may 12-14, 2014 dr. doug fridsma eu-us ehealth/health it cooperation initiative interoperability of...
TRANSCRIPT
May 12-14, 2014
Dr. Doug Fridsma
EU-US eHealth/Health IT Cooperation Initiative Interoperability of EHR Work Group
2
Agenda
• Background– Memorandum of Understanding– Vision– Roadmap– Strategy– Interoperability of EHR’s – Progress to date
• Methodology
• How to get involved
3
Background | MoU
It started with a Memorandum of Understanding
In December 2010, the European Commission and the US Dept. of Health and Human Services signed a Memorandum of Understanding (MOU) to
• Help facilitate more effective uses of eHealth/Health IT• Strengthen their international relationship • Support global cooperation in the area of health related
information and communication technologies.
Interoperability of EHRs
4
Background | Vision
The MoU vision set the framework for progress
“To support an innovative collaborative community of public- and private-sector entities working toward the shared objective of developing, deploying, and using eHealth science and technology to empower individuals, support care, improve clinical outcomes, enhance patient safety and improve the health of populations.”
Vision
5
From the MoU, a roadmap was created to help guide the work of both work streams
• Scope of Roadmap – Defines a cooperative action plan to produce deliverables aligned with the
goals outlined in the MoU, with a specific emphasis on the following two areas:
• international interoperability of Electronic Health Records information, to include semantic interoperability, syntactic interoperability, patient and healthcare provider mediated data exchange (including identification, privacy and security issues surrounding exchange of health data); and
• cooperation around the shared challenges related to eHealth/health IT workforce and eHealth proficiencies.
• Trillium Bridge Coordination– Integrates relevant Trillium Bridge work with the EU/US Interoperability
work stream
Background | Roadmap
6
Background | Strategy
To reach this vision two high priority work streams were established
• eHealth/Health IT Interoperability: – accelerate progress towards the widespread deployment and routine use
of internationally recognized standards that would support transnational interoperability of electronic health information and communication technology; and
• eHealth/Health IT Workforce Development: – identify approaches to achieving a robust supply of highly proficient
eHealth/health IT professionals and assuring health care, public health, and allied professional workforces have the eSkills needed to make optimum use of their available eHealth/health information technology. Equally, we will identify and address any competency and knowledge deficiencies among all staff in healthcare delivery, management, administration and support to ensure universal application of ICT solutions in health services.
“Accelerate progress towards the widespread deployment and routine use of internationally
recognized standards that would support transnational interoperability of electronic health
information and communication technology”
7
Background | Interoperability of EHR’s
The Interoperability work stream aims to…
8
The goal of this work stream is three-fold
Harmonize the formats for how information isStructured
Syntactic Interoperability
Identify and align a subset of commonly used vocabularies and terminologies
Empower individuals through patient-mediated data exchange, addressing privacy and security issues
Semantic Interoperability
Patient Mediated Data Exchange
Background | Goal
Validate through Pilot testing
The S&I Framework model is being used to support the Interoperability work stream
Background | Progress to Date
9
Harmonize EU/US syntax and semantics
Develop Use Case based on user stories
Collect scenarios and select user stories
Create Workgroup Charter and Scope Statement
10
Step 1: Outline Scope Statement
Using the MOU and the roadmap, we developed the foundation of our work through a Scope Statement…
• Scope Statement:– Working to accelerate and advance the progress of eHealth/health IT interoperability
standards and interoperability implementation specifications for the unambiguous semantic interpretation of clinical data that meet high standards for security and privacy protection and fidelity (faithful to the source) for the international community and for the enhanced care quality and safety of the patient.
– Working toward shared objective to support an innovative collaborative community of public- and private-sector entities, including suppliers of eHealth solutions, working toward the shared objective of developing, deploying, and using eHealth science and technology to empower individuals, support care, improve clinical outcomes, enhance patient safety and improve the health of populations.
