Regional and National Regional and National Electronic Health Records (2009)Electronic Health Records (2009)

Olivier Caudron, Senior Sales Engineer, InterSystems Corp.

Speaker’s Profile

•• Senior sales engineer @ InterSystems Senior sales engineer @ InterSystems (Benelux)(Benelux)

•• Mainly Mainly technicaltechnical profile, with a focus on profile, with a focus on objectobject--oriented, web and integration technologiesoriented, web and integration technologies

•• Specialized in the healthcare verticalSpecialized in the healthcare vertical since several yearssince several years•• Technical advisorTechnical advisor on Dutch national projects on Dutch national projects LSPLSP (national (national

HC backbone) and HC backbone) and DBC GrouperDBC Grouper (reimbursement of care)(reimbursement of care)•• Involved in the EPR project of the Brussels region Involved in the EPR project of the Brussels region

((«« BHIPBHIP »»))•• Technical advisor for the integration projects of several Technical advisor for the integration projects of several

hospitals in Belgium and the Netherlandshospitals in Belgium and the Netherlands

Still Many Regional and National Initiatives

USAUSA (RHIOs)(RHIOs)

CanadaCanada(Health Infoway)(Health Infoway)

AustraliaAustralia(HealthConnect)(HealthConnect)

New ZealandNew ZealandSouth Africa?South Africa?

Brazil?Brazil?

China?China?

Corea?Corea?Japan?Japan?

India?India?Argentina?Argentina?

Mexico?Mexico?

Thailand?Thailand?

Malaisia?Malaisia?

ChileChile

GermanyGermany (SCIPHOX)(SCIPHOX)

FranceFrance (DMP)(DMP)

UKUK (NHS)(NHS) The Netherlands The Netherlands

(AORTA)(AORTA)

Sweden Sweden (NP(NPÖÖ)) FinlandFinland

(OpenCDA)(OpenCDA)DenmarkDenmark

(MedCom)(MedCom)

ItalyItaly

Why a Transmural Patient Record (in a Nutshell)

•• The stakes are naturally related to The stakes are naturally related to quality of carequality of care::–– Better prevention of medical errorsBetter prevention of medical errors–– Better diagnosticsBetter diagnostics–– Optimization of prescriptionsOptimization of prescriptions–– Avoid redundant medical tests, etc.Avoid redundant medical tests, etc.

•• But they are also But they are also economicaleconomical::–– Optimization of the public healthcare budgetsOptimization of the public healthcare budgets–– Reducing the overall amount of compensations by Reducing the overall amount of compensations by

insurance companies related to lawsuits for malpractice insurance companies related to lawsuits for malpractice and medical errors in general, etc.and medical errors in general, etc.

Challenges of trans-mural EHR (in a nutshell)

•• InteroperabilityInteroperability: choice of a technology and an infrastructure : choice of a technology and an infrastructure for data interchange, a message format, common for data interchange, a message format, common semantics, etc.semantics, etc.

•• VolumesVolumes: at a national level, whatever the infrastructure, it : at a national level, whatever the infrastructure, it represents huge amounts of data (stored and transferred)represents huge amounts of data (stored and transferred)

•• ReliabilityReliability: data up: data up--toto--date, comprehensive and available!date, comprehensive and available!

•• SecuritySecurity: authentication (person and quality), authorisation, : authentication (person and quality), authorisation, confidentiality, auditconfidentiality, audit

•• Need (most of the time) to Need (most of the time) to adapt the lawsadapt the laws

•• Protection of fundamental patient rightsProtection of fundamental patient rights

Example: Canadian national EHR (“Health Infoway”)

•• Initiated in 2000Initiated in 2000--20012001•• 2004: 10 year plan for development2004: 10 year plan for development•• Budget 2000Budget 2000--2008: 2008: 1,6 billion Canadian $1,6 billion Canadian $

(~1 billion (~1 billion €€), funding 70% public, 30% private), funding 70% public, 30% private–– In 2010, 5 In 2010, 5 «« jurisdictionsjurisdictions »» representing almost 50% of representing almost 50% of

the total population should have established the bases of the total population should have established the bases of a patient recorda patient record

