1 The Good Electronic Health Record Overview of

1 The Good Electronic Health Record Overview of GEHR Dr Peter Schloeffel open. EHR Foundation Peter Schloeffel, Nov 2000

2 EHR definition “… a repository of information in computer readable format regarding the health of a subject of care” Committee for European Normalisation (CEN) “… an electronic longitudinal collection of personal health information, based on an individual or family, and entered or accepted by healthcare professionals. [It] can be distributed over a number of sites or aggregated at a particular source including a handheld device. The information is organised primarily to support continuing, efficient, and quality healthcare. ” Australian National EHR Taskforce Peter Schloeffel, Nov 2000

3 Purpose of the health record Primary purpose to benefit the patient through support of current and future healthcare needs Secondary purpose to provide a medico-legal record of the care provided and hence support and demonstrate the competence of clinicians Tertiary purpose education, research, public health, health service planning & management NB: must be legitimate (involve consent) and can never be allowed to compromise the primary or secondary purpose Peter Schloeffel, Nov 2000

4 EHR systems An EHR system is the set of components that form the mechanism by which patient records are created, used, stored, and retrieved. It includes: people data rules and procedures processing and storage devices communications and support facilities US National Academy of Sciences, Institute of Medicine, 1991 Peter Schloeffel, Nov 2000

5 Design of EHR systems need to be optimized to suit the primary purpose of the EHR Traditionally, EHR systems have been optimized to suit the needs of finance and administration ie tertiary purposes Peter Schloeffel, Nov 2000

6 What are we trying to achieve? Interoperability - communication Safety and security Comprehensiveness Portability Evolution - “future proof” Peter Schloeffel, Nov 2000

7 The current situation Rival medical software programs Closed systems Little or no interoperability Fragmented data Peter Schloeffel, Nov 2000

8 Vertical silos Vast fragmentation of healthcare computing systems r. A ie pl p Su data r B • All or nothing from one supplier lie • More than required pp Su • Limited range • Results in Fragmented data comms platform Peter Schloeffel, Nov 2000

9 The new model A p p l i c a t i o n s P l a t f o r m Standard Electronic Health Record Standard communications platform Standard hardware & operating system platform Peter Schloeffel, Nov 2000

10 EHR standardisation What aspect of the EHR should be standardised? Nothing? – the extremist messaging view The data contained in the EHR? The EHR system? The EHR architecture? Peter Schloeffel, Nov 2000

11 What is an EHR architecture? “The [EHR] Architecture is a model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, a useful 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. ” Proceedings, 2 nd EU-CEN Workshop on the Electronic Healthcare Record, 1997 Peter Schloeffel, Nov 2000

12 Architecture vs Format Documents Logical Architecture (Organizing principles) Proprietary Formats (based on the architecture) Electronic Formats Standard Electronic Formats De facto standard. Documents. Chapters. Paragraphs. Sentences. Words Healthcare Records GEHR standard. Electronic Health Records. Transactions. Item Complexes. Items. Attributes” WORDâ Format (. doc) HEALTH. oneâ Format (. h 1 b) XML Health record standard ? (. ghr) Peter Schloeffel, Nov 2000

13 Design investment Strategies for interoperability Record transfer Application communication EHR architecture eg GEHR Common interface architecture eg CORBAmed Messaging eg HL 7 File communication Implementation cost Peter Schloeffel, Nov 2000

14 Requirements for an EHR architecture What are we trying to achieve? Interoperability - communication Safety and security Comprehensiveness Portability Evolution - “future proof” Peter Schloeffel, Nov 2000

15 The GEHR project United Kingdom St Bartholomew’s Hospital Medical College The Royal Hospitals NHS Trust City & East London FHSA The Royal Marsden Hospital University of Hull Smith. Kline Beecham Belgium Health Data Management Partners ERIM Federation des Association Medecins Generalistes de Bruxelles Insitut D’Hygiene et d’Epidemiologie Germany Zentralinstitut fur die Kassenarztliche Versorgung France Croix Rouge Francaise C 2 V Kalamazoo S. A. France Telecom Portugal Instituto Clinica Geral Zona Norte Luxembourg Association des Medecins et Medecins Dentistes Microdata SARL Centre de Recherche Public Henri Tudor Spain Clinica Puerta de Hierro Greece University of Athens Peter Schloeffel, Nov 2000

