12 th National Convention on Statistics (NCS) EDSA Shangri-La Hotel, Mandaluyong City October 1-2, 2013

Transcription

1 12 th National Convention on Statistics (NCS) EDSA Shangri-La Hotel, Mandaluyong City October 1-2, 2013 COMMON HEALTH INDICATOR REPORTING PROTOCOL: A FRAMEWORK FOR HIERARCHICAL REPORTING FOR ELECTRONIC MEDICAL RECORDS by Alvin B. Marcelo, M.D. For additional information, please contact: Author s name : Alvin B. Marcelo, M.D. Designation : Associate Professor Affiliation : Surgery and Medical Informatics, UP Manila Address : 3 Juan Luna Street, UP Campus Manila, Q.C. Tel. no. : alvin.marcelo@gmail.com

2 COMMON HEALTH INDICATOR REPORTING PROTOCOL: A FRAMEWORK FOR HIERARCHICAL REPORTING FOR ELECTRONIC MEDICAL RECORDS by Alvin B. Marcelo, MD ABSTRACT Electronic medical records (EMRs) are getting popular in private and public health facilities. They have the potential to become reliable sources of data for health statistics. Unfortunately, there is yet no framework for reporting that will inform these EMRs how to extract and transform their data to comply with national and international standards for reporting. This paper discusses a framework for reporting data to the DOH, other national agencies and even global organizations such as WHO from EMRs that ensures consistency at all levels of the health system hierarchy (global, regional, national, provincial, district, village). With this framework, transactional systems can now be used by sub-national health units for reporting without worrying about semantic and syntactic consistency. A tabletop exercise is described in the article using a sample indicator such as vitamin A supplementation. Background When computers were still expensive and inaccessible to most health facilities, it was a challenge to submit aggregate reports to higher levels of the health system. Since the mode of reporting was in paper, the aggregation mechanism was done manually and was error-prone. In addition, the reports trickled up with varying timelines resulting in incorrect consolidation at various levels of the hierarchy. It was not surprising that most health leaders did not believe the data that was reaching their desks. Leaders need timely and accurate health statistics for decision making. Because of this, ministries require health facilities to submit reports regularly. In a paper-based clinical information system, the reporting process is tedious and difficult causing delays and errors. On contrary, facilities with electronic medical records can generate these reports easily and more accurately. Recently, the cost of computers has decreased considerably and the advent of the Internet has made it possible to submit reports electronically. A new type of software called an electronic medical record (EMR) could collect patient data and could easily aggregate them into public health reports. Unfortunately, without standards, electronic medical records will not be guided on how to submit data in a form that will allow consistent sequential aggregation as they go up to higher levels of the health system. For example, two EMR systems may have data about child mortality. Unfortunately, there is (as yet) no guidance on the standard way to report the data across all facilities and across countries. One country may report aggregate deaths for children aged 2 to 5 while another will report the same for ages 1 to 6. Since the granularities of these two reports are different, merging them for purposes of regional or global reporting is not possible. Page 1 of 7

3 These differences in granularity and specificity make comparison of basic health statistics difficult within countries and between countries. Possible solution A protocol should be defined that informs EMRs at the facility level how to extract data from their patient databases and transform these into a format that can be seamlessly consumed by higher levels of the health system (e.g., the district health department, the national ministry, the WHO regional office and WHO headquarters). The workflow starts with WHO Geneva defining a reporting schema for child mortality. Once defined, their Western Pacific Regional Office can then extend this schema. Why does the region need to extend it? WHO Geneva/HQ may probably be only interested in regional data (Asia, Europe, North America, South America, etc.) but the regions would probably want to know country level data (China, Philippines, Indonesia). Going further, the countries in turn may to view sub-national data (provinces, districts, towns, villages). If sequential extensions of the root schema (from WHO Geneva to WHO region to Philippines to Luzon to Manila) are done according to an agreed protocol, greater and greater granularity can be added as needed by the lower level entities (e.g., facilities), while still preserving the ability to aggregate back to the required report by WHO Geneva (or any other agency with a global-scope such as the UN). The ability to extend schemas also allows countries to use their specific terminology (soums and aimaks in Mongolia, districts and provinces in Lao, and provinces and regions in the Philippines). Also by adopting Unicode, the countries can even display data in their own fonts and scripts. This country-level customization is important for local acceptance and often causes inconsistency with international requirements for indicators. But using an agreed protocol, a locally customized schema can still be useful for higher-level aggregation. What is this protocol? The WHO has long maintained the Indicator and Measurement Registry (IMR). It is a webbased tool that allows global program managers (e.g., maternal program, child and nutrition program) to define their indicators. Once defined in the IMR, the indicator can be exported as a schema following the Statistical Data and Metadata Exchange for Health Domain format (SDMX-HD). This SDMX-HD schema is based on the extensible Markup Language (XML), a popular method for communicating data between systems. The SDMX-HD is then published at the IMR for download by other countries. Once downloaded, ministries of health in countries can then study the SDMX-HD schema and use this as guide in creating their XML reports to WHO headquarters. Because the SDMX-HD clearly lists all the important parameters in a report (disaggregation by geography, time, sex, age, etc.) the ministries are informed how they should package their reports in this format. In return, the ministries can also constrain facilities using electronic medical records how to submit data to the central data warehouse (managed by the ministry) so that it makes it easy to comply with the SDMX-HD schema of WHO. The ministry can simply pass on the SDMX-HD schema to the EMRs or can use a simpler format such as an HL7 query to extract patient data from the EMR that feeds into the national Page 2 of 7