–– Ambitious plan for Ambitious plan for 20152015 for afor a total budget of ~12 billiob total budget of ~12 billiob Canadian $Canadian $

•• Uses Uses HL7v2.4HL7v2.4 and and v3v3 and and DICOMDICOM messages, and messages, and SNOMEDSNOMED and and LOINCLOINC terminologiesterminologies

Example: New Zealand

•• 4 million inhabitants, 21 (health) districts4 million inhabitants, 21 (health) districts–– Centralized national health system, mainly funded by the Centralized national health system, mainly funded by the

governmentgovernment–– Focused on primary and preventive careFocused on primary and preventive care–– Very IT enabledVery IT enabled

•• Currently implemented:Currently implemented:–– Secured national networkSecured national network–– National identifier (for healthcare)National identifier (for healthcare)–– Clearly defined privacy protection rulesClearly defined privacy protection rules

Example: New Zealand

•• Currently being implemented:Currently being implemented:–– National vision for ITNational vision for IT--enablement of public healthcareenablement of public healthcare–– Electronic integration of primary and secondary careElectronic integration of primary and secondary care–– EE--laboratorieslaboratories

•• Projects not yet started:Projects not yet started:–– National electronic healthcare architectureNational electronic healthcare architecture–– PatientPatient--centric electronic healthcare systemscentric electronic healthcare systems

•• In 2005, strategy of health information with a delegated In 2005, strategy of health information with a delegated funding systemfunding system

The Situation in the USA

•• Presidential Presidential «« executive orderexecutive order »» in 2004 to establish a in 2004 to establish a national healthcare infrastructure by 2014national healthcare infrastructure by 2014

–– Coordinated by the Coordinated by the «« Office of the national coordinator Office of the national coordinator for heath information technologyfor heath information technology »»

–– Based on regional initiatives of all types and sizes Based on regional initiatives of all types and sizes called called «« RHIORHIO »» ((«« Regional Health Information Regional Health Information OrganizationOrganization »»

•• About About 150 initiatives currently active150 initiatives currently active•• About 10 About 10 statestate--level projectslevel projects

•• A strategy and a situation very disparateA strategy and a situation very disparate–– Also technologically!Also technologically!

US Department of Veteran Affairs (« VistA » project)

•• 163 hospitals, 850 clinics, 137 care facilities, 73 163 hospitals, 850 clinics, 137 care facilities, 73 home care programs in 21 regionshome care programs in 21 regions

•• 5,4 million5,4 million patientspatients

•• An organization unanimously acclaimed for its qualityAn organization unanimously acclaimed for its quality–– An EHR often taken as referenceAn EHR often taken as reference–– Secure communication between patient and practitionerSecure communication between patient and practitioner–– A A patient portalpatient portal with well over 500 000 registered userswith well over 500 000 registered users

•• IT system based on IT system based on InterSystems CachInterSystems Cachéé and and EnsembleEnsemble

VistA’s Patient Portal

A Successful Regional Initiative: Brazilian State of Brasilia

•• The state of Brasilia in Brazil has built a regional The state of Brasilia in Brazil has built a regional patient patient portalportal based on based on InterSystems TrakCareInterSystems TrakCare

–– 6,5 million inhabitants6,5 million inhabitants–– 17 hospitals, 134 clinics, 3 labs, 20 emergency 17 hospitals, 134 clinics, 3 labs, 20 emergency

services, 3 specialized diagnostic units, home care services, 3 specialized diagnostic units, home care servicesservices……

–– Over Over 5000 healthcare professionnals5000 healthcare professionnals use this central use this central electronic health recordelectronic health record

–– $20 million $20 million sparedspared in 2009 (e.g. reducing redundant in 2009 (e.g. reducing redundant medical examinations)medical examinations)

State of Brasilia: Patient Portal

Europe

GermanyGermany (SCIPHOX)(SCIPHOX)

FranceFrance (DMP)(DMP)

United KingdomUnited Kingdom(NHS)(NHS)

The NetherlandsThe Netherlands (AORTA)(AORTA)

