Patient Data on Demand Nordisk workshop København 01.02.2006

1. Patient Data on DemandNordisk workshopKøbenhavn 01.02.2006

2. Danmark • Nasjonal lab-oversikt: • kan om kort tid taste inn pasientens personnummer og få oversikt over alle laboratorier som har analysert prøver for pasienten

3. Danmark, The need for patient data on demand • Standardisering viktig • ikke standardisering av IT men av informasjon: hvordan uttrykke ting og hvordan bruke informasjonen • Danmark vil oversette SNOMED terminologien og ta den i bruk • WHO kan spille en viktig rolle mht terminologi for eHelse-agendaen

4. Danmark, GEPJ in Denmark • GEPJ (eller BEHR – Basic EHR) • Pasient-sentrert: Relevant informasjon om borgernes ‘episodes of care’ kan deles elektronisk mellom helsepersonell i hele helsetjenesten • Konsensus om nasjonal strategi for innføring av GEPJ

5. Danmark, GEPJ forts. • De 5 nye sykehusregionene er enige om: • én pasient – én EHR innen hver region • EHR skal bygges på GEPJ • felles grunnleggende IT-arkitektur-prinsipper • implementasjon ferdigstilles i 2006/2007

6. Danmark, GEPJ forts. • Pågående diskusjon om hvilke EHR-data som skal deles mellom regionene. Det nasjonale pasientregisteret er en mulig kandidat for den felles delte kjernejournalen (EHR information core)

7. Danmark, GEPJ forts. Goal for development of the Danish EHR model • developing a framework for health care documentation supporting • problem oriented approach • cross professional documentation • cross sector information sharing • longitudinal episodes of care • the clinical process • capturing structured information • facilitating re-use of data for clinical, statistical, research, planning, QA, political purposes and health statistics

8. Danmark, GEPJ forts. What is GEPJ? • GEPJ has focus on one patient and his health conditions over time irrespective of organizational boundaries. To facilitate this, GEPJ based EHR systems must use shared data. This can be implemented as a shared or a distributed database • GEPJ is a national specification regarding clinical content in an EHR • GEPJ is not a specification of the EHR documents, but specification of clinical content in an EHR • GEPJ is not an EHR system, but a ‘recipe’ for ‘preparing’ the clinical content of the EHR

9. Danmark, Web-EHR – Data-pull from multiple EHR-systems Web-EHR: Data pull from multiple EHR systems • Fylkesvise pull-servere henter data fra PAS- og EHR-system i fylket • Dataene overføres daglig, via ftp, til en nasjonal SUP-DB server • Dataene kan aksesseres via den nasjonale helseportalen Sundhed.dk, av helsepersonell, pasienter eller myndigheter • Alle overføringer er kryptert

10. Danmark, Web-EHR forts. Web-EHR: Data pull from multiple EHR systems, forts. • Etter innlogging og inntasting av pasientens personnummer må brukeren (andre enn pasienten) oppgi om vedkommende har fått pasientens samtykke • Identifikasjon av brukere er basert på digitale sertifikat • 50 % av fylkene var med i 2005 • Håper på 100 % deltakelse i 2006 • Første uka kikket 40000 pasienter på sin EHR

11. Sverige, National patient summary project • Common IT service that facilitates interaction between different health care actors • Supply certain care information to authorised care providers, with the patient’s consent, irrespective of organization • Entitle the patient access to her own information via the Internet • Pilot project started Sept 04, up and running Oct 05

12. Sverige, National patient summary project, cont. Challenges • legislation is seen as impeding and confusing by patients and care providers • lack of common terminology and information models • long tradition of local autonomy and independent powers of taxation • no national financial mobilisation

13. Sverige, National patient summary project, cont. Pilot information content • Basic patient demographics • Regular GP • Laboratory results (clinical chemistry) • Prescribed drugs • Drugs dispensed from pharmacy (national database) • Diagnoses (hospitals) • Access log (for patient’s eyes only) • Medical notes (care summary) • Referral results (radiology)

14. Sverige, National patient summary project, cont. Pilot project • Includes information retrieval, not transfer (because of the legislation) • Consent and logging is managed in a common solution • Care providers guarantee administrative authorisation • Information is stored locally

15. Sverige, National patient summary project, cont. Pilot benefits • Fresh laboratory results • Avoiding re-work, e.g. duplicated laboratory or radiology tests • Possibility to locate care providers involved in care of the patient

16. Sverige, National medication module Database content: • Each patient’s individual medication information • Present and historical prescriptions • Drugs administered to inpatients • Prescriptions to pharmacies • Drugs delivered by pharmacies (generic substitution, package, amount etc) • Drug allergies

