EHR Data Reuse through openehr Archetypes

EHR Data Reuse through openehr Archetypes Rong Chen MD, PhD Chief Medical Informatics Officer 2012.09.19-1- 2012-10-02

Agenda Background introduction (3 min) Experience of extracting EHR data from regional EHR systems to national quality registers (10 min) Quality assurance, compliance checking & clinical decision support (15 min) Software demonstration (10 min) Summary, Q&A (5 min) -2-2012-10-02

Cambio Healthcare Systems Founded in 1993 300 staff across the globe Private and Venture funded The leading provider of Regional EHR solutions in Scandinavia - presence in Sweden, Denmark, UK, others to follow COSMIC is an international standard product Close to 95 000 staff users when current projects are fully implemented Our solutions are open, scalable and flexible based on industry standards Actively involved in academic research and open source software development ISO 9001 certification and CE Marked EHR -3-2012-10-02

Cambio COSMIC Compliant Open Solutions for Modern Integrated Healthcare -4-2012-10-02

Vision -5-2012-10-02

Agenda Background introduction Experience of extracting EHR data from large scale regional EHR systems to national quality registers Quality assurance, compliance checking & clinical decision support Software demonstration Summary (Q&A) -6-2012-10-02

Quality Registers Background About 80+ quality registers (QR) in Sweden National or regional ones Usually single condition based Common challenges/issues with QR data report (Aggregated) data sets do not exist in EHRs Unsynchronized data structures among QRs Mismatched terminology bindings Some QR are guideline based, some not Multiple integrations, multiple data entries Clinical decision support from QRs (?!) -7-2012-10-02

-8-2012-10-02

RiksSvikt Cosmic -9-2012-10-02

Swedish National Heart Failure Quality Registry Pilot Project (IFK2) Introduction Working towards a national semantic interoperability framework Single logic EHR architecture Shared clinical content library for reuse Two commercial EHR systems (Cambio COSMIC & Siemens Melior) and one QR hosting organization openehr archetypes/templates as machine-readable specification with bindings to SNOMED CT Heart-failure domain, realistic requirements and test sites -10-2012-10-02

IFK2 High Level Overview -11-2012-10-02

IFK2 Results - Archetypes Total 21 archetypes 7 international archetypes openehr-ehr-observation.blood_pressure.v2 openehr-ehr-observation.body_weight.v2 openehr-ehr-observation.ecg_12_lead_standard_recording.v1 openehr-ehr-observation.heart_rate.v2 openehr-ehr-observation.height.v2 openehr-ehr-observation.lab_test.v1 openehr-ehr-observation.waist_hip.v2 Expected generally reusable openehr-ehr-observation.eq_5d.v2 openehr-ehr-observation.heart_failure_stage.v2 Some expected to be reusable in QR reports openehr-ehr-evaluation.review_of_conditions.v1 openehr-ehr-evaluation.review_of_procedures.v1-12- 2012-10-02

-13-2012-10-02

IFK2 Results Summary openehr archetypes/templates proven to be capable of communicating EHR Data to QR Reuse of existing EHR archetypes for QR report purpose Validation rules for data values and structures SNOMED CT bindings seem useful to synchronize QR terminologies Remaining issues Lack of ways to express validation rules on incorrect combinations Highly aggregated view of QR template vs detailed EHR data Mismatch between QR requirements and EHR archetypes Auto-prefill of EHR Data in QR templates very hard Perhaps we need rules? -14-2012-10-02

Agenda Background introduction (5 min) Experience of extracting EHR data from regional EHR systems to national quality registers (10 min) Clinical Decision Support, Quality assurance & compliance checking (15 min) Software demonstration (10 min) Summary, Q&A (5 min) -15-2012-10-02

openehr Archetype??? SNOMED CT A L Rector PD Johnson S Tu C Wroe and J Rogers (2001) Interface of inference models with concept and medical record models. in S Quaglini, P Barahona and S Andreassen (eds) Proc Artificial Intelligence in Medicine Europe (AIME-2001 ) Springer:314-323 -16-2012-10-02

