EHR Systems: an Introduction

Transcription

1 ehealth Week 2007 EuroRec Institute / ProRec Germany Workshop EHR Systems: an Introduction Bernd Blobel 1 & Dipak Kalra 2 1 ehealth Competence Center University of Regensburg Medical Center Regensburg, Germany 2 Centre for Health Informatics and Multiprofessional Education (CHIME) University College London ehcc

2 Definitions (according to ISO/DTR Health informatics - Electronic health record Definition, scope and context ) (1/2) EHR a repository of information regarding the health status of a subject of care, in computer processable form. An EHR provides the ability to share patient health information between authorised users of the EHR and the primary role of the EHR in supporting continuing, efficient and quality integrated health care. EHR system the set of components that form the mechanism by which electronic health records are created, used, stored, and retrieved. It includes people, data, rules and procedures, processing and storage devices, and communication and support facilities. EHR node a physical location where EHRs are stored and maintained.

3 Definitions (according to ISO/DTR Health informatics - Electronic health record Definition, scope and context ) (2/2) EHR architecture a model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, a useful and effective ethico-legal record of care, and may retain integrity across systems, countries, and time. The Architecture does not prescribe or dictate what anyone stores in their healthcare records. Nor does it prescribe or dictate how any electronic healthcare record system is implemented.... [It] places no restrictions on the types of data which can appear in the record, including those which have no counterpart in paper records.... Details like field sizes, coming from the world of physical databases, are not relevant to the electronic healthcare record Architecture.

4 Clinical drivers for the EHR EHR Systems: an Introduction Manage increasingly complex clinical care Connect multiple locations of care delivery Support team-based care Deliver evidence-based health care Improve safety - reduce errors and inequalities - reduce duplication and delay Empower and involve citizens Underpin population health and research Protect patient privacy

5 Systems feeding or accessing the EHR Clinical trials, functional genomics, public health databases Personnel registers, security services EHR repositories virtual Healthcare Record John Smith DoB : EHR Date: Whittington Hospital virtual Decision support, knowledge management and analysis components Mobile devices Clinical devices, instruments Clinical applications

6 Interoperability Levels EHR Systems: an Introduction Technical Interoperability - Technical Plug&Play, signal compatibility, protocol compatibility Simple Data Exchange Interoperability - EDI, HL7 Version 2 Meaningful Data Exchange Interoperability - agreed Vocabulary Functional Interoperability - Harmonised behaviour of communicating applications semantic I. Service-oriented Interoperability - Direct invocation of application services, co-operativity of applications }

7 Interoperability Aspects from a European Perspective Interoperability issues have to be managed from different viewpoints - Legal Member States and EC - Administrative Member States, EC and Stakeholders - Technical Industry and SDOs - Social Member States, EC and Stakeholders - Ethical/cultural Member States, EC and Stakeholders

8 Observation Data Knowledge Interpretation Information Diagnosis Therapy Action

9 EHR Projects and Standards ISO TC 215 TS 18308, DTR CEN EN Health Information System Architecture CEN EN EHR Communication openehr GEHR G-CPR ASTM CCR HL7 RIM & CDA, EHR-S Functional Model, EHR-S Interoperability Model, CCD HARP EuroRec, ProRec Centres...

10 Requirements for achieving interoperability and harmonisation (1/2) Openness, Scalability, Flexibility, Portability Distribution at Internet level Standard conformance Service-oriented semantic interoperability Consideration of timing aspects of data and information exchanged Lawfulness Appropriate security and privacy services

11 Requirements for achieving interoperability and harmonisation (2/2) Distribution, Component-orientation (flexibility, scalability) Model-driven and service-oriented design Separation of platform-independent and platform-specific modelling separation of logical and technological views (portability) Specification of reference and domain models at meta-level Interoperability at service level (concepts, contexts, knowledge) Unified Process Common terminology and ontology (semantic interoperability) Advanced security, safety and privacy services

12 Business Concepts Relations Network sic Services/Functions EHR Systems: an Introduction Component Decomposition Component View Domain n Domain 2 Domain 1 Basic Concepts Enterprise View Information View mputational View Engineering View Technology View

13 Knowledge Representation through a Metathesaurus (after Bodenreider) Concepts o Synonymous terms are clustered into a concept o Properties are attached to concepts, e.g., Unique identifier Definition Relations o Concepts are related to other concepts o Properties are attached to relations, e.g., Type of relationship Source

14 Key requirements for the logical or virtual EHR Comprehensive Faithful Life-long (and beyond) Medico-legally rigorous Appropriately available Supporting diverse cultures and professions Capable of evolution Educating Empowering and respecting Capable of interoperability

15 In a medical summary Problem List EHR Systems: an Introduction Procedure Diagnosis Procedure Diagnosis Diagnosis Appendicectomy Meningococcal meningitis Termination of pregnancy Acute psychosis Schizophrenia Can we safely interpret a diagnosis out of its context?

16 Clinical interpretation context Emergency Department Seen by junior doctor Reason for encounter Symptoms Mental state exam Diagnosis Certainty Brought to ED by family They are trying to kill me Hallucinations Delusions of persecution Disordered thoughts Schizophrenia Working hypothesis Junior doctor, emergency situation, a working hypothesis so schizophrenia is not a reliable diagnosis Management plan Admission etc...

17 Examples of clinical interpretation context within the overall clinical story - past, present - intended treatments, planned procedures clinical circumstances of an observation - e.g. standing, fasting presence / absence / certainty of the finding hypotheses, concerns a diagnosis for a relative - but not the patient! confidence and evidence - seniority of the author - justification, clinical reasoning, guideline references

18 Examples of medico-legal context Authorship and responsibilities Dates and times - occurrence, clinical encounter, recording, schedules, intentions Information subjects - whose record is this? (who is the patient?) - about whom is this observation? (e.g. family history) Version management Access rights

19 Potential interpretation contexts Data archive management Medical knowledge and health culture EHR Professional repository accountability management schizophrenia Clinical encounter Life-long EHR Medico-legal contexts Clinical contexts

20 Semantic interoperability challenges the meaningful sharing and combining of health record data between heterogeneous systems the consistent use of modern terminology systems and medical knowledge databases the integration and safe use of computerised protocols, alerts and care pathways by EHR systems data quality and consistency to enable rigourous secondary uses of longitudinal and heterogeneous data: public health, research, health service management

21 Reasons why this is hard: it s not just about agreeing terms EHR Systems: an Introduction A global and singular representation for each clinical expression is not realistic, and may not be desirable Different levels of detail, different levels of granularity are needed for different clinical settings - clinical practice is too diverse and evolving for fine grained standards - different cultures, and natural languages need to represent clinical meaning differently - patients and carers need a different level of jargon from health care professionals

22 Reasons why we make it harder The record structure influences how a term is to be interpreted - the heading it is under - other surrounding context Record structures and terminology systems have been developed in relative isolation - with no co-operation on their mutual requirements or scope - resulting in overlapping coverage or clumsy fit With co-ordinated terminology and sophisticated EHR architectures - there is a risk of introducing further inconsistency - making semantic equivalence harder to determine

23 Archetypes will help EHR Systems: an Introduction Empowerment of healthcare professionals - enable consensus clinical data sets and structures to be shared Offer a focused way of binding generic EHR models to compositional terminology Provide target knowledge representations for use by guideline and care pathway systems EHR entries identify the Archetypes used when the data were created, and/or to which they map - aids future interpretation, analysis, computation

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