Semantic Interoperabilityof the Electronic Health Record:Ambitions and realities

Semantic Interoperability

of the Electronic Health Record:

Ambitions and realities

David Moner

[email protected]

Biomedical Informatics group - ITACA Institute

Technical University of Valencia, Spain

Joint Conference on Medical Informatics in Taiwan


of the EHR

We talk about semantic

interoperability…

…but do we really know what we are

talking about?

Semantic Interoperability: ambitions and realities 4© David Moner


of the EHR


What?


What?

• Interoperability is the ability of two or more

heterogeneous systems to communicate

and share processes and data.

• Semantic Interoperability (SI) is the ability

of sharing, aggregate, analyse and use

external information automatically and in a

meaningful way.


What?

• Edwin Smith Papyrus, 16th century B.C.

• It is as incomprehensible as current EHR!!!

© David Moner Semantic Interoperability: ambitions and realities 7

What?

• SI of the Electronic Health Records (EHR)

– Share and semantically process EHR

information.

– Currently it is a key objective of Health

Information Systems.

– But is it really necessary at all places and

levels?

• Mistake: the SI for the sake of it.



of the EHR


What?

Why?


Semantic Interoperability: ambitions and realities

Why?

• Our objective is the semantic interoperability of

clinical information.

Alerts

Current history

Past history

Medications

And all the

information we

use and need

10© David Moner

Why?

Semantic Interoperability: ambitions and realities 11

• 10813 kilometres

• Different languages

• Different treatments

• Different healthcare systems

The same illness!

© David Moner

Why?


• Spain

• 17 autonomous regions

• 17 independent health systems

• 4 official languages

• 46 million inhabitants

• ~60 million tourists/year

© David Moner


EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

Why?

13© David Moner


EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

EHR server

14

Why?

© David Moner


Why?

© David Moner

Why?

Use case 1


EHR History

Country A Country B

EHR

ξβñç!

Why?

Use case 2


Consultation

EHR

EHR

Why?

Use case 3


EHR EHR EHR

Public health

EHR

EHR

EHR

Why?

• Many more use cases and benefits: public-private health transitions, clinical research, interaction with Personal Health Records, seek of a reduction of costs…

• There is a need to share health information.

• There is a wish to improve healthcare.



of the EHR


What?

How?Why?


EHR systems now


The EHR systems we need


Rules Information Presentation Soft. Hardware EHR

Instructions Ingredients MouldsKitchen

machinesOven Pastry

TechnologyKnowledge

© David Moner


© Gerard Freriks

23

How?

© David Moner

We are moving

towards a

plug-and-play

services world

How?


• Not only infrastructure is important, but

also infostructure.

– An infrastructure refers to the physical

substrate which must be laid down in order to

provide a service.

– An infostructure isn’t anything physical. It is

the layout of information in a manner such

that it can be organised, navigated and used.

Model of Knowledge

Codes/terms

Model of

Documentation

Real use

Model of Meaning

general Use

Model of Meaning

specific Use

Encyclopaedia

Dictionary

Syntaxis

Paper/Document

Generic Phrase

Specific Phrase


How?

The semantic stack

Data Model

How?


SYSTEM A SYSTEM B

Health

information

Structure A

Semantic A

Language A

Structure B

Semantic B

Language B

Context A Context B

?© David Moner

Reference Model

Clinical models

Terminology

How?

Terminologies

• We must implement and use medical

terminologies and ontologies.

– They are the interface between the daily

health care language and a first level of

formalisation.

• Mistake: The solution will not come from

the use of a unique terminology, but from

the correct combination of many of them.


How?

Standards

• Adoption of standards for the

representation and communication of the

information contained at the EHR.

• Mistake: To think that only one standard

will exist covering all needs for every case

of use.


How?

Standards

Keith Boone, Standards Geek for GE Healthcare.


Red arrows are Joint work products.

Blue arrows are MOUs.

Green arrows are Memberships.

Purple arrows are Liaison Relationships.

Yellow connections are between SCO Summit Organizations

Orange connections are between JIC Organizations

How?

Standards

• Mistake: To look for homogenisation,

instead of cooperation and harmonisation.


How?

Detailed Clinical Models

• A Detailed Clinical Model (DCM) is an information model of a

discrete set of precise clinical knowledge.

– In other words, a formal definition of the structure and meaning

of a clinical concept.

• We must agree on which DCMs we will use at our application

domain.

• This agreement, in the form of clinical and technical

specifications such as archetypes and templates, is a key

aspect for semantically interoperable systems

– Must be done with the participation of health professionals and

not by technical decisions.


How?



Model of Knowledge

Codes/terms

Model of

Documentation

Real use

Model of Meaning

general Use

Model of Meaning

specific Use

Data Model

DCM

DCM

Model/Ontology

ISO 13606

Archetypes

HL7 v3

Templates

33© David Moner Semantic Interoperability: ambitions and realities

How?


ISO 13606

• How can we bring DCMs to a working system?

• ISO 13606 – Communication of the EHR

– It has been designed specifically to achieve the semantic interoperability of the EHR.

– It is prepared to work with formal clinical concepts in the form of archetypes.

– Based on a dual model approach.


ISO 13606

• Information: statements about specific entities.

– Represented by a Reference Model.

– For example, the statement “Gina Smith (2y) has an atrial

septal defect, 1 cm x 3.5 cm” is a statement about Gina

Smith, and does not apply to other people in general.

