The Lombardy Region Electronic Health Record
-
Upload
stefano-caccavari -
Category
Documents
-
view
35 -
download
4
Transcript of The Lombardy Region Electronic Health Record
Milan, 18 November 2010
The Lombardy Region Electronic Health RecordThe Lombardy Region Electronic Health Record
Milan, 18 November 2010
Nicola ContardiSISS Department – Development Manager
Summary
The Lombardy Region
The SISS Program
The EHR
The Challenges
2
The Lombardy Region
The SISS Program
The EHR
The Challenges
Summary
3
Lombardy Region
• Is one of the twenty Italian Regions• About 16% of Italy’s citizens• Is one of the most populated Regions of Europe (more
populated than 14 EU member States)• Its GNP is about 20% of Italy’s GNP
4
The Lombardy Region
The SISS Program
The EHR
The Challenges
Summary
5
• 9.900.000 Citizens (99% of total)
• 150.000 Health & Social Care Operators
• 7.800 General Practitioners (97%)
• 2.600 Pharmacies (100%)
SISS in numbers
6
• 2.600 Pharmacies (100%)
• 35 Public Hospitals (100%)
• 15 Local Healthcare Units (100%)
• Over 2500 Private Healthcare Service Suppliers (15%)
ASL
Hospital
ASLASL
Hospital
The underlying philosophySISS is a Regional Healthcare Information Network ; the Citizen is its centre .All the data are gathered, organized and reported on the basis of the citizen’s clinical treatment within the Regional Healthcare Network.
Healthcare DataHealthcare Data
Administrative DataAdministrative Data
General Practiotioner
Practitioner
Healthcare Local Unit
Pharmacy
Healthcare DataHealthcare Data
Administrative DataAdministrative Data
General Practiotioner
Practitioner
Healthcare Local Unit
Pharmacy
Data WareHouseCluster of Patients
Electronic Health RecordVision per single Patient
Data WareHouseCluster of Patients
Electronic Health RecordVision per single Patient
7
SISS – The Model
Electronic Health
Record
Services for the
Citizen
Dematerialization
System Governance
SISS PLATFORM
8
Pharmacies
Care Homes
Private HC
GP
Hospitals
Others
LHU
SISS PLATFORMIntegration with HC Suppliers
The Lombardy Region
The SISS Program
The EHR
The Challenges
Summary
9
• Give an integrated and contextualized vision of the health
history of a specific individual
• Increase the efficacy and efficiency of clinical actions
• Make information directly available to the citizen
The SISS EHR - Scope
10
• Simplify the activities of health operators
• Interface administrative systems for secondary usage of
information
The SISS EHR: Architecture
Two-level architecture:
Level 1 (Lombardia Informatica):
•Index and “pointers”.
Level 2 (Hospitals/LHU):
HC Supplier
docClinical
HC Supplier
HC SupplierClinicaldoc
11
Level 2 (Hospitals/LHU):
•Clinical documents.
Digital DocumentsLHU: Prescriptions, Patient Summary, Vaccination recordsHealth Suppliers: Test Results, Discharge letters, First-aid reports, Pathology Cards, Therapy Plans, …
ASLASLASL
LHU
Events Link
Electronic Health Record
PS
Clinicaldoc
Prescr.
Doctors
The SISS EHR: Content
ASL
Farmacie MMG/PLSEnti Erogatori
RE
P 1
RE
P 2
RE
P n
RE
P 1
RE
P 2
RE
P n
RE
P 1
RE
P 2
RE
P n
EE 1 EE 2 EE n
REPARTO VIRTUALE (Rete di patologia)
LHU
Pharmacies GPHospitals
War
d 1
War
d 2
War
d n
War
d 1
War
d 2
War
d n
War
d 1
War
d 2
War
d n
H 1 H 2 H n
VIRTUAL WARD (Pathology Network)
12
PrescriptionsPatient Summary
Vaccinations
PrescriptionsResults“ER” ReportsDischarge Letters
Pathology ChartsDiagnostic Therapy Paths
Electronic Health Record
Patient-centric View
Each document is classified according to its typology (Radiology, Lab, ...), and is qualified by context attributes (date, ward, problem, ...).
The EHR manages documents both in textual and structured (HL7-CDA2) formats.
