Michael Mair

Timaru Eye Clinic New Zealand

Sydney 24-25 April

Health Information Technology Standards

Why do we need Standards?

Why do we need Standards?

Why do we need Standards?

Why do we need Standards?

Why do we need Standards?

Why do we need Standards?

• Healthcare Information is increasingly transmitted electronically.

• For Healthcare IT systems to exchange information, they can either:– communicate via custom interfaces– share a common data format

• Custom interfaces are costly to design and difficult to maintain (~ $100k each).

Why Standards?

A common data format is cost-effective, but needs up-front agreement and commitment =

“a Standard”.Sydney 24-25 April

Other Examples of Standards

• Mobile Phones (“GSM”)

• CDs

• ATMs

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Healthcare Economics

….are adversely affected by poor documentation quality. In the United States alone, the cost of information capture is estimated to be over $50 billion annually. A significant portion of this cost is likely to be due to inefficiencies...

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…into this

The need to share more healthcare data

• with other clinicians in the same team• with other healthcare professions

– doctors, nurses, physiotherapists, midwives, dieticians...

• with other disciplines– a diabetic patient may also be under ophthalmology,

nephrology, orthopaedics, chiropody, wheelchair clinic.

• with other institutions• with patients and their families

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Growing numbers of concepts

• Around half of the concepts believed to exist in the world (500,000) are in the medical domain

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Gartner’s Vision for Healthcare: The Next 10 years

• Analyzed the future of Healthcare on a two axis continuum:– Accountability for Payment (single purchaser

Vs – multiple purchasers (consumers are purchasers)

– Standards and Structured Data (‘blurry islands of data’ Vs ‘robust data sharing’)

Sydney 24-25 April

Healthcare 2010 Matrix

A: RationalRationing

You get what you wantand Big Brother will pay

B: Free Market

You can get what you canpay for

C: Irrational Rationing

Brute force rationing

D: Wild Wild West

Healthcare by advertisingand promotions

Accountability for Payment (single Vs multiple purchasers)

Structured

Data

Standards

Development

Sydney 24-25 April

All stakeholders would benefit from Structured Data standards

Under both ‘centralized’ and ‘user pays’ models, Healthcare provision gets more rational with Structured

Data Standards

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The Health Standards Committee of the International Organization for Standards

ISOTC/215, Mission Statement:

• “Standardization in the field of information for health, and Health Information and Communications Technology (ICT), to achieve compatibility and interoperability between independent systems. Also, to ensure compatibility of data for comparative statistical purposes (e.g. classifications), and to reduce duplication of effort and redundancies. “

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Semanticinteroperability

Interoperability has two components

Functionalinteroperability

• Interoperability: “Ability of two or more systems or components

to exchange information and to use the information that has been exchanged”

[IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries, IEEE, 1990]

Sydney 24-25 April

Standard Generalized Mark Up Language (SGML)

Standard Generalized Mark Up Language (SGML)

• Origin from efforts 30 years ago to rationalize the publishing process

Gave the ability to classify, compute, combine, and manipulate information without putting it in a database

HTML (Hypertext Mark Up Language) is an application of SGML

Sydney 24-25 April

XML—(eXtensible Markup Language)from the World Wide Web Consortium

• Emerging standard for content-aware Web pages that will replace HTML

• Separates data display from semantics• Provides atomic metadata about object in a document• Non-proprietary• Vendor, platform, application neutral

Sydney 24-25 April

XML Limitations

• XML describes grammars--is a syntactic standard--no way to recognize semantic units

• XML does NOT create a data model by itself

• BUT: XML will be the common data format that goes ‘down the wire’!

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How to achieve Structured Data

• Natural Language Processing

• Controlled Vocabularies

• Knowledge Based Models

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Natural language processing (NLP)

• Natural language processing (NLP), or natural language understanding (NLU), can turn free text into structured data.

• However without prior agreement on the meaning of terms used, its usefulness is limited

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Controlled Vocabularies

• SNOMED International, from the College of American Pathologists ‘Systematized Nomenclature of Medicine’.

• Includes REED Codes (formerly from UK)

• The International Classification of Diseases (ICD9 and ICD 10) owned by the WHO

• LOINC The Logical Observation Identifiers Names and Codes from the Regenstrief Institute

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Growth of SNOMED (from www.SNOMED.org)

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What is a Knowledge Based (KB) Model?

• A knowledge based model is capable of expressing instances of domain knowledge (knowledge about something)

• Most modern applications are written with‘Object Orientated’ programming

• A ‘knowledge based’ model defines the classes and relationships making up the domain of interest, which become‘objects’ when instantiated..Sydney 24-25 April

Controlled Vocabularies are not enough

• We still need a separate class of clinical entities that get coded, e.g. blood pressure, intra-ocular pressure, macular appearance...