– http://wiki.siframework.org/Interoperability+of+EHR+Work+Group
Step 2: Select Scenario & User Stories
We defined one scenario containing three user stories. Each user story represents a different way in which the patient can control the flow of his/her information
Patient has traveled outside of their normal geographic location. This could be from the US to the EU, or EU to US
Patient requires emergency care and visits an emergency room in the location that they have traveled to. The emergency room staff require information on the patient’s
health care
The patient is discharged from the emergency room and returns to their home for follow-up care from their customary provider
1. Patient Mediated 2. Patient Facilitated 3. Provider-Provider
Scenario
11
Patient is discharged and requires follow-up care in home country…Patient Mediated Exchange
Emergency room provides electronic summary of care
Data translated to patient language
Patient incorporates data into application, the cloud, or hard copy
Step 3: Use Case Development
Emergency room provides electronic summary of care
Data translated to patient language
Patient forwards summary of care to customary provider
Patient Mediated Exchange Provider to Provider Exchange
Patient authorizes emergency room to send electronic summary of care
to customary provider
Data translated to patient language
Customary provider incorporates into patient EHR
Patient travels abroad and requires emergency care from foreign Provider…Patient Mediated Exchange
Patient sends data to emergency room provider through
mobile application
Data translated from patientlanguage to foreign language
Patient requests customary provider to send data to emergency room
provider
Customary provider authorizes datato be sent
Data translated from patient languageto foreign language
Patient Mediated Exchange Provider to Provider Exchange
Provider sends request for patientdata from customary provider
Customary provider authorizes release
Data translated from patient language to foreign language to customary
provider
12
13
Step 4: Harmonization
Analysis of EU and US standards for clinical summary information
• Mapping SWG of EU and US experts was created
• Compared clinical (patient) summary templates between epSOS and C-CDA standards.
• Analyzed – Document structure
– Data elements
– Value sets/Vocabularies
• Comparative Analysis outcomes will be presented in a White Paper
14
Step 4: Harmonization (cont.)
Analysis of EU and US standards for clinical summary information (cont.)
Category EU US
Template Name: Patient Summary (PS)
Continuity of Care Document (CCD)
Base Standard: HL7 CDA 2.0 HL7 CDA 2.0
Pub. Date: April 2007 July 2012
Acronym epSoS PS v1.4 C-CDA R1.1 CCD
1515
<clinicalDocument>(Clinical Summary Form)
<header> (document ID, author, patient ID…)
<component> [Body]
<section> [Procedures]
<entry> (Colonoscopy)
<procedureCode>
<procedureDate><…>
<entry> [Gastroscopy]<entry> [CABG]…
<section> [Current Medications]
<section>…
<entry> [ASA]<entry> [Warfarin]<entry> [CABG]
<entry>
Phase 1 •Section level mapping between epSOS and CCD
Phase 2 •Header’ Data Element mapping
Phase 3 •Sections’ Data Element mapping
Phase 4 •Value Set mapping
Completed
Remaining
Dat
a G
ranu
larit
y an
d C
ompl
exity
Mapping work - PHASES
Step 4: Harmonization (cont.)
16
Step 4: Harmonization (cont.)
Mapping Outcomes: Observations
• Document Section:– Both standards have 13 sections (e.g. Medications, Problems,
Immunization, etc.)– C-CDA CCD has 3 sections that epSoS does not have:
• Advance Directives
• Encounters
• Family History
• Data Elements (DEs):– Some required DEs in epSoS are optional in C-CDA CCD and vice
versa
17
Step 4: Harmonization (cont.)
Mapping Outcomes: Observations (cont.)• Code Systems and Value Sets (code system subsets):
– Code system same but different code subsets used (typical for SNOMED CT and HL7 codes)
– Code system different AND codes have different granularity (one to many maps).
• Examples of differences in coding systems:
Category EU US
Patient Summary (PS)
Continuity of Care Document (CCD)
Problems/Diseases: ICT-10-CM SNOMED CT
Medications: ATC RxNorm
Vaccines SNOMED CT CVX
• Value Sets:– epSoS (EU): 9,529 codes (ICD-10-CM)
– CCDA (US): 16,443 codes (SNOMED CT)
– epSoS SNOMED CT
• Analysis performed:– Mapped epSoS disease codes to C-CDA problem codes
– Used ICD-10-to-SNOMED CT maps developed by IHTSDO• Mapping table contains mapping variables such as mapPriority and mapGroup that can
be adjusted from relaxed to strict.
• Generally, relaxed rules will display more SNOMED CT matches for a given ICD-10-CM code, while strict rule will display less matches (see next slides)
18
Step 4: Harmonization (cont.)
Mapping Outcomes: Value Sets (VS) for Problem/Disease Codes
• Observations:– SNOMED CT more granular than
ICD-10-CM codes
– In ~90% cases, a single ICD-10-CM code had more than one SNOMED CT code mapped (see table to the right)
– >50% of ICD-10-CM codes had no associated SNOMED CT code
– Generally, relaxed rules will produce more SNOMED CT codes for a (one) given ICD-10-CM code, while strict rule will produce less matches
19
Step 4: Harmonization (cont.)