The SISS EHR: Sources of Data
Preparation and signature of documentsThe specific departmental
Archiving of clinical documents in hospital repository
Publication in EHR
13
The specific departmental system (e.g. LIS or RIS) generates the clinical document and submits it for digital signature
repository The system archives the
document, along with the consultation authorisation
The hospital repository publishes the document to the SISS
• Healthcare Episodes (e.g. hospitalisations, “ER”)
• Specialist Consultations: Pathology Networks, Diagnosti c and TherapeuticPaths
• Discipline (cardiology, hematology, ...)
The SISS EHR: Consultation
The EHR permits various routes of interrogation for both doctors and the patient:
14
• Discipline (cardiology, hematology, ...)
• Graphical interface (e.g. integrated clinical history over time)
• Clinical document attributes (document type, author, date, hospital, …)
New consultation methods are being studied: problem-oriented consultation, “search engine” for free text searches
75 million Prescriptions (+10%)
5.8 million active EHR
SISS in numbers for 2010 (forecast)
15
14 million Electronic Clinical Documents (+18%)
Around 1.2 million Consultations of Clinical
Documents by GP’s (+47%)
Pathology
Networks
Pathology
Networks
Hospital Specialists
Hospital Specialists
EHR Data Sharing
Patient
Summary
Patient
Summary
Diagnostic
and Therapeutic
Paths
Diagnostic
and Therapeutic
Paths
16
Hospital Specialists
GP
GP
Hospital Specialists
Regional Social Regional Social Healthcare PlanHealthcare Plan
(PSSR)(PSSR)
Annual DecreeAnnual Decree
Regional Regional DecreeDecree
• Indicators for the level of regional programming and the definition of the implementation of the PSSR• Verify state of implementation• Monitor epidemiological activity• Verify state of implementation of primary and secondary prevention
“Technical Scientific Support”
Commission
“Technical Scientific Support”
Commission
Defines:
EHR Data Sharing: the Lombardy Region program
17
Annual DecreeAnnual Decree
Definition of new pathology
networks
� Objectives� Organisation� Components of
experimentation� Resources available
• Guide Lines Proposals• Approriateness indicators definition
• Improvment pathways definition
• Learning modules proposal
• Technical Scientific support to Lombardy Region for pathology health policies
Technical Analysis Group (GAT)
Defines:
Pathology NetworksPathology NetworksTechnical and organisational network consisting of
hospitals and operators active in the cure and assistance of patients in the various phases of illness, with the primary objective of optimising the
assistance of the patient by activating homogeneous care policies throughout the region.
Pathology Networks
18
Pathology ArchivesPathology Archives
� Level: Regional� Data: Anonymous
Pathology RegistersPathology Registers
� Level: National� Data: Patient centric
Pathology Network SpecialisationsSCOPE: Gather data with epidemiological ends, to ob tain an in-depth study of the pathology, to define better c are paths
and a better appropriateness of cure .
� ROL – Lombardy Oncology Network� REL – Lombardy Hematological
Network� Hearing Disorder Network� Epilepsy Network� EUOL – Emergency/Urgency
� PMA – Medically Assisted Procreation� TIN – Neonatal Intensive Care� CAV – Anti-venom network� SIDS – Sudden Infant Death Syndrome
PATHOLOGY NETWORKSPATHOLOGY NETWORKS
Pathology Networks: State of the Art and Evolution
19
Pathology ArchivesPathology Archives
�IMA – Acute Heart Attack�Stroke Archive
Pathology Pathology RegistriesRegistries
�Rare diseases� Nephrology
The Objective of Diagnostic Therapeutic Paths is to implement Continuity of Assistance according to the Chronic Care Model
An activity of convergence between Pathology Networks and Diagnostic
Therapeutic Paths is
Diagnostic Therapeutic Paths (PDT)Diagnostic Therapeutic Paths (PDT)
GP SPECIALISTS HC OPERATORS PATIENTS
AUTHORISATION MANAGEMENTVERTICAL APPLICATION (e.g. Cardiac Decompensation)
TEXT MESSAGENOTIFICATION NOTIFICATION NOTIFICATION
20
First usage of PDT for cardiac decompensation in the Monza/Brianza and Como areas
WIP: Oncological PDT
Therapeutic Paths is under way
NOTIFICATIONSARCHIVE
VERTICAL APPLICATION (e.g. Cardiac Decompensation)
PDT ARCHIVE(documents and
activities)
DOCUMENT TEMPLATE ARCHIVE
NOTIFICATIONS SCHEDULEDOCUMENT ARCHIVE
MANAGEMENT
As defined by the committee of GP’s
Patient SummaryPatient Summary
“An electronic clinical document, digitally signed and published in the EHR, containing the summary of the clinical history and current state of the patient. It is created and updated by the GP each time there are significant variations in the clinical history of the citizen. It contains a
predefined set of clinical data in case of emergency”.
