iehr.eu ihic 2013 presentation

2014-03-06 1

14th International HL7 Interoperability Conference

Extensions to HL7 V3 Standards Designed for the First Polish Nationwide Implementation:

Reasoning and Modelling

Roman Radomski, Sebastian Bojanowski

iEHR.eu, Warsaw, Poland

October 29, 2013

14th International HL7 Interoperability Conference

eHealth in Poland

• The main project of Polish eHealth aims at building the central information system supporting common exchange of electronic medical documents.

• Three types of documents: eReferral, ePrescription and eOrder of Supply are to be uploaded to the central repository to be accessed by the potential service providers.

• Other documents are to be stored locally, but their metadata will be sent to the same central system and published in the form of document registry.

14th International HL7 Interoperability Conference

HL7 v3 Implementation Guide

• HL7 CDA and V3 have been chosen as the standards for documents and messages to be exchanged with the central system.

• Due to the official project timeline, the large scale amendments of the current regulations and printed document forms were excluded.

• Draft CDA implementation guide for all 3 document types has been developed by iEHR.eu and distributed by the official government agency CSIOZ for review.

• The message template for other documents metadata exchange has been designed on the basis of the HL7 Medical Records R-MIM.

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Local extensions

• Most of the clinical concepts represented in the documents have been successfully mapped to the CDA, although 8 local extensions had to be defined.

• One extension has been defined for the HL7 v3 message beingsent to the central repository.

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Entitlement document

• The clinical document may contain information on non-clinicaldocument allowing patient’s entitlement to the particularmedical service coverage plan.

• The information consists of the document type and the document number (identifier).

– The special entitlement resulting from the document is not explicit in the document.

– The entitlement is subject to the operational context (planned service, local conditions, region) and may vary in time, but it does not changethe document information.

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Entitlement document

id.root = OID nodes for entitlement documents identifierscode.codeSystem = OID node for entitlement documents types value set

Constraint: Document id and code

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Special entitlement

• There are special entitlements (e.g to the drug refundcoverage plans) that should be indicated in the prescriptiondocument.

– The value sets of those coverage plans are regulated by law.

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Special entitlement

code.code = "PUBLICPOL"code.codeSystem = "2.16.840.1.113883.11.19350” (ActInsurancePolicyCode)code.qualifier.name.code = "RLEKUD" (drug refund based on special entitlement)code.qualifier.name.codeSystem = OID node for coverage plans value setcode.qualifier.value.codeSystem = OID node for special entitlements value set

Constraint: CoveragePlan.code

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Coverage eligibility confirmation

• There is a procedure for online confirmation of patienteligibility to the national health insurance.

• The confirmation has a form of a string and needs to be included in the clinical document issued when refundedservice is performed.

– The confimation string is not an identifier of an insurance policy or anyother entitlement document.

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Coverage eligibility confirmation

id.root= OID node for coverage eligibility confirmation identifierscode.code = "ELG " (eligible)code.codeSystem = "2.16.840.1.113883.11.17488" (ActCoverageEligibilityConfirmationCode)

Constraint: CoverageEligibilityConfirmation id and code

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Multiple birth indicator and order number

• Newborns are identified by their mother identifier and the birth date.

• Multiple birth newborns are identified by their motheridentifier, the birth date and the birth order number.

– All those identifying data needs to be included in every clinicaldocument until the proper national identifier is given - usually it takescouple of weeks.

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Multiple birth indicator and order number

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Close person

• There are specific document forms in Poland which require providing given names of patient’s parents as an additional patient identifying information.

– This is not an information about patient’s guardian.

– This is not a participation in the act of clinical document or in any act being documented.

– The document does not contain any other information about patient’s parents.

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Close person

code.codeSystem = "2.16.840.1.113883.11.19563" (PersonalRelationshipRoleType)

Constraint: PersonalRelationship.code

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Physician speciality

• Prescriptions for specific drugs and medical equipment supply require to be issued by physicians of particular specialities.

• Common practice is to include all medical specialities of document authenticator in every clinical document issued.

– The document content and context may not be relevant to the physician’s medical speciality.

– The value set of medical specialities is regulated by law.

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Physician speciality

code.codeSystem = OID node for physician specialities value set

Constraint: Qualification.code

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Drug payment level

• Drug may be refunded on various levels according to the public insurance/coverage plan.

• The same drug may be refunded on different levels dependingon clinical context.

– Physician is expected to determine the patient’s payment level for the drug being prescribed.

– The value set of drug payment levels is regulated by law.

– The national health fund conducts continous fraud detection to ensureproper drug refund processes.

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Drug payment level

code.code = "PUBLICPOL"code.codeSystem = "2.16.840.1.113883.11.19350” (ActInsurancePolicyCode)code.qualifier.name.code = "POLEKR" (refunded drugs payment levels)code.qualifier.name.codeSystem = OID node for coverage plans value setcode.qualifier.value.codeSystem = OID node for refunded drugs payment levels value set

Constraint: CoveragePlan.code

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Drug substitution

• The default rule is that pharmacist can substitute the prescribed drug with its equivalent, unless the drugprescription contains „no substitution” remark.

– The problem of drug substitution is rather sensitive, due to business competition between pharmaceutical companies and its potentialinfluence on the medical professionals.

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Drug substitution

code.code = "N" (none)code.codeSystem = "2.16.840.1.113883.11.16621" (ActSubstanceAdminSubstitutionCode)

Constraint: Substitution.code

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Supporting Clinical Statement

• The message containing metadata of clinical document beingissued is sent to the central repository.

– This message has to contain information about diagnosis placed in the context of the document.

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Supporting Clinical Statement

Clinical StatementMedical Records

code.codeSystem = OID node for official Polish translation of ICD-10

Constraint: Observation.code

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New Timeline for the Polish eHealth Agenda

• The central system (P1) to be ready by mid 2014

• First production use of P1 at beginning of 2015

• The electronic drug prescription obligatory for all healthcareproviders in 2015 or 2016

• Other documents will be obligatory gradually from 2016