INFORMATION TECHNOLOGY FOR UNIVERSAL HEALTH COVERAGE (IT4UHC) September 2013 Manila, Philippines

Transcription

1 INFORMATION TECHNOLOGY FOR UNIVERSAL HEALTH COVERAGE (IT4UHC) September 2013 Manila, Philippines

2 Standardizing Terminologies through Health Data Dictionary Khadzir Sheikh Ahmad Ministry of Health, Malaysia

3 Interoperability & Application of Health Informatics Standards in Malaysia Health Informatics Centre, Planning Division, MoH Malaysia

4 INTEROPERABILITY The ability of diverse systems to work together. Syntactic: the capability of communicating and exchanging data via a specified data format and communication protocol. Semantic: the ability to interpret the information exchanged meaningfully and accurately with an unambiguous, shared meaning To integrate Application/system will communicate within a dedicated IT infrastructure How to send messages? : using HL7 standard How to send data?: data embedded in a structured electronic documents (HL7) How another system/application understand the data? : metadata and content must be standardise i.e. ICD 10 for diagnosis, Snomed CT for Clinical Terminology, LOINC for Lab and document identification, Malaysia Drug Code (MDC) for medication 4

5 Health Reference Data Modeling

6 Service Event: 1 Episode 1 Visit 1: Client to Provider? Client to Service (ED) Encounter 1: MA Assessment 1: MA Mdm SA, 50 years old lady brought by family member to the Emergency Department, Hospital A. She has previous history of right fracture of head of femur and had undergone Right Total Hip Replacement 3 weeks ago. Currently, she presented with fever and pain at the surgical site. She was assessed by MA at the Triage. Service Event: 2 Encounter 2, 3: MO ED, Ortho MO Assessment 2, 3: MO ED, Ortho MO on-call Clinical Observation 1: ED Discipline 1, 2: Emergency, Orthopaedic Admission 1: Orthopaedic Ward She was seen by ED MO and sent for X-ray for suspected Infected Implant. She was referred to an Orthopaedic on-call doctor and admitted to Orthopaedic Ward. Encounter 4, 5: Ortho, Anaes Assessment 4, 5: Ortho, Anaes Discipline 3: Anaes Clinical Ob 2,3: Ortho, Anaest Specimen 1, 2, 3: Blood C&S, Swab C&S, Implant Drugs 1 Intervention 1 She was reassessed in the ward and prescribed drugs. While being observed, blood C&S and swab C&S was sent to the laboratory. Condition deteriorates despite treatment given, removal of implant was planned. She was assessed by an Anaesthetist. The operation was successful. The implant was sent to the Laboratory for analysis

7 Encounter 6 : Physiotherapist Incident 1 Assessment Clinical Observation While recovering, she was seen by physiotherapist 3 times a day. During one of the session, she slipped and hit her head on the floor. She had a small hematoma. Assessment Clinical Observation She refused to do further physiotherapy and remained bed-ridden. During ward round, she complained of chest pain and breathlessness. SpO2 80% and suspected of Pulmonary Embolism due to Deep Vein Thrombosis. Despite resuscitation, condition deteriorates and died. Encounter Next of Kin Organ Donor Intervention Discipline Discharge?Dead Person Family was called and counseled for organ donation. Family consented for cornea donation. After procedure completed, body was sent to the Mortuary and released to the family.

8 HEALTH INFORMATICS STANDARDS HL7/CDA identifies which fields are variables and values, and determines the sequence of variables MyHDD/DDSA determines the properties of each variable and values related to it e.g. naming convention, data type, field size Variable Value Nama No. ID Jantina Umur Diagnosis Nor 1234 Wanita 30 CA Breast Ah Moi 3456 Female 31 Kanser Payudara Devi 5678 Perempuan 32 Carcinoma Mammae SNOMED-CT/LOINC uniforms the C50.9 meaning of terminologies entered into ICD classifies the uniformed each field. In this example, jantina and meaning for analysis. In this diagnosis example, ICD10 which is WHO s diagnosis classification standard. 8

