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Introduction

Introduction. My name: Ernst de Bel Architect EHR UMC St Radboud Nijmegen Internist / intensivist/ econometrician 2001 : Clinical Data integration portal for the ICU using Web technology and AJAX 2004 : full time ICT 2003 : User of HL7 v3 as for application architecture sinds 2003

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Introduction

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  1. Introduction • My name: Ernst de Bel • Architect EHR UMC St Radboud Nijmegen • Internist / intensivist/ econometrician • 2001 : Clinical Data integration portal for the ICU using Web technology and AJAX • 2004 : full time ICT • 2003 : User of HL7 v3 as for application architecture sinds 2003 • HL7 NL: Pharmacy, Patient Care Project Radboud EPD

  2. Project Radboud EPD

  3. Project Radboud EPD

  4. Project Radboud EPD

  5. Implementation HL7 v3 in the UMC St Radboud Nijmegen • Why use HL7 v3 for application design • Using HL7 v3 at various levels • Examples and demonstration Project Radboud EPD

  6. How it all started IC Database Intensive Care admissions • Census • Diagnosis, complications, outcome • Registration of minimal dataset for the evaluation of quality of care (NICE) Project Radboud EPD

  7. LRD HIS Rad. DB HL7 v2 XML configuration XSLT Navigation HTML Project Radboud EPD

  8. Project Radboud EPD

  9. EHR Project Radboud EPD

  10. 2002-12 POC DBC (~ DRG) , Laboratory Result Reporting • 2003-5 Lab-Rad-Or (XpertMed web application) • 2004-1 IcWeb (NICE) • 2004 Building Order communication for the ICU • 2004-12 RvB: use XpertMed  EPD (tot 2008) • 2005-3 electronic order management ICU live • Medication orders and administration registration • Device orders : mech. Ventilation, pacemaker settings, dialysis etc. • 2005-6 RIM database (HL7-v3) for the hospital • 2006-6 progress and transfer summary (CareProvision, CDA) • 2006 new user interface, AJAX, SOA • 2007-5 interdisciplinary cooperation (oncology working group) • 2007 Concern Tracking for phycisians, configurable forms for nursing reports • 2007 Medication and Pharmacy • 2008 CareProvision as the basis for data integration Project Radboud EPD

  11. Projects, plans….

  12. Planning Subst. preparation Observation planning Devicepreparation Device setting Orders Medication/ Food Observations Devices DeviceParameters Order Results Subst.Administration Observations Deviceapplied DeviceParameters Actors Physicians Nurses Otherstaff Patient Project Radboud EPD

  13. Project Radboud EPD

  14. Discovery of Heaven : To Do • HL7 education  shift of paradigm • HL7 tools for application development • HL7 database to persist HL7 structures • Project • Story board • Process / workflow modelling • Use cases • Actors, minimal datasets • Coding (HL7,SNOMED,ICF,LOINC) • Adherence to standards (NICTIZ-HL7) • Configuration of items for the UI • Implementation

  15. Paradigm shift Focus on applications •  focus on information management •  services Database modelling  object modelling Stable database design, with optional horizontal and vertical splitting and scaling Models reflect domain specific infromation the database not Project Radboud EPD

  16. Story to model Pineut (Patient ) comes (12 juni 2004)to the ER department of of the UMC because ofshortness of breath. DrSmartlistensand hearsweezingleading to the diagnosis of astma. SheprescribesSalbutamolandrefersthe patienttoKliniekSt.Elsewhereforlung functionmeasurement RIMdb

  17. Observation • classCode <= OBS • code <= ‘chief complaint’ • value <= ‘dyspnoea’ • Person • classCode <= PSN • id<= 1001188 (UMCN) • name<=Pineut • typeCode <=SUBJ • contextControlCode <=AP • Role • classCode <= PAT • id <= 101188 • typeCode<=RSNcontextControl <= AP • Role • classCode <= DSDLOC • code <= ER • typeCode <=LOC • contextControlCode <=AN • Ambulatory Encounter • classCode <= ENC • code <= EMER • moodCode <= EVN • effectiveTime <= 12-06-04 • Place • classCode <= PLC • name<=SEH • typeCode <=COMP • contextControl <= AP • Role • classCode <= PHYS • id<= Z047110 • typeCode <=AUTH • contextControlCode <=AP • Person • classCode <= PSN • id<= Z047110 (HRM) • name<=Smart • Observation • code <= ‘ausc lungs’ • value <= ‘weezing’ • typeCode <=MFST • contextControl <= AP • ManufacturedMaterial • classCode <= MMAT • determinerCode <=KIND • name <= Salbutamol • SubstancAdministration • moodCode RQO • doseQuantity 200µg • routeCode <= inhalation • effectiveTime <= (period =360) • Observation • code <= ‘diagnosis’ • value <= ‘astma’ • typeCode <=RSN • Role • classCode <= THER • typeCode <=TPA • typeCode <=RSN • Procedure • moodCode: RQO • code <= ‘lung function’ • Role • classCode <= PROV • typeCode <=RESP • contextControlCode <=AP • Organization • classCode <= ORG • code<=HOSP • name<=St ElseWhere RIMdb

