Making E-Health work Why would a clinician be interested in Somantic Interoperability?

1. ICT expo Dublin 14th April 2005 Making E-Health workWhy would a clinician be interested in Somantic Interoperability? Jeremy R L Nettle European Healthcare Director Oracle Corporation UK Ltd Jeremy.nettle@oracle.com April 2005

2. The Interoperability Consortium In November 2004, Oracle Corporation one of the eight leading services and technology companies came together as the Interoperability Consortium to respond to a request from the newly-formed office of the National Coordinator for Health Information Technology (ONCHIT) to submit information on how the National Health Information Network (NHIN) could be designed and deployed. The Interoperability Consortium outlined an initial plan for patient-centered health care delivery systems, secure and private communications, open information exchange standards and public-private financing

3. Making e-Health Work Agenda • Why deliver Integrated Healthcare • The proliferation of non Integrated systems • What do we mean by Integrated healthcare • Understanding the architecture and standards to deliver interoperability • A normalised clinical data repository model • Why has Oracle entered this market?

4. The healthcare marketplaceEnabling the healthcare enterprise… Suppliers Payers / Regulators Pharmaceutical Medical Eqpt Distributor/Wholesaler Biotech Employer Other Payer Outpatient Primary Care Hospitals Physicians RegulatoryAgency IntegratedNetworks Patients Providers

5. Why deliver integrated healthcare? Reducing Medical Errors • Between 50,000 and 100,000 deaths each year are attributable to adverse drug events (ADEs).1 • Computerised Physician Order Entry can play a significant role decreasing the number of ADEs.2 “The report (Audit Commission, Spoonful of Sugar) estimates that adverse drug events might cost the NHS in the UK £1.1 billion per year. It also cites evidence to suggest that improved information systems could avoid 78% of transcription errors that lead to such adverse drug events.” A Patient is at a higher risk of an ADE than of loosing their luggage when travelling! 1 “To Err is Human”, Institute of Medicine, 1999 2 “Crossing the Quality Chasm”, Institute of Medicine, 2001

6. A Simple Case • SP, a 38 year old businessman • 14/08 – donates blood; hematocrit 45 • 21/08 – visits GP; obtains prescription for sulindac, an anti-inflammatory agent • 10/10 – in traffic accident • Visits emergency room • hematocrit is 40 • 10% drop in Hematocrit could indicate gastro-intestinal bleeding….

7. . ? Beginning a Transaction Chain • As clinicians speak with and examine patients, they also begin to develop plans of care. I need a chest X ray for Mr Smith.

8. Following a Transaction Chain • A clinical thought can spawn a series of clinical activities. Check technician availability Check room, equipment availability Schedule chest x ray Perform procedure Order chest x ray Place image in radiologist work queue Fulfill Interpret study Report result I need a chest x ray for Mr Smith.

9. Following a transaction chain • A clinical thought can spawn a series of clinical and business activities. Perform procedure Check room, equipment availability Check technician availability Interpret study Schedule chest x ray Submit facilities charge Report result Order chest x ray Verify insurance coverage for chest x ray Submit professional fee I need a chest x ray for Mr Smith. Reimburse providers

10. Creating an Transaction Entity • When a clinical thought is entered in an EHR application as a part of a clinical plan, a medical entity-attribute complex should be created. Order for chest x ray X-ray, chest rt 3766207 Ordered by James Miller, MD prv 56647-9 Ordered for Marshall Smith mpi 885757439 12/04/05 0900.34.33 tr 334678898373 I need a chest x ray for Mr Smith.

11. Standardising Transactions • All clinical and business events need to reference all or part of the complex. Check technician availability Check room, equipment availability Schedule chest x ray Perform procedure Order chest x ray Place image in radiologist work queue Fulfill Interpret study Report result I need a chest x ray for Mr Smith.

12. Work vs medical entities Work Activities Schedule Draw Specimen to Lab Draw Order FBC Send Order to Lab Receive Lab result Process Specimen Done RBC Medical Entities WBC Hg

13. Ancillary results Clinician orders and observations a b u l a o c r v y v Devices o y c a b a r u l Patient input Constructing the System • A pervasive information model allows many parties to contribute to the EHR. u

14. Interoperability is more than exchange HL7 Mission Statement:“Develop specifications for and that support interoperability in healthcare, i.e. “computer systems exchanging information in the healthcare space will predictably compute on the exchanged information based on an agreed upon set of specifications defining the structureand meaning of the exchanged information.”

15. Semanticinteroperability Functionalinteroperability Enforcing interoperability • Interoperability “Ability of two or more systems or components to exchange information and to use the information that has been exchanged” IEE Standard Computer Dictionary, IEE, 1990

16. Syntax and Semantics • Syntax vs Semantics • Syntax  structure • Semantics  meaning • Time flies like an arrow. • Fruit flies like a banana. (no meaning) • Give pain medication. • Give medication for pain. different syntaxes can have same meaning

17. What is Interoperability? • Interoperability: • “The ability of one or more systems to exchange data/information and to be able to utilise the exchanged information. ” (IEEE, 1990) • Exchange information  syntactic interoperability • Systems recognize the structure of the data • Utilise information  semantic interoperability • Systems understand the meaningof the information • “Healthcare is a business in which information exchange is the norm, not the exception.”(Bob Herbold, Microsoft COO)

18. What is the HL7 RIM? • The RIM (Reference Information Model) is documentation of information from the healthcare domain. • It is used as a common reference for the data content of all HL7 version 3 standards. • The RIM has graphical expression and an accompanying data dictionary. • It is expressed using the Unified Modeling Language notation.