17. Sverige, National medication module, cont. National medication database users: • Patients: patients portal (look at own prescriptions, historical; enter own non prescription drugs; enter compliance to prescriptions, eventual adverse reactions etc?) • County council care provider: care systems • Municipal care: Care systems (Drug administration at municipal care: access to complete list of medication; administer drugs according to medication list; ) • Pharmacies: pharmacy systems (get prescriptions; pharmaceutical checks vs present prescriptions; feedback of delivered drugs: generic substitution, amount etc, • National board of health and welfare (statistics, follow up, quality systems, drug alarms etc,) • Medical product agency

18. Sverige, National medication module, cont. Critical points for success: • Analysis of operation • county council care • municipal care • private care • pharmacy • Definition of terms and concepts • Information modelling • Security • Personnel identification • Log function • Juridical changes

19. Sverige, National medication module, cont. Architecture • One central storage or distributed databases that communicate with each other? This shouldn’t care too much to the user. • There is no decision on who will pay for a solution like this

20. Iceland • Many very small health care organizations, but 2 larger ones: • Eastern region from 2000 • Southern region from 2004 • Current plans call for similar consoli-dation in other areas in the near future, making stronger regional organizations

21. Iceland, cont. Benefits regarding IT in the Eastern Region Health organisations: • one organisation, one control – gives a larger and stronger entity • health records are now gradually being consolidated into one database • currently they are using two databases – consolidation into one depends on better connections

22. Iceland, cont. Specialist doctors: • Various IT systems • one system is strong on the market • a group of 200 doctors will soon be using the system • connected to a closed private ‘doctors network’ • information contained within the network • no info sent into the network • no info sent out from the network • doctors use electronic identification

23. Iceland, cont. Current developments • Medication database from 2005 • all prescriptions collected from the Social Security Institute • Gives the Directorate of Health the possibilities needed for control • Electronic prescriptions 2006 • pilot since 2003 • general implementation 2006 • Central vaccination database 2006 • directorate of Health – infectious disease control • all vaccinations collected • primary healthcare can access the data

24. Iceland, cont. Should there be one database for all primary healthcare patient data? • technically quite easy providing all connections are in place • legal aspects • political aspects We can answer this question when we see the results of the previous questions

25. Iceland, cont. Should we integrate the hospital EPR-systems with the primary care systems, making a total country-wide patient data solution? • No, at least not yet. Let’s first take other important steps. • Doctors’ letters (epikrise) and lab information can fill a large piece of the picture • The smaller hospitals can make use of ‘big brother’s’ systems

26. Iceland, cont. The steps to take: • Building on the vaccination database • The most important data made accessible on demand (minimum data set) • 9 primary healthcare databases • Possibly consolidation of the 9 databases • Make the hospitals work more closely together, sharing the current know how and infrastructure

27. The Dutch approach to nationwide information interchange in healthcare NICTIZ organization: • Nationwide and neutral • All parties involved take part (umbrella organizations of care-providers, patients, healthcare insurers, IT-industry) • Funding by the government: 2002 – 2007: € 10 mill pr year • Staff: 21 fte + 5-10 fte hired expertise • Cooperation with Dutch Normalization Institute (NEN) for healthcare IT

28. The Dutch approach to nationwide information interchange in healthcare General approach: • Dutch National EPR will be virtual • Data on demand (request for distributed data) • Pointer index to medical records • “Well Managed Care IS” • Unique patient identifier • e-Medication Record, e-Locum Services (professional summary for GP) are killer applications – National, mandatory use • Simultaneous work on other EPR-chapters • Local -> regional -> national ->

29. The Dutch approach to nationwide information interchange in healthcare AORTA • Nationwide IT-infrastructure for healthcare

30. The Dutch approach to nationwide information interchange in healthcare e-Medication • Medication = core chapter of EPR • Significant: • avoidable errors in medication: Approx. 90 000 cases of hospitalization/year • € 300 million/year avoidable costs • Tight time schedule • 2004 regional examples • 2006 nation-wide available = 1760 pharmacies • 2007(?) 100 % coverage • Mandatory use for all care providers • Infrastructure suitable for complete spectrum of e-Health

31. The Dutch approach to nationwide information interchange in healthcare Legen kan klikke på en knapp i journalsystemet for å få tilgang til medikamentinformasjon for pasienten. Systemet sender da personnummeret til pasienten til det sentrale systemet (National Switchpoint). Dette systemet finner fram til de apotekene som har levert ut medisiner til pasienten. Opplysninger om det som er utlevert kan vises til legen.