• Knowledge: statements which apply to all entities of a

class.

– Represented by an Archetype Model.

– For example, “the atrial septum divides the right and left

atrial chambers of the human heart”.


• The archetype model is a formal framework to define high

level and semantically rich definitions of health concepts

(archetypes)

• Properties

– Defines constraints over data structures

– Defines semantic descriptions of concepts

– It is automatically computable

– It is multilingual

– It can evolve and change to new requirements

– It can be defined by clinicians and shared

– It can generate screen forms automatically


ISO 13606


25571000000103

(Discharge report)

SNOMED-CT

89100005

(Final diagnosis - discharge)

85097005

(Secondary diagnosis )

…

ISO 13606

http://www.linkehr.com/



English German Spanish


ISO 13606


39© David Moner Semantic Interoperability: ambitions and realitieshttp://ehrflex.sourceforge.net/

http://ehrflex.sourceforge.net/


ISO 13606


• We can create

archetypes for any

reference model.

– Ex. HL7 CDA

archetype


ISO 13606

• We can automatically convert an archetype

from one reference model to another.

© David Moner Semantic Interoperability: ambitions and realities 41http://miuras.inf.um.es:9080/PoseacleConverter/

http://miuras.inf.um.es:9080/PoseacleConverter/

DCM

Coding systems

Rules

Software

Tools

Services

Archetypes

Templates


How?

How?

• Some projects in Europe:

– Spain. Generation and communication of a common patient summary among all the regions.

– Sweden. Roadmap towards an ISO 13606 native system for all the country.

– United Kingdom. National implementation of a Logical Record Architecture (ISO 13606) and a spine for communications (HL7 v3)


Large Scale Pilot: epSOS

• European Patient Smart Open Services (epSOS)

– The project is co-financed by the European Commission and

member states with EUR 22.000.000.

– epSOS was launched on July 1, 2008 and will finish on June 30,

2011


– It is a Europe-wide project organized by 27

beneficiaries representing twelve EU-

member states, including ministries of

health, national competence centres and

numerous companies.


• The epSOS project cover three use cases:

– Communication of the Patient Summary, including alerts,

medical problems (past and current), list of medications…

– ePrescription, a medical professional decides

to prescribe medicine to a visiting patient from another

country.

– eDispensation, allowing a pharmacist to electronically

access the prescription from the same eHealth interface

used for prescriptions ordered in the local country.



• Methodology:

1. Clinical specifications were developed by a clinicians

2. A set of terminologies was selected, from international sources or as an own development.

3. Technical specifications in HL7 CDA and ISO 13606 were defined following the clinical specifications.

4. Pilot tests are being implemented.



An epSOS pilot experience

• The semantic interoperability of the Patient

Summary is being tested between the Hospital

General Universitario in Valencia (HGUV) and

the Hospital de Fuenlabrada in Madrid.

– Based both on the Spanish and epSOS definition of

the contents of the Patient Summary.

– The information is communicated using the ISO

13606 norm.

47© David Moner



Hospital de Fuenlabrada

Madrid

Hospital General Universitario

Valencia

Communication of standardized

ISO 13606 informationEHR

Server

EHR

Server


• The LinkEHR Normalisation Platform is a multi-

standard system that helps to achieve the

Semantic Interoperability of existing EHR systems.

• The methodology is based on three steps:

1. Definition of clinical archetypes.

2. Normalisation of legacy EHR systems.

3. Communication of EHR extracts.

http://www.linkehr.com




1. Agree a concept definition and define the archetype

• We used two different definitions

– Spanish National Patient Summary

– epSOS Patient Summary

• They can be easily edited or modified

with open source archetype editors

such as LinkEHR.

50© David Moner



2. Map the archetype to original/legacy data

• With these mappings we can

automatically generate transformation

programs for the EHR system.

XML

Existing

EHR systems

© David Moner



3. Deploy the transformation program in the EHR server

• Set up a standard ISO 13606 extract server in both hospitals to

generate and communicate the standardized information

– Transformation is applied on demand

– Web-service based

– Includes a standard ISO 13606 web viewer

EHR

Server

XML

ISO 13606

Standard

Information

Mapped

Archetype

CHGUV

HISHF

HIS

EHR

Server

Mapped

Archetype

52© David Moner



of the EHR


What?

How?

Who?

Why?


Who?

• Clinicians

– Clinical users must be involved from the

beginning.

– They are responsible of defining their own

domain (DCMs, archetypes).

– They must share and reuse this knowledge.

• A global DCM/archetype governance is needed.


http://www.openehr.org/knowledge/

http://www.openehr.org/knowledge/

Who?

• Technicians

– Technical decisions must not modify the

clinical ones.

• Standardisation bodies

– They need more harmonisation and

coordination efforts.



of the EHR


What?

How?

When?Who?

Why?


When?

• To achieve SI is still a long way ahead.

• We have the tools, but we still need to use

them correctly.

• The big problem still to be solved: to

compute the EHR semantically.

– How can a machine correctly use the

semantic information to behave correctly?




Conclusion

• Clinicians must lead the process

– They must be aware of the benefits of SI for their daily

work.

• They keys are agreements and harmonisation:

– Agree on using common and generic DCMs.

– There will always exist several standards and

terminologies, and each of them can be adequate for

a specific duty.



It always seems impossible

until its done Nelson Mandela

David Moner

[email protected]

Date post:	07-May-2015
Category:	Technology
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