Mapping Outcomes: Value Sets (VS) for Problem/Disease Codes
ICD-10-CM codes:
SNOMED CT codes associated with ICD-10 code:
7% 1
6% 2
5% 3
15% 4-9
7% 10-19
3% 20-49
1% 50-99
1% ~100-350
55% No maps
ICD-10-CM codes:
SNOMED CT codes associated with ICD-10 code:
11% 1
7% 2
5% 3
14% 4-9
3% 10-19
1% 20-49
1% 50-99
<0.05% >100
58% No maps
Relaxed Strict
Interpretation example:
In 7% of all epSoS disease codes, a single (one) ICD-10-CM codes has between 10 and 19 associated (mapped) SNOMED CT codes in C-CDA Problem Value Set
20
Example 1: Relaxed vs. Strict Rules
Step 4: Harmonization (cont.)
Mapping rule: relaxed (#360)
Mapping rule: strict (#3)
Constraining mapping variables from relaxed-to strict limited display of SNOMED CT codes for a given ICD-10-CM code.
21
Example 2: Relaxed vs. Strict RulesMapping variables: relaxed (#258)
Mapping variables: strict (#184)
Constraining mapping variables from relaxed-to strict did not significantly limit display of SNOMED CT codes for a given ICD-10-CM code.
Step 4: Harmonization (cont.)
• Conclusions: – More specific ICD-10-CM codes will have a smaller number of associated SNOMED CT
codes than less specific ICD-10-CM codes.
– Even the strictest application of a map rule (variables) does not significantly reduce in all cases the number of SNOMED CT codes associated with a given ICD-10-CM code.
– Conversion from epSoS Disease codes to C-CDA Problem codes is unlikely to be entirely automated process because:
• 10% or less epSoS codes have a single (one) associated C-CDA problem codes.
• >50% epSoS codes have no associated C-CDA problem codes
• ~40% epSoS codes have more than one associated C-CDA problem codes
– Conversion from C-CDA Problem codes to epSoS Disease codes poses other challenges:
• Since SNOMED CT is more granular than ICD-10-CM codes, transcoding will invariably lead to loss of granularity in clinical information
Step 4: Harmonization (cont.)
Mapping Outcomes: Value Sets (VS) for Problem/Disease Codes
22
23
Step 4: Harmonization (cont.)
Comparative Analysis White Paper
• Purpose:– To summarize outcomes of document structure, data elements and
value sets between Patient (Clinical) Summary document in the EU and the US
• Goal:– To identify minimally required clinical data and associated
vocabulary subsets that would constitute a new, International Patient Summary document, based on HL7 CDA R2.0 standard
24
Step 4: Harmonization (cont.)
International (Harmonized) Patient Summary template
• The Mapping work concluded that a universal Patient Summary template and global vocabulary subsets would best address requirements and support harmonization across the standards
• A template WG will launch in mid-May and focus on developing the international template
25
Step 5: Pilot Testing
The Harmonization work will be validated through Pilot Testing
• Pilot recruitment has begun
• Pilot efforts will begin in September 2014
• Please reach out if you are interested in participating as a pilot project
26
Recap of Activities
The Interoperability work stream continues to progress towards the MOU vision
COMPLETED• Interoperability Use Case• Detailed mapping of epSOS
Patient Summary and C-CDA CCD
FUTURE WORK• Continue collaboration with
Trillium Bridge• Standards balloting in
September• Pilot test
IN PROGRESS• Comparative Analysis White
Paper• International/Harmonized
Patient Summary template• Collaboration with Trillium
Bridge
27
How to get involved?
• Link to EU initiative: http://wiki.siframework.org (EU-US eHealth Cooperation initiative link on the left hand side)
• Project Charter, Meeting Schedules, Minutes, Reference Materials, Use Case, and all Announcements are posted on the Wiki page
• Join the project and the project mailing list: http://wiki.siframework.org/EU-US+MOU+Roadmap+Project+Sign+Up
28
Questions
29
Contacts
For more information on the EU-US Interoperability work
– ONC Contacts:• Doug Fridsma: [email protected]
• Mera Choi: [email protected]
– Project Management Team:• Jamie Parker: [email protected]
• Virginia Riehl: [email protected]
• Amanda Merrill: [email protected]
– Clinical and Technical Contact:• Mark Roche: [email protected]