China National EHR How Far We Are?

1. China National EHRHow Far We Are? Huilong Duan, Ph.D. School of Biomedical Engineering & Instrument Science Zhejiang University Email: duanhl@zju.edu.cn

2. Global Challenges in Health Care • Cost-containment and affordability • Expanded access • High quality of health care • Chronic disease management (e.g. Cardiovascular diseases, diabetes) • Infectious disease prevention and management (e.g. H1N1 Flu, AIDS, SARS, TB)

3. Current Health Care in China 57% population in rural areas 80% hospitals in cities Large amount of migrant people (0.147 billion) Limited health Infrastructure (2.75 bed/1000) Aging population (0.144billion) • Uneven distributed & limited health care resources • Limited medical insurance coverage • Increasing costs

4. Medical Expenses in China government 32 %–> 17% government 48 %–> 29% society 20 %–> 54% private society private “Difficulty and high cost in seeking medical service” is the TOP ONE concern! -- Society of China Analysis and Forecast Blue Book, 2007

5. Reform to Provide Better Health Care Establish national essential drug system  medical insurance systems that will cover all urban and rural residents. medical insurance systems that will cover all urban and rural residents. Rural health Rural health Public health Public health Community health Community health

6. Basic Health Care System Covering all Residents in the Urban and Rural Areas PublicHealth Service MedicalService Medical Insurance Pharmaceutical Supply Management HIT Legal Operating mechanism Investment Mechanism Price determining Mechanism Regulatory HumanResource Medical and Health System Reform Health Care Reform in China

7. 5 Systems in Public Health Urban and Rural Community Health Service e-government Web Port e-hospital TCM、Research and Education Rural Cooperative Medical System BME HIT Supports in the Reform e-Health

8. EHR is Critical in e-Health Personalization Healthcare Face-To-Face • Passive treatment to proactive prevention • Seamless access to health services Heal th service City hospital Regionalization • Isolation of the medical resources to subdivision, share, synergy regionalization Government agencies Data center County or city level hospital Citizen Informationization • Medical and health technology based on modern electronics, engineering, information and bio-engineering Related medical and health institutions Urban and rural community health service agencies Electronic health record as the core Resources sharing as the basic

9. Case 1:Community health service in Dongcheng district of Beijing

10. Case 2:Health Information System in Xiamen City Civil Affairs Insurance Bank Price Control Supply Drug administration e-Hospital e-Health Administration e-Community Healthcare Regional Health Data Center e-CDC e-Health Supervision e-family healthcare Up level health data center

11. Case 3:Regional health information network (医联工程) of Shanghai • Avoid unnecessary repeated lab test and medical imaging examination • Goal • Connect hospitals and share medical information • Improve HIT adoption in hospitals • Provide economical and convenient healthcare • First phase  • Share information among hospitals: patients’ basic information, medical record, laboratory result, medical image and report • Web port: query, consult, appointment • Public Health: statistics, monitoring

12. Case 4:National e-Health Key Technology and Regional Trial Implementation in Zhejiang Province Zhejiang Province 22 regions Covering 8 million population • Supported by Ministry of Health, Ministry of Science and Technology, and Zhejiang Province • 7 tasks to evaluate key technologies and the applications in e-health

13. Task 1：EHR modeling • Define health meta data and data sets from fetus to death • Model EHR to cover all the key health points of entire life • Define the services to integrate all the health information together death birth Health care service cover the entire life

14. Task 2：Standards and specifications development Cooperation with organizations such as Ministry of Health, Chinese Association of Health Information, Standardization Administration of China, to develop and integrate standards that will meet the needs of e-health • Data classification and coding specification • Data collection and exchange norms • Standardize business processes “HealthRecordbasicinfrastructureanddataspecification”(ontrial) “EMRbasicinfrastructureanddataspecification”(Draft)

15. Task 3：Applications development on EMR • Advanced clinical information systems • Data mining and analysis technologies on EMR EMR Standard Interface regional information share platform

16. Task 4：Regional health information exchange platform social insurance government business insurance blood station pharmacy antiepidemic organization supplier Regional Data Center maternity and child healthcare bank health supervision emergence center citizen hospitals community health service center

17. Task 5：EMR based Tele-medicine platform Large-scale hospital Remote clinics andeducation center Community health services center Households Small and medium-sized hospital

18. Task 6：Prompt clinical pathway and other CDSS adoption in hospitals Doctor A Patient Treatment program A Medical Treatment Quality Control Doctor B Treatment program B Doctor C Treatment program C Disease knowledge base Implementation of clinical pathways Doctor A Patient Hospitals Quality Control Clinical pathway program Doctor B Doctor C

19. Task 7：Regional implementation and evaluation • Every 1,500 residents has a family doctor • Health examinations for EHR (free of charge) every 2 years • Depends on the adoption of HIT

20. EHR related Actions in China • Starting in 2009, a unified health record for all residents will be established throughout the country, promoting equality in right to basic health service • -- National Human Rights Action Plan of China (2009-2010) • Focus on developing regional health information platform upon resident electronic health record, and hospital information platform upon EMR • -- major work plan of Ministry of Health in the year 2009

21. Establish a National EHR in China • Interoperability • Health policy level • Health services level • Semantic level • Technical and functional level • Security and privacy • Laws, regulations, and standards • Security and privacy education • Technical practices • The cost • Government role in investment Three major challenges:

