EHR Systems: an Introductionehealth.gvg.org/cms/medium/491/02blobel.pdf · EHR Systems: an Introduction Bernd Blobel 1 & Dipak Kalra 2 1eHealth Competence Center University of Regensburg

EHR Systems: an Introduction

Bernd Blobel1 & Dipak Kalra2

1eHealth Competence Center

University of Regensburg Medical Center

Regensburg, Germany

2Centre for Health Informatics and Multiprofessional Education

(CHIME)

University College London

eHCC

eHealth Week 2007 – EuroRec Institute / ProRec Germany Workshop“Electronic Health Records and eHealth – State of the Art”Wednesday, 18 April 2007, Berlin Germany


Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –

State of the Art”

Wednesday, 18 April 2007, Berlin Germany

Definitions (according to ISO/DTR 20514 Health informatics - Electronic

health record – Definition, scope and context ) (1/2)

EHRa repository of information regarding the health status of a subject of care, in computer processable form.An EHR provides the ability to share patient health information between authorised users of the EHR and the primary role of the EHR in supporting continuing, efficient and quality integrated health care.

EHR systemthe set of components that form the mechanism by which electronic health records are created, used, stored, and retrieved. It includes people, data, rules and procedures, processing and storage devices, and communication and support facilities.

EHR nodea physical location where EHRs are stored and maintained.



State of the Art”


Definitions (according to ISO/DTR 20514 Health informatics - Electronic

health record – Definition, scope and context ) (2/2)

EHR architecturea model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, auseful and effective ethico-legal record of care, and may retain integrity across systems, countries, and time. The Architecture does not prescribe or dictate what anyone stores in their healthcare records. Nor does it prescribe or dictate how any electronic healthcare record system is implemented. ... [It] places no restrictions on the types of data which can appear in the record, including those which have no counterpart in paper records. ... Details like “field sizes”, coming from the world of physical databases, are not relevant to the electronic healthcare record Architecture.



State of the Art”


Clinical drivers for the EHR

• Manage increasingly complex clinical care• Connect multiple locations of care delivery• Support team-based care• Deliver evidence-based health care• Improve safety

- reduce errors and inequalities- reduce duplication and delay

• Empower and involve citizens • Underpin population health and research• Protect patient privacy



State of the Art”


Clinical trials,

functional genomics,

public health databasesEHR repositories

Clinical devices,

instruments

Clinical

applications

Decision support,

knowledge

management

and analysis

components

Mobile devices

Personnel registers,

security services

Systems feeding or accessing the EHR

Date: 1.7.94

WhittingtonHospital

Healthcare Record

John SmithDoB: 12.5.46

virtual virtual

EHREHR



State of the Art”


Interoperability Levels

•Technical Interoperability- Technical Plug&Play, signal compatibility, protocol compatibility

•Simple Data Exchange Interoperability- EDI, HL7 Version 2

•Meaningful Data Exchange Interoperability- agreed Vocabulary

•Functional Interoperability- Harmonised behaviour of communicating

applicationssemantic I.

•Service-oriented Interoperability- Direct invocation of application services,

co-operativity of applications

}



State of the Art”


Interoperability Aspects from a European Perspective

Interoperability issues have to be managed from different viewpoints

- Legal Member States and EC- Administrative Member States, EC and Stakeholders- Technical Industry and SDOs- Social Member States, EC and Stakeholders- Ethical/cultural Member States, EC and Stakeholders



State of the Art”


Observation

Interpretation Action

Data

Information

Observation

Diagnosis Therapy

Knowledge



State of the Art”


EHR Projects and Standards

• ISO TC 215 TS 18308, DTR 20514

• CEN EN 12967 „Health Information System Architecture“

• CEN EN 13606 „EHR Communication“

• openEHR• GEHR

• G-CPR• ASTM CCR• HL7 RIM & CDA, EHR-S

Functional Model, EHR-S Interoperability Model, CCD

• HARP• EuroRec, ProRec Centres• ...