21
• Hospitalisation: Information from GP to Specialist
• Emergency Room
• Home care
• GP change
Usage
HL7-CDA2
Digital Signature - PKCS#11
Smart Card
SOA
Standards
22
National Standards:
SPCoop
CNS
ICAR - INF.1 e INF.3
HL7 is the chosen standard.It’s adoption is gradual according to the specific level of
consolidation. • Lombardy Region has decided to promote its adoption:
�Step 1: intra-hospital integration;
�Step 2: integration over the SISS Extranet.
Digital documentation: standards (1/2)
23
�Step 2: integration over the SISS Extranet.
• Documents currently available are text (PDF) and structured(HL7-CDA2).• Each document in the EHR has a relative electronically signedPDF (PKCS#11).
• Objective: semantic interoperability, i.e.:
� clinical documents structured and encoded in conformancewith HL7-CDA2 standards;
� “import” of structured documents into clinical applications.
• Documents managed : discharge letters and out-patient
Digital documentation: standards (2/2)
24
• Documents managed : discharge letters and out-patientreports (pathology networks), patient summary.
• Short-term Evolution : generic discharge letters, “ER” reports,therapy plans, rehabilitation plans, anatomical pathology.
The definition of the lab-test report
(“Implementation Guide” ) in CDA2
format was published by HL7 in 2009.
Since then, Lombardy Region has launched a program such
that all Lombardy HC providers generate HL7-CDA2 lab-test
reports..
- 2 Hospitals generate HL7-CDA2reports.
From 2011 gradual extension over all
Digital documentation: Lab-test reports
EXPERIMENTATION 2010
25
Lombardy Region has published a further document, available on the Internet, such that lab-test reports
prpduced conform to:
• Structured in compliance withHL7-CDA2;• “Entry”-level encoding (level 3);• Minimum dataset encodingaccording to LOINC standard.
reports.
- 100 GP’s receive the reports andimport data into personal GP SW.
- 2 SWH for LIS and 4 SWH for GP SW.
The GP SW imports automatically andarchives at least the LOINC-encodedparts, taking into account that eachsingle test could be associated withmore than one LOINC code due todifferent test methodologies, ....
Lombardy.
• “Personal zone” for the citizen in his EHR – creationof an area for the insertion of clinical data by the citizenhim/herself (Personalized Health Information – PHI)
• Diagnostic & Therapeutic plans in the graphicalclinical history interface
Electronic Health Record - Evolution
26
• Hospital patient chart management
• Extensive use of structured documents
• DICOM Image consultation
The Lombardy Region
The SISS Program
The EHR
The Challenges
Summary
27
1. Involvement of Doctors• Ensure participation in
the decision processes• Ensure benefits for the
doctors
1. Involvement of Doctors• Facilitate dialogue between specialists, GP’s and
citizens (pathology networks, Patient Summary, ...)
• On-the-road services• Active involvement of stake-holders (Medical
Experts Group, Hospital Coordination Group, ...)
Challenge Response
Organisational Challenges and the SISS response (1/2)
2. Involvment of Citizens• In the area of health,
citizens entrust themselves to doctors, not public administration
• Privacy and data security• Contribution of the citizen
28
2. Involvement of Citizens• A system for the healthy too• Personal Health Record• Interface revision with user groups• Simple functions with short Time-to-Market• Bidirectional communication services (Text
messages, outbound call centre, email, ...)
3. Supplier Management• Balance between risks
and gain• Careful monitoring of
aggregations
3. Supplier Management• Competition/Cooperation• Creation of an ecosystem of partners
cooperating in the construction of the system
4. Ensure an effective governance
Challenge Response
Organisational Challenges and the SISS response (2/2)
4. Ensure an effective governance
• Leadership, political involvement, financing
• Balance between decisions made above and proposals from the operative level
29
4. Ensure an effective governance• Data gathering, organising, and
processing of citizen-centric data (EHR, Citizen Registry, DWH, ...)
• Evolution of mechanisms (electronic prescriptions, ...)