Sweden (NPSweden (NPÖÖ)) FinlandFinland (OpenCDA)(OpenCDA)

DenmarkDenmark(MedCom)(MedCom)

ItalyItaly

Denmark: Digital Health, Sundhed.dk, Medcom

•• «« Digital HealthDigital Health »» initiativeinitiative

•• MedcomMedcom: national data network initiated : national data network initiated in 1994in 1994–– Currently in Currently in phase 6phase 6–– Uses EDIFACT et XMLUses EDIFACT et XML–– Used by GPs for Used by GPs for referencingreferencing, , prescriptionsprescriptions, , diagnostic diagnostic

test requeststest requests, , reportsreports, , discharge lettersdischarge letters, discharge , discharge notification for notification for home care serviceshome care services, and , and reimbursementsreimbursements

•• Sundhed.dkSundhed.dk: official electronic patient portal: official electronic patient portal

The British Project: NHS

•• The The ““National Health ServiceNational Health Service”” delivers free healthcare in all delivers free healthcare in all GreatGreat--BritainBritain

•• Project Project ““Connecting For HealthConnecting For Health”” ((““CfHCfH””) started in 2002 as a ) started in 2002 as a means to control exploding public spending in healthcaremeans to control exploding public spending in healthcare

•• Project Project ““National Programme for ITNational Programme for IT”” ((““NPfITNPfIT””) limited to ) limited to England onlyEngland only

–– Total 10 years budget: Total 10 years budget: ££12,4 billion12,4 billion (source: CSC)(source: CSC)–– The other parts of UK (Scotland, Wales, Northern The other parts of UK (Scotland, Wales, Northern

Ireland) have decided to Ireland) have decided to «« wait and seewait and see »»

Organization in “clusters”

>35 000 users>35 000 users

>40 000 users>40 000 users>20 000 users>20 000 users

>30 000 users>30 000 users

>25 000 users>25 000 users

(>150 000 users)(>150 000 users)

NHS Organization

•• Each Each ““clustercluster”” federates many federates many ““truststrusts””, which are professional , which are professional organizations representing their members to the NHSorganizations representing their members to the NHS

•• Each cluster was attributed to a specific Each cluster was attributed to a specific serviceservice and and software software providerprovider

•• Some general services were attributed separately:Some general services were attributed separately:–– The The «« SPINESPINE »»: central database for summary patient : central database for summary patient

records records --> BT> BT–– «« Choose and bookChoose and book »»: service allowing a patient to select : service allowing a patient to select

an hospital and book an appointment an hospital and book an appointment --> Atos> Atos–– Etc.Etc.

Software Providers: December 2003

Software Providers: Summer 2006

Software Providers: Fall 2006

Software Providers: May 2008

??

A Situation being Stabilized?

•• Beyond the Beyond the ““waltzwaltz”” of providers, delays in the development of providers, delays in the development of iSoftof iSoft’’s application s application ““LorenzoLorenzo””, diverse implementation , diverse implementation problemsproblems…… contribute to the fact that the project has been contribute to the fact that the project has been long in a long in a very uncertain statevery uncertain state

•• The fact CSC is now in charge of a great part of the project The fact CSC is now in charge of a great part of the project seems to have a seems to have a positive impactpositive impact thanks to a thanks to a better better leadershipleadership

•• New solutions have been recently considered to help put New solutions have been recently considered to help put the project back on railsthe project back on rails

InterSystems and the NHS

•• In 2008, the NHS and CSC selected InterSystems Ensemble In 2008, the NHS and CSC selected InterSystems Ensemble as as ““trust integration enginetrust integration engine””, which places it at the , which places it at the heart of the solutionheart of the solution

–– Better standardization of the communication between Better standardization of the communication between trusts and between existing medical applications and trusts and between existing medical applications and new solutions created by CSCnew solutions created by CSC

–– 50 standardized HL7v2 interfaces50 standardized HL7v2 interfaces to common departmental to common departmental applications already developed by InterSystemsapplications already developed by InterSystems

•• Ensemble used as Ensemble used as integration engineintegration engine in the NHS version of in the NHS version of LorenzoLorenzo

