Interoperability in Health Informatics: saving data from obsolescence, and putting the patient first

1. Interoperability in Health Informatics:saving data from obsolescence,and putting the patient first Thomas Beale Ocean Informatics, Australia

2. � 2005 Ocean Informatics * * * Programme * * * The problems of health IT The problem of Interoperability Ontological basis for solutions Standards Strategy

3. � 2005 Ocean Informatics The Problem

4. � 2005 Ocean Informatics The human view

5. � 2005 Ocean Informatics The engineering view

6. � 2005 Ocean Informatics * * * Programme * * * The problems of health The problem of Interoperability 3 principles for solutions Standards Strategy

7. � 2005 Ocean Informatics The Clinical Information Trail

8. � 2005 Ocean Informatics First Improvement - Messages

9. � 2005 Ocean Informatics Introducing the EHR

10. � 2005 Ocean Informatics Difficult Questions revisited (1) Which items are copied to shared EHR? Rule-based � e.g. �current meds�, �therapeutic precautions� + major event categories + ad hoc requests ...these rules must be able to evolve...security/consent... Where is the master copy of each item? Usually in the shared EHR, to enable standardised reads...but if EHR technology used at care sites, could be there as well � �system of EHR systems� Where & how to achieve interoperability? Standards-based middleware + web services highly enabled if EPRs are converted to EHR technology

11. � 2005 Ocean Informatics Difficult Questions revisited (2) Where is the �EHR�? The patient-centred, longitudinal, shared care EHR is in its own servers � where? Depends... Governance by e.g. GP organisations, local health authorities or other trusted bodies Who is in charge of the EHR? The patient can be in charge of consent GP or other carer can be clinical �co-driver� How does decision support work? It now has a standardised & longitudinal database to work with

12. � 2005 Ocean Informatics Difficult Questions revisited (3) Who is managing the patient�s care? Could be anyone, but now there is a mechanism to communicate who it is How does each clinician determine where the relevant information for next decision is? By using shared EHR: problem- and issue-threading, other derived information structures; relies on fidelity of EPR->EHR synchronisation How are medico-legal problems addressed? All decisions in the EHR are linked back to their input items � via causal links, issues, problem classifiers etc Only one place � shared EHR � needs to have reliable technology for non-repudiation, notary, etc

13. � 2005 Ocean Informatics Strategic Issues for the interoperable EHR Technical Consolidated versus �pure federated� EHR Where are EHRs, what governance? Human users and other systems need access to EHR Centralised and distributed deployment possible Problem of language and vocabulary Socio-political Doctors� Fear of making their information so available Confidentiality needs of patients Fear of doctors losing control (?!) over patient care Differing national legislation on privacy & consent Clinician fear of more data entry Cost and consequences of user training

14. � 2005 Ocean Informatics A multi-layer EHR strategy

15. � 2005 Ocean Informatics * * * Programme * * * The problems of health IT The problem of Interoperability 3 principles for solutions Standards Strategy

16. � 2005 Ocean Informatics Principles for �good� models 1 - Limited scope � targeted at one area such as demographics, workflow, ehr Why? Same principle as low-coupled software 2 - Separation of viewpoints - RM/ODP EV, IV, CV Why? Separates information (fine-grained) and service (coarse-grained) semantics; don�t hardwire policies & bus process into the software 3 - Ontologically layered Why? Separates progressively more specific & changeable concepts into modular layers, allows division of what is hard-wired into software and what is knowledge available at runtime A good standard will usually have components reflecting these separations�

17. � 2005 Ocean Informatics Is �ontology� just academic preciousness? Ontologies exist wherever there are definitions of the meaning of symbols, such as words Definitions can be in the form of a UML model (implicit), a functional specification, a clinical terminology (explicit), etc So if we care about any kind of model, we are using ontology But�usually we are not conscious of it, and mix ontological levels up� Leading to brittle, unmaintainable software

18. � 2005 Ocean Informatics Ontologies and modelling ISO OSI is a well-known attempt to consciously design layers of models based on ontological thinking, I.e. layers of meaning, and is still influential TCP/IP is a post-hoc description of layers which emerged from organic development The big question is always: how much of any domain�s ontology will you hard-wire into the software & db schemas?

19. � 2005 Ocean Informatics Ontological levels in health

20. � 2005 Ocean Informatics �and corresponding models

21. � 2005 Ocean Informatics * * * Programme * * * The problems of health IT The problem of Interoperability 3 principles for solutions Standards Strategy

22. � 2005 Ocean Informatics What is a �good� standard? Based on the 3 principles Componentised Validated by implementation feedback

23. � 2005 Ocean Informatics Are good standards being built? Some are based on the 3 principles, and will lead to modular software and interoperable platforms (CEN 13606, HISA, openEHR) Some are very mixed, e.g. HL7v3 RIM � contains Act, Observation, but also Medication, Invoice, RMIMs more focussed� HL7/OMG services project � updating Corbamed In Australia, archetypes being developed for standardisation But � still no good standard for clinical data types - Quantity, Coded_term, Ordinal, Text, etc Emergence is ad hoc, uncontrolled, and sometimes competitive�.

24. � 2005 Ocean Informatics Standards today

25. � 2005 Ocean Informatics An EHR Standards Comparison �Ontological dimension

26. � 2005 Ocean Informatics Proposal: a new CEN standard (WG2-led)

27. � 2005 Ocean Informatics * * * Programme * * * The problems of health IT The problem of Interoperability 3 principles for solutions Standards Strategy

28. � 2005 Ocean Informatics What should government do? The market will not solve the problem - it is a �commons� problem Define & design national EHR infrastructure based on standardised information, services and knowledge (like defining the internet) Centrally manage knowledge resources - data sets, archetypes, terminologies - but allow distributed development! Use economic encouragements and legislative pressure to get compliance Engage clinicians and consumers all the way

29. � 2005 Ocean Informatics What should Standards Orgs do? Follow 3 principles of modularity Analyse todays standards and improve Improve development MO to more disciplined engineering, less ad hoc discussion Use constant implementation to provide validation � work with implementation orgs (these are the principles of openEHR)

30. � 2005 Ocean Informatics What should vendors do? Get involved in standards development Choose standards judiciously Plan for the health computing platform Modularise your software using 3 principles Expect service-oriented computing environment, e.g. PIDS, CTS etc Be ready to use archetypes, templates, terminology

31. � 2005 Ocean Informatics Final thoughts

32. � 2005 Ocean Informatics Where we need to go

33. � 2005 Ocean Informatics Where we can get in 5 years

34. � 2005 Ocean Informatics Where most of us are today