22. Semantic Interoperable EHR StandardizedArchitecture StandardizedInterfaces StandardizedData Structures StandardizedData Vocabularies StandardizedFunctional Behaviour • Generic reference models for representing clinical (EHR) data e.g. EN 13606, HL7 CDA, openEHR Reference Model • Agreed clinical data structure definitions e.g. openEHR archetypes, HL7 templates, generic templates and data sets • Clinical terminology systems e.g. LOINC, SNOMED-CT

23. Major difficulties to achieve interoperability • Chinese version medical terminology standard, code systems and message exchange standard • Management and regulation lag behind the requirement of HIT • Agreed EHR/EMRconception and recognition • Standard-based HIT systems and products • Clinical informatics research and knowledge base support • Difficult to share data between information islands • Clinical information system adoption is low, clinician get insufficient benefits from HIT • Repeated low-level HIT applications exhausted most of the investment

24. Security and Privacy • MOH “Measuresfor the Administration of Electronic Certification Services in Healthcare (on trial)”begin trial implementation at Jan. 1, 2010 • Privacy & Security standard and implementation specifications like HIPAA in the US are not available • Should coordinate with interoperable architecture design work and general privacy legislation procedure • Electronic certification service provider is needed to support the future national EHR • Both clinicians and patients lack security and privacy consciousness

25. Government’s role • Many roles for the government to choose in e-health. Different role has different cost and risk • Planner and investor Strategic investor System developer Standard maker Construction supervisor Policy maker Industry supporter Strategy Planner Infrastructure constructor System operator Best practice promoter

26. HIT standards break out in China Ministry of Health of China published several HIT standards since 2009: • HealthRecordbasicinfrastructureanddataspecification(ontrial) at May 19, 2009. • EMRbasicinfrastructureanddataspecification(Draft) at August4, 2009. • TechnicalSolutionforRegionalHealth Information Platform based-on EHR (on trial) at December,2009 • National Health Data Dictionary and Meta Data Management System at December, 2009 • Measuresfor the Administration of Electronic Certification Services in Healthcare (on trial) at December,2009 • Electronic Medical Record basic specification (on trial) at March, 2010

27. A Study on Information Infrastructure of A nationwide EHR Project Director: Huilong Duan • Jointly funded by China NSF and Chinese Academy of Engineering • Part of the study on national long term development strategy of engineering science and technology of China

28. National EHR Roadmap Operation & Refinement (2025-2030) Preparation & Trial (2010-2016) Construction & Development (2017-2025) 2010 2020 2030 2015 50%3-level hospital 30% urban community health center 20% rural hospital or clinic Adoption interoperable EMR/EHR Demonstration regional EHR 2025 100%3-level hospital 90% urban community health center 80% rural hospital or clinic Adoption interoperability EMR/EHR A nationwide interoperable health information network formed 2020 80%3-level hospital 50% urban community health center 50% rural hospital or clinic Adoption interoperable EMR/EHR Establish above 10 province level EHR systems.

29. Preparation and Trial (2010-2016) • Tasks • Medical informatics basic construction • Enterprise information construction • Regional EHR demonstration • Plans in detail • Establish a national organization to lead and coordinate the national wide Health IT efforts and responsible for drawing the detail blue print of National EHR • Establish professional standard organizations • Modify and new law and regulation adjusting to e-health • Healthcare information security and privacy act • EMR regulation • Launch finance and policy to accelerate standard-based interoperability EMR adoption in hospitals

30. Construction and development (2017-2025) • Tasks • Widespread standard-based interoperability EMR in hospitals • National EHR infrastructure construction • Plans in detail • Nationwide high speed networks for health information exchange • Construct national standard EHR information infrastructure, such as Identity, Service, Auditing Service, Encryption Service, User Authentication Service, et al. • Promote knowledge systems and applications such as clinical decision support system, digital clinical guideline, clinical pathway • Promote self-care and household medical systems and devices integrated in the EHR • Online billing in the new medical security systems, develop funding monitoring tools

31. Operation and refinement (2025-2030) • Tasks • Refine the operation mode and regulation system • A complete e-health system based on national EHR • Plans in detail • Establish professional national EHR operator, gradually operates in market mode • Study the deep utilization of national EHR data resource and add value for enterprise connect in national EHR networks • Popularize the self-care and family-care health service supported by professional systems and applications • Accelerate the new healthcare service mode • Community health deal with most of the health problems • 3rd level hospital only accept transfer patient from GP

32. EHR in translational medicine Standard semantic interoperable EHR provide the possibility to reuse the data for research purposes • Integration of genomic information in EHR may lead to genotype-to-phenotype correlation analysis • China national EHR, on 1.3 billion persons’ health and medical data and information, will have a significant impact on translational research

33. Colorectal Cancer Translational Research Center at ZJU • Participating institutions -- School of Medicine -- Sir Shaw Run Run Hospital -- School of Biomedical Engineering & Instrument Science • Provide efficient communications and resource sharing between biomedical and clinical researches in colorectal cancer • Benefit patients with medical discoveries

34. Information infrastructure to enable translational research

35. Translational EHR in future Translational EHR EHR EMR cell-level data molecular-level data Public Data Bank

36. China National EHR – long way ahead • Most of the hospitals still use paper-based medical records • Currently available standards are far from enough for e-health • a common problem in most countries, especially in China • Lack of professional talents in both research and industry • medical informatics education just began • Short of products and systems in the market • Some social obstacle will exist for a long time • hospitals unwilling to share their data • clinician unwilling to change their workflow • people unwilling their privacy under risk

37. Thank you!