•• Several trusts are considering Ensemble for their local Several trusts are considering Ensemble for their local integration needsintegration needs

The Swedish National Project (NPÖ)

•• The Swedish The Swedish ““national patient summarynational patient summary”” project (project (““Nationell Nationell PatientPatientööversiktversikt”” or or ““NPNPÖ”Ö”) was won in ) was won in march 2008march 2008 by by integrator integrator Tieto EnatorTieto Enator and and InterSystemsInterSystems

–– Project manager: Project manager: CarelinkCarelink, an organization founded by , an organization founded by the Swedish governmentthe Swedish government

–– 21 regions involved/9 million inhabitants21 regions involved/9 million inhabitants–– 8 regional hospitals, 65 district/county hospitals, 1000 8 regional hospitals, 65 district/county hospitals, 1000

care centers, 290 municipalitiescare centers, 290 municipalities

•• Interoperability based on the European norm Interoperability based on the European norm CEN 13606CEN 13606

The Swedish National Project (NPÖ)

•• The Swedish The Swedish ““national patient summarynational patient summary”” project (project (““Nationell Nationell PatientPatientööversiktversikt”” or or ““NPNPÖ”Ö”) was won in ) was won in march 2008march 2008 by by integrator integrator Tieto EnatorTieto Enator and and InterSystemsInterSystems

–– Built on Built on InterSystems HealthShareInterSystems HealthShare, platform dedicated to , platform dedicated to regional and national healthcare infrastructuresregional and national healthcare infrastructures

–– Pilot project live since May 4, 2009Pilot project live since May 4, 2009•• 9 years of clinical data over 1.5 million patients imported9 years of clinical data over 1.5 million patients imported

–– Establishment phase to be completed in June 2009Establishment phase to be completed in June 2009–– At least 3 counties will be connected by end 2009At least 3 counties will be connected by end 2009–– 5 year contract plus 2 years optional extension5 year contract plus 2 years optional extension

Clinical Summary of Project NPÖ: Patient Search & Select

Clinical Summary of Project NPÖ: Patient Overview

Clinical Summary of Project NPÖ: Medication & Medication Details

Clinical Summary of Project NPÖ: Home Services

Clinical Summary of Project NPÖ: Diagnoses

Clinical Summary of Project NPÖ: Biochemistry

The Dutch Project (LSP)

•• September 2005September 2005: the headlines in all the Dutch press read:: the headlines in all the Dutch press read:

““The LSP project is not keeping its delays!The LSP project is not keeping its delays!””•• October 2005October 2005: the contract between the Dutch government : the contract between the Dutch government

and CSC/InterSystems is signed, officially starting the and CSC/InterSystems is signed, officially starting the project on project on 11stst november 2005november 2005

Is it me, or is there something wrong with the Is it me, or is there something wrong with the above?above?

The Dutch Project (LSP)

•• October 2005October 2005: the contract between the Dutch government : the contract between the Dutch government and CSC/InterSystems is signed, officially starting the and CSC/InterSystems is signed, officially starting the project on project on 11stst november 2005november 2005

•• February 2006February 2006: the project is : the project is delivereddelivered and and certifiedcertified by by NICTIZ: NICTIZ: on timeon time, and , and exactlyexactly according to specaccording to spec!!

•• The press acknowledges this beautiful successThe press acknowledges this beautiful success……

The LSP in a Nutshell

•• ““Landelijk SchakelPuntLandelijk SchakelPunt””: National : National ““Switch PointSwitch Point””•• Decentralized system: information is accessed Decentralized system: information is accessed in situin situ and and

NOT copied centrallyNOT copied centrally–– Less monolithic system, more flexible, better protection Less monolithic system, more flexible, better protection

for patient datafor patient data•• Interchange of full or summary medical dataInterchange of full or summary medical data

–– Entirely based on Entirely based on HL7v3 (RIM)HL7v3 (RIM)–– DoesnDoesn’’t include imaging (yet?)t include imaging (yet?)

