China National EHRChina National EHRHow Far We Are?How Far We Are?

Huilong Duan, Ph.D.School of Biomedical Engineering & Instrument Science

Zhejiang UniversityEmail: duanhl@zju.edu.cn

Global Challenges in Health CareGlobal 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)

Current Health Care in ChinaCurrent Health Care in China

Uneven distributed & limited health care resources

Limited medical insurance coverage

Increasing costs

57% population in rural areas

80% hospitals in cities

Large amount ofmigrant people(0.147 billion)

Limited health Infrastructure

(2.75 bed/1000)

Aging population(0.144 billion)

0

1000

2000

3000

4000

5000

6000

7000

8000

人民

币（

亿元

） R

MB

100 m

32 %–> 17% government

48 %–> 29% society

20 %–> 54% private

government

society

private

“Difficulty and high cost in seeking medical service” is the TOP ONE concern!

-- Society of China Analysis and Forecast Blue Book, 2007

Medical Expenses in ChinaMedical Expenses in China

Reform to Provide Better Health CareReform to Provide Better Health Care

Rural health

Public health

Community health

medical insurance

systems that will

cover all urban

and rural residents.

Rural health

Public health

Community health

medical insurance

systems that will

cover all urban

and rural residents.

Establish

national

essentia

l drug sy

stem 

Health Care Reform in ChinaHealth Care Reform in China

Basic Health Care System Covering all Residents in the Urban and Rural Areas

Medical and Health System Reform

PublicPublic Health ServiceHealth Service MedicalMedical ServiceService Medical InsuranceMedical Insurance Pharmaceutical SupplyPharmaceutical Supply

Man

agemen

t

Op

erating

mech

anism

Legal

HIT

HIT

Hu

man

Resou

rce

Regu

latory

Price

determ

inin

g M

echan

ism

Investm

ent

Mech

anism

HIT Supports in the ReformHIT Supports in the Reform

e-governmente-governmentWeb PortWeb Port

e-hospitale-hospital

Urban and Rural Urban and Rural Community Health ServiceCommunity Health Service

Rural Cooperative Rural Cooperative Medical SystemMedical System

TCMTCM 、、 Research Research and Educationand Education

e-Healthe-Health

5 Systems in 5 Systems in Public HealthPublic Health

EHR is Critical in e-HealthEHR is Critical in e-Health

Personalization

Regionalization

Passive treatment to proactive preventionPassive treatment to proactive preventionSeamless access to health servicesSeamless access to health services

Passive treatment to proactive preventionPassive treatment to proactive preventionSeamless access to health servicesSeamless access to health services

Medical and health technologyMedical and health technologybased on modern electronics, engineering, based on modern electronics, engineering, information and bio-engineering information and bio-engineering   

Medical and health technologyMedical and health technologybased on modern electronics, engineering, based on modern electronics, engineering, information and bio-engineering information and bio-engineering   

Isolation of the medical resources to Isolation of the medical resources to subdivision, share, synergy subdivision, share, synergy regionalizationregionalization

Isolation of the medical resources to Isolation of the medical resources to subdivision, share, synergy subdivision, share, synergy regionalizationregionalization

Electronic health record Electronic health record as the core as the core Resources sharing Resources sharing as the basicas the basic

County or city level

hospital

Data center

Government agencies

Urban and rural Urban and rural community health community health service agenciesservice agencies

City hospital

Related medical

and health institutions

Citizen

HealthcareHealthcare

Face-To-FaceFace-To-Face

Heal

th service

Informationization

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

Case 2:Case 2: Health Information System in Xiamen CityHealth Information System in Xiamen City

Regional Health Data Centere-CDC

e-Community Healthcare

e-Hospital

e-Health Administration

e-Health Supervision

e-family healthcare

Up level health data center

Bank Price Control Supply Drug administration Civil Affairs Insurance

Case 3:Case 3: Regional health information network (Regional health information network ( 医联工程医联工程 ) of Shanghai) of Shanghai

GoalGoal– Connect hospitals and share medical information

– Improve HIT adoption in hospitals

– Provide economical and convenient healthcare

First phase 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

Avoid unnecessary repeated lab test and medical imaging examination

Case 4:Case 4: National e-Health Key Technology and Regional Trial National e-Health Key Technology and Regional Trial Implementation in Zhejiang ProvinceImplementation in Zhejiang Province

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

Zhejiang Province22 regionsCovering 8 million population

Task 1Task 1 ：： EHR modelingEHR modeling

Define health meta data and data sets from fetus to deathDefine health meta data and data sets from fetus to death Model EHR to cover all the key health points of entire lifeModel EHR to cover all the key health points of entire life Define the services to integrate all the health information togetherDefine the services to integrate all the health information together

Health care service cover the entire lifeHealth care service cover the entire life

birth death

Task 2Task 2 ：： Standards and specifications development 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 specificationData classification and coding specification

Data collection and exchange normsData collection and exchange norms

Standardize business processesStandardize business processes

“Health Record basic infrastructure and data specification”(on trial)“EMR basic infrastructure and data specification” (Draft)