  18. player • scoper • II RIMdb

  19. Implementation RDBMS MS SQL Server Databases • TerminologyServices • Templates (constraints) • RIM • Domain applications for business logic (AdministrativeManagement, CareProvision, Observations, Medication, Pharmacy) XML + xsltxml or html

  20. Basic abstract class instances tableExtension classes : side table • Entity – LivingSubject – Person • Entity – Material – ManufacturedMaterial – Device • Role – Patient , Employee, Access • Act – SubstanceAdministrationAct, SupplyAct, EncounterAct, ObservationAct • Relations defined using internal parameters: entityId, roleId, actId • Relation tables : Participation, ActRelationship, RoleLink • Tables for messaging domein : Interaction, Message, QueryParameter

  21. Datatypes • Simple mapping • BL,BN  xs:boolean  bit • ST xs:string  varchar • ED (text/plain of text/html) text + attributes in supplementary table • INT xs:integer integer,bigint • FLOATxs:numeric float • TS  datetimestring • Variabele mapping • ANY  SQLvariant

  22. CS :HL7 structural attributes classCode (ActClass,RoleClass,EntityClas) determinerCode (EntityDeterminer) moodCode (ActMood) statusCode (ActStatus,RoleStatus, EntityStatus,ParticipationStatus)

  23. Codes Alle codes (except CS) mapped to internalId TerminologyServices CodeSystem : OID, CodeSystemName ConceptCode : internalId, code, codeSystem ConceptDesignation (displayName, languge) ConceptDescription (originalText, language)

  24. RIMdb

  25. Complex datatypes Cardinality = 1  fields Role.effectivetime (IVL_TS)  effectiveTimeStart, effectiveTimeEnd Role.quantiy  numeratorValue, numeratorUnit, denominatorValue, denominatorUnit Cardinality > 1  table EntityName, Telecom, Address ActAttribute for priorityCode, confidentialityCode enz. methodeCode, reasonCode etc. II (ActII,RoleII,EntityII) : internalId, root , extension IVL_TS : effectiveTimeStart/effectiveTimeEndtimeStart/timeEnd GTS : effectiveTimeLiteral + PIVL_TS (phase, width, period, operator)

  26. Entity

  27. Role

  28. RIMdb

  29. Project Radboud EPD

  30. Query strategy Decomposing Message • Message • ControlAct • Participations : AUT,ENT,VRF • ParameterItem Writing DetectedIssueEvent (if any) Filling “Act tree” in memory: set of ActRelationships Pull out ActRelationship – Act – Participation – Role – Entity based on primary keys Assemble Message with XSLT

  31. Writing from Message: Stored Procedures createRole • createPatient createAct • createObservation • createSupply • createEncounter obsoleteAct, nullifyAct, holdAct, activateAct, suspendAct….

  32. Building new instances from Templates Configuration tool to define standard acts and actrelationship New instances are created from these definitions createActFromTemplate createActRelationshipFromTemplate Participations are added by the application

  33. Implementation Entities + Roles PersonnellManagement : HRM  Active Directory Services  RIM (Roles + Role Based Authorizations) PatientAdministration : HIS  RIM (HL7 v2) Places: reference database  RIM OrganizationManagement: ADS  RIM (specialties, working groups etc.) Materials : Pharmacy + Food Care + Matrix  RIM Project Radboud EPD

  34. Acts : domain specific applications Encounter overview from 4 separate systems Ordering substances to administer + administration registration Ordering device settings and observations (ICU) Care Transfer Request Clinical summaries Concern and diagnosis tracking Multidisciplinary cooperation Care Tracking and generation of billable Care Provision episodes Document management Project Radboud EPD

  35. Project Radboud EPD

  36. Project Radboud EPD

  37. Project Radboud EPD

  38. Project Radboud EPD

  39. Project Radboud EPD

  40. Project Radboud EPD

  41. Work flow in the application : sticking objects together PrescriptionRXPredeterminstionRequest Selecting patient Create new prescription Connect patient to prescription Sticking product as directTarget to prescription Adding author, dataEnterer Sticking DetectedIssues interactions, double medications ActivatePrescriptionRequest Adding SubstanceAdministrationRequest Add DetectedIssues for dosage Add Verifier Activate Project Radboud EPD

  42. Voorschrijven van medicatie Project Radboud EPD

  43. Registratie bij toediening Project Radboud EPD

  44. Problems with HL7 v3 • Steep learning curve • Much overhead compared to amount of information • Model sometimes ‘clumsy’ • Too tight, too open? Project Radboud EPD

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