•• Access for professionals secured by smartcard (Access for professionals secured by smartcard (““UZIUZI--PasPas””))•• Use of a national patient register number (Use of a national patient register number (““BSNBSN””))

Working Principles of the “LSP” in a Nutshell

““LandelijkLandelijk SchakelPuntSchakelPunt””

Certified DataCertified DataCommunicationCommunicationNetworksNetworks

Certified ClientCertified Client““Goed BeheerdGoed BeheerdZorgsysteemZorgsysteem””

MetaMeta--indexindex((““verwijsindexverwijsindex””))No patient dataNo patient data stored centrallystored centrally

Communication usesCommunication uses SOAP on tokenSOAP on token--securesecure

HTTPS channelHTTPS channel

HC data exchange entirely basedHC data exchange entirely based on HL7v3 RIM (Dutch variant)on HL7v3 RIM (Dutch variant)

Communication standardsCommunication standards between end user between end user

and GBZ are indifferentand GBZ are indifferent

Working Principles of the “LSP” in a Nutshell

Working Principles of the “LSP” in a Nutshell

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??!!!!!!??!!

!!

!!

!!

??!!!!!!??

History of the Project since Rollout

•• March 2006 March 2006 –– May 2007:May 2007:–– Collaborative test phase between Collaborative test phase between 8 regions8 regions–– Prototypes of patient portal, ePrototypes of patient portal, e--signature, esignature, e--pathology, pathology,

ee--laboratorylaboratory–– Several extensions of the base project implementedSeveral extensions of the base project implemented

History of the Project since Rollout

•• May 2007 May 2007 –– May 2008:May 2008:–– Capacity of production systems greatly enhanced to Capacity of production systems greatly enhanced to

prepare transition to prepare transition to phase phase «« 2++2++ »»–– New prototypes of patient portal, eNew prototypes of patient portal, e--signature, signature,

ee--pathologypathology–– Extension of the specs of the LSP, including Extension of the specs of the LSP, including ““tokentoken””--

based authenticationbased authentication–– Additional connections in test regionsAdditional connections in test regions–– 11 medical applications certified11 medical applications certified

History of the Project since Rollout

•• May 2008 May 2008 –– September 2008:September 2008:–– New production version of the LSP including tokenNew production version of the LSP including token--

based authentication and medication securitybased authentication and medication security–– 7 7 newnew medical application certifiedmedical application certified–– 11 network and added value providers11 network and added value providers certified for certified for

connection to the LSPconnection to the LSP–– New extended version of the spec, including an New extended version of the spec, including an

““address bookaddress book”” in healthcarein healthcare–– Preparation of Preparation of phase 2++ rolloutphase 2++ rollout

History of the Project since Rollout

•• September 2008 September 2008 –– today: today: –– Organization of GPs in conflict with the government Organization of GPs in conflict with the government

uses the LSP as leverage for their (unrelated) demandsuses the LSP as leverage for their (unrelated) demands–– Patient and consumer organizations worry about what Patient and consumer organizations worry about what

they perceive as an they perceive as an ““opaqueopaque”” systemsystem–– Health domain associations are positive towards the Health domain associations are positive towards the

LSP but feel that LSP but feel that ““it is going too fastit is going too fast””

•• The Minister of Health decides to calm things down a bitThe Minister of Health decides to calm things down a bit

Current Situation

•• The Minister decides that access of patient to their personal The Minister decides that access of patient to their personal record must be improved before the next releaserecord must be improved before the next release

–– Will probably be done through implementation of a Will probably be done through implementation of a patient portalpatient portal

–– NICTIZ did not originally include the patient portal in the NICTIZ did not originally include the patient portal in the project to keep it to a manageable sizeproject to keep it to a manageable size

•• This should delay 2++ rollout This should delay 2++ rollout a few monthsa few months, between , between September 2009 and early 2010September 2009 and early 2010

•• As of today, As of today, 10 test regions10 test regions actively use the LSP, which actively use the LSP, which represents represents 87 healthcare organizations87 healthcare organizations

LSP: Patient Rights

•• The public has been informed of their rights with regards to The public has been informed of their rights with regards to the LSP by information campaigns in the Dutch mediathe LSP by information campaigns in the Dutch media