19. Why Build a Reference Information Model? Healthcare Interoperability  The Electronic Health Record • ‘A cradle-to-grave collection of all of a person’s healthcare transactions’ • ‘The integration of clinical, administrative, and financial information’ • ‘Converting from sickness care to health maintenance’ • ‘Evidence-based healthcare’ • ‘Outcomes-based healthcare’ • ‘Providers assuming the risk for healthcare’ • ‘Patients receive healthcare services at a number of points in time and space’s

20. Why Build a Reference Information Model? • To achieve any / all of these goals, we must have a set of standards that enable healthcare system interoperability at both the functional (syntactic) and operational (semantic) level. • The RIM is a structural standard • Defines Concepts • Defines Attributes of Concepts • Defines Relationships between Concepts • Semantic interoperability ? • V2.x: In principle but not in fact • No standard structures to facilitate reuse across multiple healthcare domains • No formal interface to external terminologies • ‘Bottom-up’ message development process

21. The RIM’s Value Proposition • The RIM is ‘more than just the basis for a messaging model’ • It is also a knowledge repository containing • Concepts • Relationships • Cross-domain knowledge • World-wide depth and breath of input • An emerging ANSI and ISO standard in and of itself (i.e. separate from the V3 messaging standard per se) • The RIM is increasingly being used as a source set of abstractions and relationships around which to build logical data models which can, in turn, support real-work healthcare information systems from both a clinical and/or an administrative/financial perspective.

22. Core concepts of RIM • Every happening is an Act • Procedures, observations, medications, supply, registration, etc. • Acts are related through an Act_relationship • composition, preconditions, revisions, support, etc. • Participation defines the context for an Act • author, performer, subject, location, etc. • The participants are Roles • patient, provider, practitioner, specimen, healthcare facility etc. • Roles are played by Entities • persons, organizations, material, places, devices, etc.

23. Entity Role Participation Clinical Acts FinancialActs • Roles participate in Acts • patient • provider • Practitioner • Specimen • Etc. • Acts are everything that happens • Procedures • Observations • Medications • Registration • Etc. • Participation defines the context of an Act • Author • Performer • Subject • Location • Etc. • Entities play roles • persons • organizations • material • places • devices • Etc. Reference Information ModelClass Diagram

24. Deriving the RIM BackboneThe Essential Structures of Healthcare • A Healthcare Action can be the source of zero-to-many Healthcare Relationships, each of which relate the source Healthcare Action to one-and-only one other Healthcare Action (the target action). AR: “is supported by” ACT: Temp 101F has target is source for ACT: Dx Pneumonia AR: “is supported by” ACT: Abnormal CXR has target is source for is source for AR: “is supported by” ACT: Elevated WBC has target

25. A Simple Case • SP, a 38 year old businessman • 14/08 – donates blood; hematocrit 45 • 21/08 – visits GP; obtains prescription for sulindac, an anti-inflammatory agent • 10/10 – in traffic accident • Visits emergency room • hematocrit is 40 • 10% drop in Hematocrit could indicate gastro-intestinal bleeding….

26. ? 10/10 14/08 21/08 21/08 10/10 10/10 Blood bank GP office ER Pharmacy Radiology Lab A normalised clinical data repository model Any clinician, with appropriate authorization from the patient and permissions from the system, can view clinical data Notification Viewing Application Rules Engine ? R E A L D A T A • Message Processing • Person Management • Terminology Management • Security, authentication CentralizedDataRepository CDR LocalSystems

27. Consent Security Check Blood bank GP office ER Pharmacy Radiology Lab A normalised clinical data repository model Any clinician, with appropriate authorization from the patient and permissions from the system, can view clinical data Notification Viewing Application R E A L D A T A • Message Processing • Person Management • Terminology Management • Security, authentication CentralizedDataRepository CDR LocalSystems

28. Why has Oracle entered this market? • Oracle has the fundamental infrastructure • Growing need for electronic health records (EHR) • Regulations for data standards, security, confidentiality • Growing awareness of the need to re-use clinical data • HL7 standards movement • The other guys cannot do it The implications of our approach: • Evolve Oracle’s database functionality into a health care platform • Deploy the ideal model for multi-centered systems, including those with regional, and national responsibilities • Occupy the center of the clinical data re-use, data exchange and warehouse business • Offer the most efficient solutions for dealing with legacy systems

29. Scalability and performance A foundation for healthcare • Enables interoperability and meaningful data integration • Built to support large, complex healthcare communities as well as single hospitals • Standards-based, open architecture • Adaptive development, integration and operation platform • Leverages Oracle’s core expertise and products • Global platform Healthcare Transaction Base (HTB)

30. Making E-Health work “Knowledge of what is possible is the beginning of happiness” George Santayana (1863 - 1952) US (Spanish-born) philosopher Jeremy R L Nettle European Healthcare Director Oracle Corporation UK Ltd Jeremy.nettle@oracle.com April 2005

31. Q & Q U E S T I O N S A N S W E R S The Healthcare Transaction Base A