CDS Strategy openehr Archetypes as semantic building blocks Reuse existing archetypes High quality clinical information, language independence.. Reference Terminology, ontology as concept models in different domains SNOMED CT, FMA,.. Rule-based CDS Industry strength rule engine, standard rule language features All based on open / standard specifications to improve interoperability & the able to share rules -17-2012-10-02

Guide Definition Language (GDL) A sub-language of dadl, driven by an object model The object model consists of Header: Id, concept, language, description, translation Archetype binding Guide definition, pre-condition and list of rules Each rule has when and then expressions Term definition for language-dependent labels Extensive reuse of existing openehr specifications Aiming to release through openehr -18-2012-10-02

Guide Definition Language (GDL) Blue: Yellow: openehr new -19-2012-10-02

Clinical Decision Support Workbench (GDL implementation) A tool to import, export and author clinical rules 2. Model new or find existing clinical rules using evidence based guidelines A rule engine to execute the rules Linked to COSMIC (EHR) Intelligence for verification, simulation and compliance checking An extension of Cambio COSMIC (EHR) 1. Identify or monitor the clinical problems 5. Deploy Runtime CDSS inside COSMIC (EHR) 3. Analyze EHR data in CDS workbench 4. Confirm the clinical gaps and find areas for improvements -20-2012-10-02

Case Study: Antithrombotic Management in Atrial Fibrillation 20% of strokes caused by atrial fibrillation Evidence-based European guideline on management of atrial fibrillation, European Heart Journal (2010) 31, 2369 2429 doi:10.1093/eurheartj/ehq278-21- 2012-10-02

Archetype -22-2012-10-02

Guide (GDL) -23-2012-10-02

Compliance Checking -24-2012-10-02

Compliance Checking Results -25-2012-10-02

Does Result from CDS Workbench Match the Result from the Quality Register? keep in mind Coverage of patient groups, data sets size Multiple data entry or not Linkage to Clinical Decision Support In order to improve clinical practice at point of care -26-2012-10-02

Warfarin Treatment AURICULA QR, 1 yr (AF Unit Patients) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 84% 16% Ja (434) Nej (80) -27-2012-10-02

Warfarin Treatment CDS Workbench/EHR, 1 yr (whole region) 80% 70% 60% 50% 40% 30% 75% 20% 10% 0% 25% Ja (2025) Nej (6105) -28-2012-10-02

CHADS2, AURICULA QR (CHA2DS2VASc kom senare än registret ) -29-2012-10-02

Compliance Checking Results Divided per CHA 2 DS 2 VASc score by CDS Workbench -30-2012-10-02

Reason for not having Warfarin Treatment, AURICULA 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 43% Ej indikation (212) 18% Refused (89) 13% Contraindicated (66) 4% Problem i vården (20) 22% Unknown (109) -31-2012-10-02

Some Thoughts Instead of extraction data from EHR for various reuse, reuse of EHR data on-site with EHR extension like CDS Workbench? With shared common clinical models like openehr archetypes, possible to reuse EHR data for multiple purpose without re-entries? With open source GDL specification and OS reference implementation, possible to share rules for data reuse, e.g. quality indicators, decision support & quality assurance? -32-2012-10-02

Agenda Background introduction (3 min) Experience of extracting EHR data from regional EHR systems to national quality registers (10 min) Clinical Decision Support, quality assurance & compliance checking (15 min) Software demonstration (10 min) Summary, Q&A (5 min) -33-2012-10-02

Summary openehr archetype provides common definition of clinical information models that could facilitate reuse of EHR data for various purposes Guide Definition Language (GDL) Built on archetypes and standard rule language for increased interoperability and able to share guides open specification and standardized through openehr Reference GDL Editor to be release as Open Source Software May facilitate further EHR data reuse -34-2012-10-02

Questions & feedback? Rong.Chen@cambio.se SNOMED CT Implementation Showcase 2012, Stockholm FRIDAY 26 th October, 13:30 to 14:15 Clinical Decision Support Using openehr Archetypes and SNOMED CT -35-2012-10-02