Task 3Task 3 ：： Applications development on EMR Applications development on EMR

Advanced clinical information systems

Data mining and analysis technologies on EMR

regional information share platform

EMR

Standard Interface

Task 4Task 4 ：： RegioRegional health information exchange platformnal health information exchange platform

hospitals community health service center

citizen

bank

supplier

pharmacy

business insurancegovernmentsocial insurance

blood station

antiepidemic organization

maternity and child healthcare

health supervision

emergence center

Regional Regional Data CenterData Center

Task 5Task 5 ：： EMR based Tele-medicine platformEMR based Tele-medicine platform

Remote clinics andRemote clinics andeducation centereducation center

Large-scale Large-scale hospitalhospital

Small and medium-sized Small and medium-sized hospitalhospital

Community health Community health services centerservices center

HouseholdsHouseholds

Task 6Task 6 ：： Prompt clinical pathway and other CDSS adoption in hospitalsPrompt clinical pathway and other CDSS adoption in hospitals

Medical Treatment

Quality Control

Medical Treatment

Quality Control

Treatment program ATreatment program ADoctor ADoctor ADoctor ADoctor A

Doctor BDoctor BDoctor BDoctor B

Doctor CDoctor CDoctor CDoctor C

Treatment program BTreatment program B

Treatment program CTreatment program C

Patient

Patient

Hospitals Quality Control

Hospitals Quality Control

Doctor ADoctor ADoctor ADoctor A

Doctor BDoctor BDoctor BDoctor B

Doctor CDoctor CDoctor CDoctor CP

atientP

atient

Implementation of Implementation of clinical pathwaysclinical pathways Disease knowledge baseDisease knowledge base

Clinical Clinical pathway pathway programprogram

Task 7Task 7 ：： Regional implementation and evaluationRegional implementation and evaluation

Every 1,500 residents has a Every 1,500 residents has a family doctorfamily doctor

Health examinations for EHR (free Health examinations for EHR (free of charge) every 2 yearsof charge) every 2 years

Depends on the adoption of HITDepends on the adoption of HIT

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

EHR related Actions in ChinaEHR related Actions in China

Establish a National EHR in ChinaEstablish a National EHR in China

Three major challenges: 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

Semantic Interoperable EHRSemantic Interoperable EHR

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

StandardizedArchitecture

StandardizedInterfaces

StandardizedData

Structures

StandardizedData

Vocabularies

StandardizedFunctional Behaviour

Major difficulties to achieve interoperability 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/EMR conception 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

Security and Privacy Security and Privacy

MOH “Measures for 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

Government’s roleGovernment’s role

Standard maker

Systemdeveloper

Strategic investor

StrategyPlanner

Policy maker

Industrysupporter

Best practice promoter

Infrastructureconstructor

Constructionsupervisor

Systemoperator

Many roles for the government to choose in e-health. Different role has different cost and risk

Planner and investor

HIT standards break out in ChinaHIT standards break out in China

Health Record basic infrastructure and data specification (on trial) at May 19, 2009.

EMR basic infrastructure and data specification (Draft) at August 4, 2009.

Technical Solution for Regional Health Information Platform based-on EHR (on trial) at December, 2009

National Health Data Dictionary and Meta Data Management System at December, 2009

Measures for the Administration of Electronic Certification Services in Healthcare (on trial) at December, 2009

Electronic Medical Record basic specification (on trial) at March, 2010

Ministry of Health of China published several HIT standards since 2009:

A Study on Information Infrastructure of A A Study on Information Infrastructure of A nationwide EHRnationwide EHR

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

Project Director: Huilong Duan

National EHR RoadmapNational EHR Roadmap

2010 2020 2030

Preparation &Preparation &TrialTrial(2010-2016)

Construction &Construction &DevelopmentDevelopment(2017-2025)

Operation &Operation &RefinementRefinement(2025-2030)

201550% 3-level hospital30% urban community health center20% rural hospital or clinicAdoption interoperable EMR/EHRDemonstration regional EHR

202080% 3-level hospital50% urban community health center50% rural hospital or clinicAdoption interoperable EMR/EHREstablish above 10 province level EHR systems.

2025100% 3-level hospital90% urban community health center80% rural hospital or clinicAdoption interoperability EMR/EHRA nationwide interoperable health information network formed

Preparation and Trial (2010-2016)Preparation and Trial (2010-2016)

TasksTasks– Medical informatics basic construction

– Enterprise information construction

– Regional EHR demonstration

Plans in detailPlans 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

Construction and development (2017-2025)Construction and development (2017-2025)

TasksTasks– Widespread standard-based interoperability EMR in hospitals – National EHR infrastructure construction

Plans in detailPlans 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

Operation and refinement (2025-2030)Operation and refinement (2025-2030)

TasksTasks– Refine the operation mode and regulation system

– A complete e-health system based on national EHR

Plans in detailPlans 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

EHR in translational medicineEHR in translational medicine

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

Standard semantic interoperable EHR provide the possibility to reuse the data for research purposes

Colorectal Cancer Translational Research Center at ZJUColorectal 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

Information infrastructure to enable translational research Information infrastructure to enable translational research

Translational EHR in futureTranslational EHR in future

TranslationalEHR

Mol. PathwayGene/ProteinInteractions

DNA Gene

RNA Functional genome

Proteome

Cell CellModel

TissueCells-populations

Organ Model

System(human)

Medical Service

Population Public Health

Bioinformatics

Computational System Biology

Medical Imaging/Modeling

Medical Informatics

TranslationalBioinformatics

Biomedical Informatics

EHR

EMR

Public Data Bank

molecular-level data

cell-level data

China National EHR – long way aheadChina 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

Thank you!Thank you!