16 Current EHR standards activity Europe: CEN TC/251 – pr. ENV 13606 1 -4 United States ASTM, HL 7/CDA, CORBAmed, CPRI New Zealand Standards NZ SC 606 WG 3 Australia Standards Australia IT/14/9 National EHR Taskforce International ISO/TC 215 WG 1 Peter Schloeffel, Nov 2000

17 Successful standards For any standard to succeed in the ‘marketplace’ must have dual thrust of formal standards development and commercial standards-based product availability. A continuing positive feedback loop between implementation experience and formal standards development is essential for success. Peter Schloeffel, Nov 2000

18 The need for health IT standards “In conventional sectors of industry, standards are well known for increasing companies’ market opportunities and for lowering the cost of equipment and services to users. The same arguments hold for the field of healthcare informatics, where European industry currently supplies to a fragmented market, products which have a short life cycle and are over-customised and therefore expensive to develop, to buy, and to maintain. Agreement on common requirements will reduce the cost of healthcare information systems and open up the market. ” Directory of the European Standardisation Requirements for Healthcare Informatics and Telematics: Program for the Development of Standards. European Committee for Standardisation, CEN/TC 251, 1996. Peter Schloeffel, Nov 2000

19 Benefits to software vendors Greater certainty for planning Lower development costs Can concentrate on added-value end-user applications rather than middleware Promotes modular application development Lower maintenance costs Longer product cycles Peter Schloeffel, Nov 2000

20 GEHR in Australia IBM GPCS Consultancy report - Aug 1997 recommends GEHR adoption for Australian General Practice Ocean GEHR kernel commenced - Feb 1998 Standards Australia EHR WG formed - Jul 1999 National EHR Task Force established - Nov 1999 Federally funded GPCG GEHR project - Feb 2000 HINA report - Jul 2000 GEHR favored as architecture for national EHR Peter Schloeffel, Nov 2000

21 The “new” GEHR architecture Good Electronic Health Record Extended “Oz” GEHR model developed 1998 Major breakthrough for implementation Two level model Concrete model – GEHR object model (GOM) Meta-model – Archetypes for clinical content Peter Schloeffel, Nov 2000

22 Archetypes and Lego designs GOM is a generic knowledge representation model The components (objects) of the GOM are like Lego bricks Archetypes express knowledge in a particular domain Archetypes are like the designs for Lego structures Designs constrain use of Lego pieces to meaningful structures Concrete model can be standardised independent of archetypes Peter Schloeffel, Nov 2000

23 Public domain “Oz-GEHR” deliverables Technical requirements document Architecture description document Archetype description document Implementation guidelines A generated diagrammatic (UML) expression of the model Various exchange specifications (XML) COM API Provisional set of archetypes (diabetes, patient summary) The core Ocean kernel with Open Source licence Located on www. gehr. org Peter Schloeffel, Nov 2000

24 The “Ocean” GEHR kernel Application COM GEHR model CORBA Session manager Core Kernel Archetypes Persistence interface Binding Database Exchange formats Peter Schloeffel, Nov 2000

25 The GPCG GEHR project Funded by Australian Federal Government Ocean GEHR kernel 3 GP clinical systems adapted to GEHR Standard application interface: COM Generic GEHR transaction viewer Archetypes for diabetes management and patient summary Peter Schloeffel, Nov 2000

26 What next? Further software development Clinical archetype development Education and training Advocacy and promotion Implementation trials Multi-discipline and multi-sector Peter Schloeffel, Nov 2000

27 Areas for GEHR R&D Kernel development Archetype software tools Archetype development APIs Database bindings Clinical modelling review and development Standards convergence Exchange formats and data transformation XML, HL 7, Translation wrappers for legacy systems Peter Schloeffel, Nov 2000

28 Future Australian GEHR trials Hospital non-GEHR to GEHR translation HL 7 to GEHR translation Series of multi-sector implementation trials Hospital – GP GP – medical specialists GP – community-based allied health Hospital/GP – home NGI Quality of Service for GEHR-based apps. eg remote consultations, home tele-monitoring Australia (ANP), US (Internet 2), ? UK Peter Schloeffel, Nov 2000

29 Data Sources Courtesy of DSTC Peter Schloeffel, Nov 2000

30 Translating between EHRs Courtesy of DSTC Peter Schloeffel, Nov 2000

31 Questions and discussion Peter Schloeffel, Nov 2000