Applying HL7 in the Acute Hospital setting Philip Firth IM&T Strategy Implementation Manager...
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Transcript of Applying HL7 in the Acute Hospital setting Philip Firth IM&T Strategy Implementation Manager...
Applying HL7 in the Acute Hospital setting
Philip Firth
IM&T Strategy Implementation ManagerWrightington, Wigan & Leigh NHS Trust
Introduction
Look at some of the integration issues that Acute Hospital NHS Trusts typically need to address
Look at an example project with complex interface needs – accident & emergency
Look at requirements for linking Acute Hospital NHS Trust systems to LSP solutions and the Spine
Acute Systems Integration
Typical Issues
Issues …
Standards - what standards???
Implementation issues – PAS, Pathology
Data quality
Stylesheet issues
TIME
Standards - what standards???
Interface standards/output formats in Wigan– HL7 v2 (various implementations of)– EDIFACT– ASTM– System specific output – eg. Torex PAS
openlink
Acute Trusts need to learn to work with what’s available !!!
Implementation issues - PAS
PAS ‘real-time’ interface
No guarantee that messages would be delivered in the right order – Could get an Admission message prior to a Patient
Registration
Had to introduce a 15 minute time delay
Result: bed-status in EPR system slightly out of sink
Implementation issues - Pathology Handling previous results – append or overwrite?
– Microbiology – overwrite– Haematology, Chemistry – currently append
Collection date and time not always supplied Reference ranges can change
– Implication for graphing
Sensitive tests– What is the best way to deal with HIV, GUM, pregnancy
tests etc?
Implementation issues - Pathology Multiple patient IDs (NHS number, Hospital number) Multiple casenote numbers (Trust mergers)
– Need to establish systems for cross referencing patient IDs
Missing patient ID Pathology system sending internal patient ID Missing key patient data – DOB, Gender
– Unable to guarantee a match – need to Dump message
Data Quality Biggest issue by far is unique person referencing
Major education / change mgmt task to
– Get patient administration staff to register patient details accurately and avoid duplicates
– Get clinicians to use the Hospital / NHS Number
Problem especially big in emergency care
Issue has a huge knock on effect for the remainder of each episode care
Example: A consultant asked me to investigate why a particular chemistry result did not appear in the patient’s EPR record
In this instance the patient ID recorded in the Hospital Number field turned out to be the patient’s telephone numberMSH|^~\&|MLAB||||20040519113446||ORU^R01|X99156|P|2.3
PID|1||217779^^^^PAS~773702^^^^DEP||SURNAME^FORENAME^^^||19371113|M|||999 ACACIA AVENUE^ORRELL^WIGAN^^WN9 9XX|||||
ZMP|G3417810^^NAT^SS^^L|^^L
ZPV|AE|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|ACC|CC|CH|20177803|20040519|200405191026||FITS.|U||P
OBR|1||20177803^CCMLAB|CC_RUEGK^Urea, Elects. Gluc (urgent)^L^^^L|||20040519||||||FITS.|200405191026||&AP^PINTO^A.^^^Mr.||||||||CH|F||^^^20040519^S|
OBX|1|ST|CC_TONA^Sodium^L^44I5.^^RC||140|mmol/L|135-145|N|||F
Data Quality
Lesson: CANNOT use patient ID as the sole identifier – also need to cross reference with patient’s DOB, Gender, Surname …
Addressing data quality issues in Casualty
Solution Integrated emergency floor system
New emergency floor system is integrated with PAS to enable staff to retrieve up-to-date patient demograhics, including NHS Number
New emergency floor Pathology / X-ray requests automatically include patient ID - improvement departmental system data quality
New emergency floor system will be able to automatically register new patients on PAS - improvement 24 hour bed status
Patient ID data quality
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1.1.04 1.3.04 1.5.04 1.7.04 1.9.04 1.11.04
Time
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IDIntegrated
emergency system live
Addressing data quality issues in Casualty
Issues that are not so easy to address …
Real-time data capture – Not easy when an A&E receptionist is face to face with a patient
who is either • Confused• Uncooperative• Abusive• Unconscious
– Addressing these issues is proving to be a much more challenging task!!!
Addressing data quality issues in Casualty
Rapid application development approach :
(1) Present the HL7 results in the EPR test system environment via a stylesheet, and ask the domain experts for comments
(2) Amend stylesheet, and repeat (1) until domain experts are happy to sign off stylesheet design
(3) Implement stylesheet in live EPR system
Addressing presentation issues using XSL Stylesheets
Microbiology example - Legacy Pathology System view
Sensitivities in a fairly non user-friendly cross tabulation format
HL7v2 messages
A Culture and Sensitivity result is reported using multiple OBX segments.
A single organism result comprises an Organism OBX segment with subID N followed by an Organism Growth OBX segment with subID N followed by zero, one or more Organism Sensitivity OBX segments also with a subID value of N.
Microbiology
The final stylesheet design was deemed an improvement to the legacy system text based screen
More user-friendly cross tab for Organism vs Sensitivities
Critical issue - TIME Building interfaces is not a 5 minute job
Tasks TIME– Find funding to initiate project ? (show-stopper?)– Design interface, agree end-to-end requirements 1-3 months ?– Supplier set-up / configure interface 1-3 months ?– NHS Trust set-up / configure interface 1-3 months ?– End-to-end testing 1-3 months ?– On-going Stylesheet development ?
In summary, even a bog-standard unidirectional HL7 interface could take anything from 3 to 15 months, from start to finish
Key benefit of basing your integration architecture
around XML
EXCHANGE OF BOTH DATA AND
PRESENTATION
Data and Presentation Web technology is enabling the Trust to
benefit from both
Data exchange: development of interfaces which move XML patient data between an EPR (an XML clinical repository) and other departmental systems
Presentation: development and sharing of stylesheets which present a common view of departmental system data across multiple applications
ExampleBi-directional transfer of data and presentation between EPR and A&E EPR
Electronic Patient Records
Emergency FloorElectronic Patient
Records
Discharge Letters, Emergency Care summary
Pathology results, Patient demographics
Data and Presentation
JOIN
Shared XML data and stylesheets
Haematology result in the EPR system
Haematology result in the A&E system
Addressing issues and
Planning ahead for HL7 v3 messaging
Emergency Floor system design Change management issues
– A&E clinicians had never previously entered clinical data into a computer – all notes were recorded on a paper cascard
– Solution had to be QUICK and USER-FRIENDLY !!!
Single screen to record all discharge information
Order comms – all requests for investigations recorded
Treatment given – point and click
Drugs administered – point and click
Diagnosis – point and click
Clinician notes – free text
Emergency Care System
Emergency Floor system designSimple / Quick point and click data capture
Emergency floor system
Discharge screen auto generates an XML discharge summary message
Stylesheets to produce 2 documents on discharge:
(a) Patient letter
(b) GP letter
Emergency floor discharge summaries
Discharge summaries are currently stored in raw XML and presented on screen using an XSL stylesheet
Diagnosis values are coded ICD10, but can easily be coded in SNOMEDCT as well
Raw XML can be transformed into valid HL7v3 A&E Encounter and Provision of care messages using XSLT prior to routing to the Spine
NPfIT Integration Challenges
Existing Systems Integration
Replacement of NHS IT systems will not happen overnight in Acute Hospital Trusts
Key department systems may not be replaced before 2010
Existing systems integration is therefore a key issue for Acute Hospital Trusts
WWL / CSC NPfIT integration approach