• These will need to include the 5 WH of their capture (the what, where, why, when, who)

• It is the definition and collection of these that makes up a ‘knowledge base’

Sydney 24-25 April

Examples of KB Models

• The Health Level Seven (HL7) v3 Reference Information Model (RIM)

• The Good Electronic Health Record (GEHR) Object Model (GOM)

• The Health Records Committee of the Centre Europeen de Normalization (CEN) Four Part Standard ( ENV 13606)

• The Common Object Request Broker Architecture Medical Model (CORBAmed)

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Only two. since a Recent ‘Memorandum of Understanding’ between GEHR and CEN, CORBA (Aix en Provence Nov 2001)

• Open EHR foundation: GEHR Object Model/CEN ENV13606/CORBAmed, for a global EHR architecture www.openehr.org

• HL7 v3 RIM Reference Information Model. HL7 version 2.* is already widely used in healthcare messaging. www.HL7org

Sydney 24-25 April

Digital Imaging and Communications in Medicine (DICOM)

• Formed in 1983 by American College of Radiology (ACR) and the National Electrical Manufacturers Association

• permits the transfer of medical images in a multi-vendor environment.

• facilitates the development and expansion of picture archiving and communication systems, and interfacing with medical information systems.

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A Convergence is apparent: (from Tom Beale of GEHR)

• A general model of "containers” and “content”.. The "container" can be equated with:

Documents (including in the web sense of a unit of information transmission)

The unit of committal to record systems

The unit for security setting

The unit of transmission of health info.

• The container is called a "transaction" in GEHR, a "component" in CEN 13606, and a Clinical Document Architecture unit (CDA) in HL7 speak

Sydney 24-25 April

Baskets and Objects• The ‘standard’ might consist of standard

‘baskets’ that could be containers for standard ‘objects’.

• Objects are already common place in modern programming, easy to ‘align’

• A non-proprietary protocol already exists to securely exchange them - the Simple Object Access Protocol (SOAP)

• Subjective-Objective-Assessment-Plan is a common record keeping format (SOAP units from Lawerence Weed)

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The standard in a nut-shell (or basket….)

Share ‘SOAPS’

with

‘SOAPS’(but there can be multiimedia objects in the baskets as well..)

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From:JJ Michon, M.D.Duke University School of Medicine

HTML & XML Tags

HTML-Display

<TITLE>

<HEAD>

<BODY>

<TABLE> etc.

XML-Semantics (limited)

<PT ID#><IMAGE TYPE><DIABETES

DURATION><LAST DFE><BLOOD SUGAR LEVEL><LASER HISTORY><VISUAL ACUITY> etc=> METADATA Sydney 24-25 April

Data ‘Objects’: the HL7 Structured Documents group is looking at:

GEHR Archetypes

CEN Archetypes

3M Information Models

SNOMED/DICOM Microglossary

A convergence in now possible

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• Is a kind of container.

• A snapshot of the patient’s health event

• Includes: referrals and discharge summaries

• Includes as data types: structured data, free text, images and multimedia

The Health Event Summary (HES): What is it?

2Sydney 24-25 April

Why HES?

• HES can provide the standard architecture for effective electronic transmissions of clinical / health data between providers

• Provides a credible foundation architecture for evolution towards electronic healthcare record

4

Based on standard

Stakeholdersupport

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Clinical Guidelines and Decision Support

• There are already a number of ‘engines’ that deliver these services to Electronic Health Records

• It is important that there is a level of the ‘standard’ which is non evaluative or prescriptive

• Clinical Guidelines should not be intrinsic to the standard. The container should be ‘dumb’

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If such a ‘standard’ was achieved

• conduct and control of health services would remain entirely local, including access control

• the ‘means of production’ of health information would not be owned (a non proprietary standard)

• there would potentially be access to the huge resource of shared data for research and feedback into clinical practice

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If such a ‘standard’ was achieved

• The same standard would work for complex and simple record taking systems

• it would facilitate the private ‘open source’ developer

• ‘compliance’ would be the same as ‘use’• no need to reconfigure existing software• the existence of the standard would give

vendors a goal, would be a facilitator..

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The ‘transcending’ benefit…...

• the same standard containers for all technological levels and cultures

• it might prove a catalyst for global healthcare, and a global currency for it

• it might become a channel for free decision support…

• who knows where it might lead..

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With thanks to::

• Liora Alschuler • Thomas Beale• Jane Curry• David Lloyd• JJ Michon• Peter Schloeffel• Klaus Veil• Peter Waegemann

………….and many othersSydney 24-25 April

Sydney 24-25 April 2002Timaru Eye Clinic, New Zealand.

THANK YOU FOR YOUR ATTENTION !