State of the Art”


Requirements for achieving interoperability and harmonisation (1/2)

• Openness, Scalability, Flexibility,

Portability

• Distribution at Internet level

• Standard conformance

• Service-oriented semantic

interoperability

• Consideration of timing aspects of

data and information exchanged

• Lawfulness

• Appropriate security and privacy

services



State of the Art”


Requirements for achieving interoperability and harmonisation (2/2)

• Distribution, Component-orientation (flexibility, scalability)

• Model-driven and service-oriented design

• Separation of platform-independent and platform-specific

modelling → separation of logical and technological views

(portability)

• Specification of reference and domain models at meta-level

• Interoperability at service level (concepts, contexts,

knowledge)

• Unified Process

• Common terminology and ontology (semantic interoperability)

• Advanced security, safety and privacy services



State of the Art”


En

terp

rise

Vie

w

Info

rma

tion

Vie

w

Com

pu

tationa

l V

iew

En

gin

ee

ring V

iew

Te

chno

log

y V

iew

Business Concepts

Relations Network

Basic Services/Functions

Basic Concepts

Domain n

Domain 2

Domain 1

Component View

Com

ponent

Decom

positio

n



State of the Art”


Knowledge Representation through a Metathesaurus

(after Bodenreider)

• Conceptso Synonymous terms are clustered into a concepto Properties are attached to concepts, e.g.,

� Unique identifier

� Definition

• Relationso Concepts are related to other concepts

o Properties are attached to relations, e.g.,� Type of relationship

� Source



State of the Art”


Key requirements for the logical or virtual EHR

• Comprehensive • Faithful• Life-long (and beyond)• Medico-legally rigorous• Appropriately available• Supporting diverse cultures and professions• Capable of evolution• Educating• Empowering and respecting• Capable of interoperability



State of the Art”


In a medical summary

Procedure Appendicectomy

Problem List

1993

Diagnosis Acute psychosis2003

Diagnosis Meningococcal meningitis1996

Procedure Termination of pregnancy1997

Diagnosis Schizophrenia2006

Can we safely interpret a diagnosis out of its context?



State of the Art”


Clinical interpretation context

Emergency Department

“They are trying to kill me”Symptoms

Reason for encounter Brought to ED by family

Mental state exam Hallucinations

Delusions of persecution

Disordered thoughts

Management plan Admission etc.....

Diagnosis Schizophrenia

Working hypothesisCertainty

Seen by junior doctor

Junior doctor,

emergency situation,

a working hypothesis

so

schizophrenia is not

a

reliable diagnosis



State of the Art”


Examples of clinical interpretation context

• within the overall clinical story - past, present- intended treatments, planned procedures

• clinical circumstances of an observation- e.g. standing, fasting

• presence / absence / certainty of the finding• hypotheses, concerns• a diagnosis for a relative

- but not the patient!• confidence and evidence

- seniority of the author- justification, clinical reasoning, guideline references



State of the Art”


Examples of medico-legal context

• Authorship and responsibilities• Dates and times

- occurrence, clinical encounter, recording, schedules, intentions

• Information subjects- whose record is this? (who is the patient?)- about whom is this observation? (e.g. family history)

• Version management• Access rights



State of the Art”


Data archive

management

EHR

repository

management

Professional

accountability

Medical

knowledge and

health culture

Life-long

EHR

Clinical

encounter

Clinical contextsMedico-legal contexts

Potential interpretation contexts

schizophreniaschizophrenia



State of the Art”


Semantic interoperability challenges

• the meaningful sharing and combining of health record data between heterogeneous systems

• the consistent use of modern terminology systems and medical knowledge databases

• the integration and safe use of computerised protocols, alerts and care pathways by EHR systems

• data quality and consistency to enable rigourous secondary uses of longitudinal and heterogeneous data: public health, research,health service management



State of the Art”


Reasons why this is hard:

it’s not just about agreeing terms

• A global and singular representation for each clinical expression is not realistic, and may not be desirable

• Different levels of detail, different levels of granularity are needed for different clinical settings

- clinical practice is too diverse and evolving for fine grained standards

- different cultures, and natural languages need to represent clinical meaning differently

- patients and carers need a different level of jargon from healthcare professionals



State of the Art”


Reasons why we make it harder

• The record structure influences how a term is to be interpreted- the heading it is under- other surrounding context

• Record structures and terminology systems have been developed in relative isolation

- with no co-operation on their mutual requirements or scope- resulting in overlapping coverage or clumsy fit

• With co-ordinated terminology and sophisticated EHR architectures- there is a risk of introducing further inconsistency- making semantic equivalence harder to determine



State of the Art”


Archetypes will help

• Empowerment of healthcare professionals- enable consensus clinical data sets and structures to be shared

• Offer a focused way of binding generic EHR models to compositional terminology

• Provide target knowledge representations for use by guideline and care pathway systems

• EHR entries identify the Archetypes used when the data were created, and/or to which they map

- aids future interpretation, analysis, computation



State of the Art”


Documents

EHR Systems: an Introductionehealth.gvg.org/cms/medium/491/02blobel.pdf · EHR Systems: an Introduction Bernd Blobel 1 & Dipak Kalra 2 1eHealth Competence Center University of Regensburg