9 Malaysian Health Data Dictionary

10 Overview Health Information Management in Malaysia is evolving from a basic statistical reporting system through papers and collecting aggregated data to an ICT enabled Health Information Management System and collecting granular data. In order to ensure integration and interoperability between the sources providing health and health related information a systematic approach is necessary for adoption and development of health informatics standards in the country Malaysian Health Data Dictionary is a step towards standardization of health and health and health related information to ensure data quality and integrity and to enhance interoperability

11 Objectives of Malaysian Health Data Dictionary Make available a Malaysian Health Data Dictionary for the use by individuals and organisations involved in the generation, capture, storage and use of health and health related information esp vendors & developers Consensus among clinician provide semantic understanding of data elements uses in health care industry Conform to nationally agreed protocols and standards i.e. demographic data elements from *Public Sector Data Dictionary by MAMPU Be consistent with international standards wherever possible * Data Dictionary Sektor Awam by Malaysian Administrative Modernisation and Management Planning Unit

12 Strategy used in the development of MyHDD Identification of stakeholders LHR / EMR components Discipline Process of building of MyHDD Data Dictionary Workshops to develop data elements Consensus driven methodology Review current guidelines and standards in use Endorsement by experts and authorized committees Adoption and application of standards by all healthcare stakeholders including industry partners

13 Data Dictionary contains:

14 The Process of Building the Malaysian Health Data Dictionary Individual Data Requirements Data Sets Obstetrics and Newborn Person Record Hospital Discharge Summary Cancer Emergency Forensic Harmonization Malaysian Health Data Dictionary Person Encounter Procedure Provider Radiotherapy & Oncology Nuclear Medicine Oral Health Validation (HITSP, WHO) Medications Others Pharmacy

15 Example Cancer Forensic Nuclear Medicine Data Elements

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17 Meta data

18 Harmonisation Terminology Standards Systemized Nomenclature Of Medicine Clinical Terms (SNOMED CT) Logical Observation Identifiers Names and Codes (LOINC) Malaysian Health Data Dictionary International Classifications International Classification of Diseases (ICD 10 / ICD 9CM) International Classification of Disease for Oncology (ICD O) International / Local Data Dictionary Healthcare Information Technology Standards Panel (HITSP) Data Dictionary Sektor Awam (DDSA)

19 MyHDD Publication on MOH website

20 MyHDW Definition and Characteristics A trusted source of truth of comprehensive healthcare data structured for query and analysis purposes. MyHDW will have the following characteristics: A dedicated system that is optimized for analysis and reporting Build based on national health informatics standards Data is integrated, interoperable and comprehensive Data Quality is of the highest level and will be supported through appropriate methods, tools and techniques Information available in 'right time Employs an overarching healthcare system governance Evolution is aligned and prioritized in accordance with key programs, initiates and information needs Employs the notion of 'build once use many' with the objective of reducing the burden of data collection and processing This implies where possible aligning primary and secondary usage consideration Can support many reporting and analysis tools and interfaces Implements secure and privacy sensitive access

21 Tools Comparison MyHDD DB Access, OpenHDD.org and DDSA MAMPU

22 MyHDD Ms Access OpenHDD.org DDSA Developed in-house by HIC, Planning Division, MoH Format controlled by MoH Content / Database developed by MoH Content: MyHDD only Able to edit database immediately before publication Developed by JLN Format controlled by user organization Content / Database from MoH then uploaded into system by JLN; content can also be entered/editted straightaway Content: JLN, MyHDD, Microinsurance network, Philipines HDD, openhdd Content editable by user organization Developed by MAMPU Format controlled by user organisation and MAMPU Content / Database from MoH then uploaded into system by MAMPU Content: Data Dictionaries from various government agencies in Malaysia Content editable by user organization For internal use only Public able to view content Public able to view content but required to register with admin / MAMPU Content can be published to different formats e.g. Excel, PDF, XML, text etc Content can be downloaded to XML, PDF or FreeMind format Works off-line Works online Works online Content can be downloaded to excel, CSV and PDF format 22

23 Way forward National Release Centre (NRC) To manage release and versioning Development of Health Reference Data Modeling Updates & completion of scope

24 Thank you