Dimitrios G. Katehakis

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Nordic Workshop Copenhagen, March 13, 2003
The Shared Record Service Web-access to patient
data from different record systems

• Dimitrios G. Katehakis
• Senior Telecommunications Engineer
• Center of Medical Informatics and Health
  Telematics Applications

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Institute of Computer Science

• one of the largest research centers of Greece
• distributed national research center (seven
  institutes)

FOR MORE INFO...

• http//www.ics.forth.gr/

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CMI/ HTA
Innovative RD and its application in the domain
of medical informatics and health telematics
CRETE Health Telematics Center
HEALTHNET
I.H.I.S.
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What is the EHR?

• an electronic longitudinal collection of personal
  health information usually based on the
  individual, entered or accepted by health care
  providers, which can be distributed over a number
  of sites or aggregated at a particular source.
  The information is organised primarily to support
  continuing, efficient and quality health care.
  The record is under the control of the consumer
  and is stored and secured securely. (HINA)
• a longitudinal collection of personal health
  information of a single individual, entered or
  accepted by health care providers, and stored
  electronically. The record may be made available
  at any time to providers, who have been
  authorized by the individual, as a tool in the
  provision of health care services. The individual
  has access to the record and can request changes
  to its contents. The transmission and storage of
  the record is under strict security. (OHIH)
• a collection of data and information gathered or
  generated to record clinical care rendered to an
  individual. (ASTM)
• a healthcare record in computer readable format
  (CEN)

• a comprehensive, structured set of clinical,
  demographic, environmental, social, and financial
  data and information in electronic form,
  documenting the health care given to a single
  individual. (ASTM)
• an electronic patient record that resides in a
  system designed to support users through
  availability of complete and accurate data,
  practitioner reminders and alerts, clinical
  decision support systems, links to bodies of
  medical knowledge, and other aids. (IOM)
• a virtual compilation of non-redundant health
  data about a person across a lifetime, including
  facts, observations, interpretations, plans,
  actions, and outcomes. Health data include
  information on allergies, history of illness and
  injury, functional status, diagnostic studies,
  assessments, orders, consultation reports,
  treatment records, etc. Health data also include
  wellness data such as immunization history,
  behavioral data, environmental information,
  demographics, administrative data for care
  delivery processes, health insurance, and legal
  data such as consents. (CPRI)

ISO/ TC 215 Ad Hoc Group Report, Standards
Requirements for the Electronic Health Record
Discharge/ Referral Plans, Final Report, July 26,
2002.
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The Shared Records Service

• An IT Service for professionals or citizens who
  need a uniform way to access parts of patient
  record data that are physically located in
  different clinical information systems.
• Provides fast, secure and authorized access to
  distributed patient record information from
  multiple disparate sources.

• This service should not be confused with
• Autonomous Clinical Information Systems (CIS)
• Message based communication of EHR data
• Centralized Clinical Data Repositories (CDR), or
• Monolithic information systems that have embedded
  in their structure mechanisms for accessing
  directly host systems.

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The Concept in Space
Medical Encounter
Health Record Segment
Fast Virtual Link
Slow Virtual Link
Temporarily Available Virtual Link
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The Concept in Time
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Shared Records Why?

• Vital health information available and accessible
  24 hours a day, seven days a week.
• Healthcare practitioners better positioned to
  offer more effective and efficient treatment, and
  could spend more quality time with the patient.
• Access to information on previous medical or lab
  tests would reduce the number of redundant
  procedures and result in greater cost savings.
• Empowered individuals make informed choices about
  options available to them and exercise greater
  control over their own health.
• Improved quality of care, based on an enhanced
  ability of health planners and administrators to
  develop relevant healthcare policies for the
  future.