4 data warehouse. From the data warehouse, it is a simple matter to run a script that prepares the report that is compliant with SDMX-HD schema. Figure 1 shows how the lifecycle from strategy to indicator to reporting and back to strategy Tabletop exercise In order to demonstrate how the lifecycle works in real life and how the agreed protocol will manifest in practice, the following example for vitamin A supplementation reporting is shown. First a search is done for the global indicator definition from the Indicator and Measurement Registry. At the URL, the published global indicator for vitamin A supplementation can be searched and viewed (figure 2). Page 3 of 7

5 Figure 2. The WHO Indicator and Measurement Registry Once found, the SDMX-HD schema for vitamin A supplementation can be downloaded by clicking on the Export as SDMX-HD button (figure 3). Figure 3. Vitamin A supplementation as an indicator in the WHO-IMR. Page 4 of 7

6 This creates a zip file that can be downloaded and expanded into its own folder (figure 4). In this folder, the DSD.xml file contains the constraints for the report. Figure 4. Contents of the SDMX-HD folder for vitamin A supplementation For further simplification, this article will focus on one element in the required report - age. The SDMX-HD schema coming from WHO will reflect that there is only one group of children in the report: those who are 6 to 59 months old. But upon closer inspection of the DSD.XML file, the following snippet will be found: <CodeList id="cl_age_group" agencyid="who" version="1.0" isfinal="false" urn="urn:sdmx:org.sdmx.infomodel.codelist.codelist=who:cl_age_group[ 1.0]" isexternalreference="true" uri="custom/who/codelists/cl_age_group.who.1.0.xml" xmlns=" <Name xml:lang="en">age</name> </CodeList> The uri attribute shows the location of the internal file (/CUSTOM/WHO/codelists/CL_AGE_GROUP.WHO.1.0.xml) that contains the codelists for the age groupings to be used in the report (and other SDMX-HD compliant reports requiring age groups). Reports expected from submitters must use these codes for age groups consistently. In this snippet, the code value for the age group 6 to 11 months is 1496 while it is 1497 for the age group 12 to 59 months. <Code value="1496" urn="urn:sdmx:org.sdmx.infomodel.codelist.code=who:cl_age_group[1.0].1496"> <Description xml:lang="en">6-11 months</description> </Code> <Code value="1497" urn="urn:sdmx:org.sdmx.infomodel.codelist.code=who:cl_age_group[1.0] Page 5 of 7

7 .1497"> <Description xml:lang="en">12-59 months</description> </Code> The SDMX-HD s requirement for age in months means the extraction from the EMRs should contain patient age (also in months). If the SDMX-HD is made available to the EMRs, this would become obvious. Here is a simplified sample XML extract from an EMR (informed by the SDMX-HD) that will be submitted to the national data warehouse: <patient> <patient_id> 12345</patient_id> <patient_age_months>6</patient_age_months> <patient_sex>male</patient_sex> <service>vitamin_a_supplementation</service> <provider_id>675767</ provider_id> <facility_id>842536</facility_id> <timestamp> </timestamp> </patient> <patient> <patient_id> 34523</patient_id> <patient_age_months>34</patient_age_months> <patient_sex>female</patient_sex> <service>vitamin_a_supplementation</service> <provider_id>675767</ provider_id> <facility_id>842536</facility_id> <timestamp> </timestamp> </patient> <patient>. </patient> This XML file above is submitted to the national data warehouse. In turn, the national data warehouse can extract data in the following format for reporting purposes to WHO (this sample data indicates there are 32 patients between age 6 to 11 months and 65 between 12 and 59 months): <xml > <WHO:CL_AGE_GROUP[1.0].1496>32</WHO:CL_AGE_GROUP[1.0].1496> <WHO:CL_AGE_GROUP[1.0].1497>65</WHO:CL_AGE_GROUP[1.0].1497> </xml> Conclusion. Using an agreed protocol - starting from WHO headquarters to national ministries to facility EMRs - it is possible to define patient-level extracts from electronic medical records that will enable ministries to package SMDX-HD compliant reports to WHO. In order to make this possible, the WHO must first define the global indicator in the Indicator and Measurement Registry, export it in SDMX-HD format, and publish it for guidance of ministries of health. In turn, the ministries should publish the SDMX-HD or a simpler XML schema for guidance of facilities nationally. Guided by the SDMX-HD or the XML schema, EMRs in facilities can then submit patient-level data to the national data warehouse in a form that will make it easy to create SDMX-HD compliant reports to WHO. Page 6 of 7

8 In order to comply with this protocol, new skills should be developed among ministries of health. This includes understanding SDMX-HD, XML, and HL7. The protocol will be more powerful if countries have standard terminology services. A national data warehouse built for the purpose of collecting patient-level data can then be populated with these simple XML extracts from EMRs. Since these XML extracts were constrained by an SDMX-HD or XML schema, they can be easily aggregated to create SDMX-HD complaint reports to WHO or to other national level agencies. Page 7 of 7