32. The Dutch approach to nationwide information interchange in healthcare Healthcare professional card • 3 functions • Authentication • Confidenciality and integrity • Irrefutability/electronic signature • Norms for production, how to issue and card-reader • Issued by IZU-register (CIBG) through post office • Already operational, introduction per project

33. The Dutch approach to nationwide information interchange in healthcare Current status: • Patient unique identifier: ok • Healthcare professional card: ok • National switchpoint • ready for POC with application vendors • goal: 10 % pharmacies, GPs and hospitals connected in 2006 • goal: 100 % connected in 2007

34. The Dutch approach to nationwide information interchange in healthcare “Every truth passes through three stages before it is recognized: • In the first it is ridiculed, • in the second it is strongly opposed, • in the third it is regarded as self evident.” Arthur Schopenhager

35. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), Edgar Glück Patient data on demand – requirements: • Make existing info accessible • Need to know • which information exists • where is this info available • Access control – who, when, where

36. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. Tele Radiology Project of Western Norway • “Seamless” co-operation • Between organizations/hospitals • Between applications from different vendors • Based upon a generic solution • Using an IHE profil: • XDS – Cross-Enterprise Document Sharing

37. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. The IHE Initiative – Integrating the Healthcare Enterprise: • To achieve co-operation between applications from different vendors • Solution: use of international standards • Problem: existing standards are not specific enough to achieve this cooperation • Started within radiology • Many activities are not domain specific • Today becoming a major architectural element for healthcare IT

38. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. IHE domain areas: • Radiology • IT infrastructure • Laboratory information • Cardiology • Patient care • others

39. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. XDS main components: • Document Repository (web server) • Stores documents persistently • Allows for retrieval of specified documents • Document Registry (web server) • Maintains meta-data about registered documents • Responds to queries for documents meeting specified criteria

40. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. Status for the project: • product from Agfa and eCare (InfoBroker) selected • involvement of Siemens, DIPS and Kodak • Production 3Q2006 • partly proprietary interfaces • some additions to XDS (for access control) • Next version 2007

41. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. Implemented Document Repositories: • Local RIS • Request • Reports • Local PACS archive • Radiology objects (X-rays, MR, CT, etc) • Regional document repository • Copies of requests and reports

42. Cross-Enterprise Clinical Documents Sharing in Norway (XDS), cont. Summary and future development: • XDS is used in the Tele-Radiology project to give access to radiology objects • keeps track of available information • generic solution – may be used to give access to EHR information in general • also for patient’s to access their own EHR

43. The Data-Gathering Broker (IBHIS) Professor Michael Rigby, Keele Univ (UK) and colleagues at Durham and Manchester Univ A User-Based Approach to Viable EPR systems in England The IBHIS Vision: • the authorised persons can get what they need, in real time • records are secure, specific access when it is really needed • data from different records are merged virtually as needed • all record searching is audited

44. The Data-Gathering Broker (IBHIS), cont. Where are we going with current approach and is there a different approach? • Vertical integration • linking primary and secondary care • Horizontal integration • linking health providers in a region • Temporal integration • Linking to previous medical history

45. The Data-Gathering Broker (IBHIS), cont. • Exponential increase in the EHR size. Little thought on viability or practicality • Birth to death • Digitisation of investigations • volume of investigations • population longevity • genetic analysis • designer drugs and personalised dosages • domestic monitoring • continuous in vivo monitoring • remote service delivery (telemedicine, etc)

46. The Data-Gathering Broker (IBHIS), cont. The concerns: • record size and volume of transactions • navigating the record and data swamping • not proven (has never been done) • enterprise precedents not good • there will always be boundaries

47. The Data-Gathering Broker (IBHIS), cont. The IBHIS broker – an intelligent broker that can search in all the EHR systems, despite that they exist behind firewalls

48. The Data-Gathering Broker (IBHIS), cont. What is significant about his? Employs a data access service model to provide a service-oriented front-end. This is an academic research. Prototype is now tested and demonstrated. It is not connected with the NHS. The NHS was started without much research and without questioning. They just wanted to do something. But what will they get?

49. eHealth Interoperability – proposed activitiesDr Octavian Purcarea, Unit H1 – ICT for Health, Directorate ICT for citizens and business, DG INFSO, EU Commission e-Health action plan: main areas of activity • National/regional roadmaps (MS; 2005) • Common approaches for patient identifier (EC+MS, 2006) • Interoperability standards for EHR and messaging (EC+MS, 2006) • Boosting investments in eHealth (MS, 2007) • Conformity testing and accreditation (MS 2007) • Deployment of health information networks (MS, 2004-2008) • Legal framework, certification of qualifications (EC+MS, 2009) (Petra Wilson)

50. eHealth Interoperability – proposed activities, cont. • GOAL: agree on a Recommendation on eHealth Interoperability (see slides) • The ultimate goal is to enable access to the patient’s electronic health record, patient summary and emergency data from any place in Europe.