–– Patients have the right to Patients have the right to ““unregisterunregister”” themselves from themselves from the system, the system, completelycompletely or with exception of or with exception of emergency emergency situationssituations ((““break the glassbreak the glass”” procedure)procedure)

–– They can also ask that a They can also ask that a specific information providerspecific information provider doesndoesn’’t make their data available to the LSPt make their data available to the LSP

–– In the longer term, In the longer term, ““granularitygranularity”” of this patient rights of this patient rights system should be further refined (with the help of the system should be further refined (with the help of the patient portal)patient portal)

The LSP: (Temporary!) Conclusion

•• Project LSP is more Project LSP is more ““alive and kickingalive and kicking”” than everthan ever, and its , and its constant technical success is a strong encouragement for constant technical success is a strong encouragement for continuation to political decisioncontinuation to political decision--makers (possibly with makers (possibly with adaptations)adaptations)

•• From the beginning, the LSP itself was never a problem:From the beginning, the LSP itself was never a problem:–– Design, development and deployment were always Design, development and deployment were always

within delays (and budget)within delays (and budget)–– So far tests have always been successfulSo far tests have always been successful–– So far audits have always been satisfactorySo far audits have always been satisfactory

The LSP: (Temporary!) Conclusion

•• ““Large cultural and social changes, like this one, always take Large cultural and social changes, like this one, always take their time. Because of the success of the LSP from an ITtheir time. Because of the success of the LSP from an IT-- perspective, the focus always has been (and still is) on the nonperspective, the focus always has been (and still is) on the non-- technical aspects. technical aspects. In special because of the large impact on responsibilities and In special because of the large impact on responsibilities and openness in care provision the smallest technical problem (like openness in care provision the smallest technical problem (like availability) would have led to large discussions about technicaavailability) would have led to large discussions about technical l issues. issues. The current focus on access for the patient and control to the The current focus on access for the patient and control to the patient indicate that the LSP is a success.patient indicate that the LSP is a success.””

Bob Schat (CSC), Architect of the LSPBob Schat (CSC), Architect of the LSP

Some Other European Countries

•• GermanyGermany: national HER project (SCIPHOX) based on : national HER project (SCIPHOX) based on HL7v3 and CDAr2, focusing on interHL7v3 and CDAr2, focusing on inter--regional regional interoperabilityinteroperability

•• ItalyItaly: public will to federate diverse initiatives in 21 regions : public will to federate diverse initiatives in 21 regions ((““Virtual EHRVirtual EHR””) using ebXML v3.0 and ebRIM) using ebXML v3.0 and ebRIM

•• FinlandFinland: very advanced regional initiatives (all using : very advanced regional initiatives (all using InterSystems technology), often based on HL7v2. Situation InterSystems technology), often based on HL7v2. Situation of a possible national EHR unclear at this timeof a possible national EHR unclear at this time

•• And a great many independent regional initiativesAnd a great many independent regional initiatives……

Keys to Success to Extrapolate from Current EHR Projects

•• RealisticRealistic and and pragmaticpragmatic approach (avoid shortapproach (avoid short--lived lived ““fashionsfashions””, incorrect definition of the project, incorrect definition of the project’’s span, etc.)s span, etc.)

•• Clear political willClear political will, firmly committed on the , firmly committed on the long termlong term•• ImplicationImplication of patients and professionals organizationsof patients and professionals organizations•• ……But without excess (a strong But without excess (a strong leadershipleadership is paramount!)is paramount!)•• Reasonable Reasonable andand reasoned technical choicesreasoned technical choices, fitting the needs, fitting the needs•• Choice of a Choice of a reliable and proven technical infrastructurereliable and proven technical infrastructure•• ... And ... And patiencepatience, unavoidably, that kind of process/project , unavoidably, that kind of process/project

takes time!takes time!

Regional and National Regional and National Electronic Health Records (2009)Electronic Health Records (2009)

Olivier Caudron, Senior Sales Engineer, InterSystems Corp.Olivier.Caudron@InterSystems.com

Thank you for your Attention!Thank you for your Attention!