European Patient Summaries: What is next? Tackling the Semantic Interoperability challenge Dipak Kalra
Cross-border health care The context for sharing health summaries Also useful for within-border health care Unscheduled care (emergency, unexpected) Generic patient summary Continuity of care for acute exacerbations, complications (predictable, even if not predicted) Scheduled care (planned by clinician, arranged by patient) Condition specific summaries are needed, including care plans Procedure referral summary? These must be clinically driven, engaging multiple stakeholders
Mortality for patients hospitalised with HF Inpatient Mortality 11.1% Cardiology ward 7.8% General medical 13.2% Other ward 17.4% Source: John Cleland, Suzanna Hardman, SHN WP1
What are we trying to do? Develop a useful and credible electronic health record for use in patients for HF, as an exemplar of other chronic conditions Starting with a Shared Care Summary This must contain basis for a reliable diagnosis This must support downstream care providers who may be unfamiliar with the patient
Collation of Heart Failure Data-Sets & Guidelines Existing trial data-bases delivered Hull Life Lab Data-Base SICA-HF (FP7 funded epidemiology study of HF) UK National Audit Data-Base Heart Failure Guidelines Collated European Society of Cardiology American Heart Association/American College of Cardiology Heart Failure Society of America NICE Guidelines and Quality Standards SIGN Australia & New Zealand Guidelines Source: John Cleland, Suzanna Hardman, SHN WP1
Is it heart failure? Key information needed for diagnosis and management Source: John Cleland, Suzanna Hardman, SHN WP1
Proposal for a Heart Failure Summary Items that Occasionally Change Aetiology: Coronary Artery Disease Prior Myocardial Infarction?: Yes: Anterior 2005 Co-morbidity: Type 2 Diabetes and Arthritis Implanted Device: No (drop down of ICD, PM or CRT) ECG Heart Rhythm: Sinus PR interval: 210msec QRS duration: 110msec Echocardiogram LVEF: 32% Mitral regurgitation: moderate Other important valve disease: no Lung Function: FEV1: 2.1 (83% of predicted) FEV1/FVC: 75% Urine Protein: Trace Source: John Cleland, Suzanna Hardman, SHN WP1
Proposal for a Heart Failure Summary Symptoms Symptoms Orthopnoea: No Exertional Breathlessness: Moderate Ankle Swelling: No Fatigue Moderate Chest pains: No Cough: Fair Well-being: Good Sleep Quality Poor Snoring Yes Items in grey are required less often Source: John Cleland, Suzanna Hardman, SHN WP1
Proposal for a Heart Failure Summary Items that Often Change Heart rate: 88 bpm Systolic BP: 144mmHg Diastolic BP: 102mmHg Weight: 69.8kg (BMI calculated ) Target Dry Weight: 68.0kg Haemoglobin: 10.8g/dL If Anaemic, Haematinic screen: Iron Deficiency Sodium: 138mmol/L Potassium: 4.0mmol/L Urea: 11.5mmol/L Creatinine: 137umol/L Albumin: 44g/dL BNP/NT-proBNP: 3,127ng/L Blood Glucose (Random): 7.2mmol/L HbA1c: 7.4% Source: John Cleland, Suzanna Hardman, SHN WP1
Therapeutic Targets Instructions ACE Inhibitor: Yes, Ramipril 5mg bd Angiotensin Receptor Blocker: Not required Beta-blocker: Yes, Carvedilol 25mg bd Spironolactone: Yes, 25mg/day Loop Diuretic: Bumetanide 2mg/day Ferrous sulphate: Yes, Stop in 3m Digoxin: Not required Anticoagulant: Not required Antiplatelet: Clopidogrel 75mg/day Exercise: Yes, for 20 min x 3/wk Physiological Targets (may modify instructions) Symptom Control None or Mild Resting heart rate 50-70bpm Systolic BP 110-130mmHg Dry weight 68kg +/- 2kg HbA1c 6.5-8.5% Source: John Cleland, Suzanna Hardman, SHN WP1
Discharge Instructions Double Carvedilol every 2wks until target achieved Double Ramipril in one week to achieve target Stop ferrous sulphate in 3months and re-check haemoglobin Advise on dietary salt and exercise Increase bumetanide in one month if Source: John Cleland, Suzanna Hardman, SHN WP1
Heart Failure summary template (openehr format) Source: Ian McNicholl, openehr, SHN WP4
Overlap Terminologies / Information Models Clinical Terminologies Terminologies to be used without information models Clinical Information Models Clinical Information models to be used without or with inexpressive terminologies Contextual statements (negation, plans, beliefs ) within terminologies SNOMED CT context model ICD 11 content model Local terminology within IMs Post-coordination within IMs Source: Stefan Schulz, Cati Martinez, SHN WP4
Suspected heart failure caused by ischaemic heart disease Three heterogeneous representations of the same statement Three different atomic information entities Organ Failure Diagnosis Diagnosis Diagnosis Organ Status Heart Suspected Suspected heart failure caused by ischaemic heart disease Status Heart Failure Caused by ischaemic heart disease Yes x No Unknown Cause Suspected Ischaemic heart disease Source: Stefan Schulz, Cati Martinez, SHN WP4
SHN Semantic Patterns approach SEMANTIC PATTERNS compliant with SHN Ontology Framework 27 Use cases: heart failure and cardiovascular health
SHN Semantic Patterns approach SHN Ontological Framework Heterogeneous Clinical Models SEMANTIC PATTERNS DL Reasoning HOMOGENEOUS QUERY
A Semantic Pattern to represent a non-smoker information about patients without past history of smoking NPH_CS_PT Query pattern shn:informationitem result from process describes situation has temporal context has finding context Semantic Query Pattern shn:evaluationprocess sct:smoking sct:inthepast sct:absent
Semantic interoperability: key stakeholders who need to be involved Patients, patient associations Clinicians, professional associations, clinical specialty associations Healthcare provider organisations Healthcare payers: public health authorities, insurers Health ministries Public health organisations EHR system vendors, medical device vendors, ICT infrastructure vendors, Industry associations Pharma, research organisations Standards Development Organisations The European Commission, ONC, WHO, OECD... For cross-border patient care, population health, comparisons, surveillance, research, products and services
Information patients would like included in a long term condition summary