3 messages one way to model the forms, but: general document characteristics (authored, persistent, metadata,..) some forms have narrative sections

21 Using CDA for forms Quick mechanism for defining a standard XML format that systems can use for exchange CDA R2 "header" is needed as-is CDA Section.Entry.Observation has bunch of usefull attributes and Observation.Value is of type ANY Group of fields is a section Each field within the group is a section Field's datatype and the actual value is given in Observation.Value Each form and field has a unique ID

22 example of a form specification

23 Thoughts about our forms approach Quick-and-dirty but easy for vendors to implement, gets the job done Encourages the use of HL7 datatypes Other types of structured documents and SD infrastructure? Forms could be one area for development? Would need a easy but extendable mechanism, maybe like V3 query infrastructure define the query parameters define the form fields and datatypes

24 Overview of CDA R2 implementation status (vendor statements) some implementations on rest of the forms, mostly planned

25 Getting back to more general issues

26 National architecture Several drafts during the national project Based on the regional architectures, covering local, regional and national level Granularity level: big picture (identification of the needed services) Tender from the ministry to define the national architecture (spring 2006) Consortium of companies selected: WM-data, Medici Data, Commit, Avain technologies, CSW group limited SOA, functional description on national services

27 National IT services for healthcare Record archival and registry service Log and audit service Consent service Code service (already in use) Messaging service Digital signature service, Certification and authentication service outside of the architecture project: eprescription

28 V3 messaging in Finland? Death notification to the national person registry - finalizing the specification Regional scheduling based on V3 finalizing specification V3 messages in the national architecture and services? initial plan for eprescription based on a combination of CDA and V3 messaging archive and registry service? national messaging service? initial acceptence architecture meeting, need further education & consensus, implementation guidelines and localization ( )?

29 Things about the national project not covered in this presentation a very long list...

30 Summary Goverment (strategy & funding) and vendors strongly supporting the CDA approach Will we have a national EHR by the end of next year? Collection of standardized information: Structuring main systems and implementing CDA R2 will be ready extensively Use of information: system-to-system, very little through national services, eprescription to go live early 2008 Work the continue in the information society program? Elections? Sufficient budget funding for the national actor? Migration paths are a challenge

31 Danke! Thanks to Vesa Pakarinen, Timo Tarhonen and Antero Ensio for help and advice Questions?