• Medical errors are of growing concern
• Approximately 100,000 Americans die each year
  from preventable errors in hospitals1
• More than combined number of deaths from breast
  cancer, AIDS motor vehicles2

1 J. Corrigan, et al (Eds) To Err is Human
Building a safer health system, Committee on
Quality of Healthcare in America, Washington,
Institute of Medicine, 1999 2 Reducing medical
errors and improving patient safety The National
Coalition of Healthcare and the Institute for
Healthcare Improvements, Feb. 2000
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Current International Efforts

• EU Projects
• GEHR
• Synapses
• InterCare
• SynEx
• Open Source Software
• OpenEMed
• Los Alamos, NM, USA
• Australia Initiatives
• GEHR
• OpenEHR

• Standards
• CEN/ TC 251
• WGI, Information Models
• WGIV, Technology for Interoperability
• ISO TC 215
• WG1, Health Records and Modeling Coordination
• ASTM
• E31, Health Informatics
• HL7
• CDA, RIM
• OMG
• Healthcare DTF

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in the US

• along with the Health Insurance Portability and
  Accountability Act of 1996 (HIPAA) financial and
  administrative transaction standards, a
  comprehensive set of Patient Medical Record
  Information (PMRI) standards can move the Nation
  closer to a healthcare environment where
  clinically specific data can be captured once at
  the point of care with derivatives of this data
  available for meeting the needs of payers,
  healthcare administrators, clinical research, and
  public health. This environment could
  significantly reduce the administrative and data
  capture burden on clinicians dramatically
  shorten the time for clinical data to be
  available for public health emergencies and for
  traditional health purposes profoundly reduce
  the cost for communicating, duplicating and
  processing healthcare information and, last but
  not least, greatly improve the quality of care
  and safety for all patients

Report and Recommendations From the National
Committee on Vital and Health Statistics
Information for Health, Report and
Recommendations from the National Committee on
Vital and Health Statistics, U.S. Department of
Health and Human Services, Washington, D.C.,
November 15, 2001
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Standards for the EHR
ISO/ TC 215 Ad Hoc Group Report, Standards
Requirements for the Electronic Health Record
Discharge/ Referral Plans, Final Report, July 26,
2002.
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Inter-enterprise Integration
Collaboration (consultation, telemedicine)
Integrating patient data (i-EHR)
Patient validation
Messaging
PICNIC services
SRS
COLS
CDA
PIDS
...
interfaces based on World Wide Web Consortium
standards
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The Unified Process
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Enabling Components

• Clinical Observations Access Service
• Collaboration Service
• Message Broker
• Patient Identification Service
• Resource Service
• Shared Records Indexing Service
• Shared Records Update Broker
• Terminology Service
• User Profile Service

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Security Services

• Access Control
• Auditing
• Certification
• Client Authentication
• Client Impersonation and Delegation
• Consent Management
• Cryptography
• Smart Cards

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Component Orchestration
PIDS
CIS
COAS
GUI
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Generic Components

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AUDS
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CIS
COAS
UB
AUTS
ENCS
RESS
IS
Access to Patient Data
TERS
UPS
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Sequence diagram
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Federated Approach
Federated Schema Or Schemata

• Reference Model
• Contains generic data structures (RIM, CEN 13606)

Mapping
Mapping
schema integration/ translation effort depends on
the richness of the federated model
Export Schema or Schemata
Export Schema or Schemata
Local Schema
Local Schema

Independent, heterogeneous local schemata
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PICNIC Prototype for Crete

• Involves
• two hospitals
• Sitia
• Rethymno
• five vendors
• FORTH (?)
• ?????f????? ????da? (?)
• Computer Team (?)
• Unisoft (?)
• CCS (?)

• nine clinical information systems
• PHCCIS (?)
• PATHIS (?)
• XRFDC (?)
• CARDIS (?)
• NIS (? ? )
• LIS (? ?)
• Administrative (? ?)
• Financial (? ?)
• Pharmacy (?)

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PICNIC Prototype for SEBT
Allergy Referral Medication Event Consultation
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Dependencies

• Existence of Reliable and Useful Information
• Patient Identification
• Availability of Information
• Use of Coding Schemes
• Systems Interoperability
• Patient Consent on Sharing Personal Information
• Organizational Commitment
• Legal Framework

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Lessons Learned Conclusions

• The needs for stability, manageability,
  maintainability and most importantly ability to
  evolve are of paramount importance
• the multitude of complex issues arising in
  developing a longitudinal SRS was successfully
  solved through
• evolving technical infrastructure
• a component based architecture
• consistent use of widely available standards and
  technical frameworks
• Whatever the technical platform is in real life,
  its selection is only part of the solution.