towards interoperable clinical systems - evolution or ...in depth, because finer-grained detail is...
TRANSCRIPT
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Towards interoperable clinical systems
Evolution or revolution?
Gustav [email protected]
Medical Informatics and Telemedicine (MIT) group
Department of Computer Science, University of Tromsø
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Agenda
• Our health prospects, as we age
• The health service need and the expected support ratio
• So, what have we done the last ten years?
• Interoperability - what is the problem?
• What do we need to do the next ten to meet the needs?
• My claims
• My advice
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Prevalence of chronic conditionsUSA 2004
[1] Anderson, G. and J. Horvath (2004). Public Health Reports 119(3): 263.
[1]
Our health prospects
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In Canada, 60%–80% of general medical costs are related to the care of persons with chronic disease[1].
[1] Rapoport J, Jacobs P, Bell NR, Klarenbach S. Refining the measurement of the economic burden of chronic diseases in Canada. Chronic Dis Can. 2004;25(1):13-21.
Our health prospects
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Rates hospital usage pr. age
Norway 2002-2006Weighted for no. of inhabitants
Our health prospects
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Rates of primary care service usage pr. age in Norway
Our health prospects
?Does anybody in the audience know?If nobody knows, why dont we know?
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Health service needs forcastExpected support ratio
Now
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Patient pathways and future needs
Focus area
Focus area
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What do we need to do?
• Patients must be allowed to do part of the job of staying healthy!– Diabetics
– COPD
– CHF
• Good thing is, giving patients the knowledge and responsibility also seems to influence the medical outcome in a positive direction.
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What do we need to do?
• Structure our EHR systems to support
– Clinical Desicion Support
– Evidence Based Clinical Guidelines
– Research
– Disease surveillance
– …..
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We need structured interoperable systems
PHR - Personal health record (for patients)EPR - Electronic patient record (for GP’s)EMR - Electronic medical record (Hospitals)RR - Rehabilitation RecordsNHCR - Nursing Home Care RecordHCR - Home Care Record
PHR EPR EMR RR
NH
CR
HC
R
3-4 6 2 (3) 3 3Systems: =17-19
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So, what have we done the last ten years?
Now
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So, what have we done the last ten years?
The 20th of June 2000 the first XML based discharge letter were transferred electronically from the University Hospital of North Norway to a GP office, Sentrum Legekontor in the centre of Tromsø, using software developed at Norwegian Centre for Integrated care and Telemedicine.
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So, what have we done the last ten years?
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jan.06 jul.06 jan.07 jul.07 jan.08 jul.08 jan.09 jul.09 jan.10
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Helse Sør-øst
Helse Nord
Helse Midt
Messages in the Norwegian health net January 2006 - May 2010
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So, what have we done the last ten years?
Messages types
• Discharge letters
• Referrals
• Radiology request / reply
• Bio-chemistry
• Others
• Message acknowledgement
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So, what more have we done the last ten years?
• Discussed…. need, security, privacy…
• Fixed the adress registry (2009)
• Fixed the legislation (2010)
• ….
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Progress is hinderred by
• Many actors and systems lead to complexity
• Many projects and interdependencies between them
• Lack of resources for implementors
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How can we acheive interoperability?
R71
Interoperability => IM A = IM B
IMA
Information Model
IMB
Information Model
SystemA
SystemB
What does R71 mean?
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Information models in healthcare
Requirements:
• Stable over time
• Simple and implementable
The reality:
• Constant change
• Increasingly complex
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Problem
1. In breadth, because new information is always being discovered or becoming relevant
2. In depth, because finer-grained detail is always being discovered or becoming relevant
3. In complexity, because new relationships are always being discovered or becoming relevant.
Source: Rector, A. L. Clinical Terminology: Why Is It So Hard? Yearbook of Medical Informatics 2001.
Change factors in medicine have been characterized by Rector as follows: Not only is medicine big, it is open-ended:
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My claimsBinding software to information content
If the medical software is tied to the information content handled in the system (implicit model), then medical software needs to change constantly
– Brilliant business model for EHR vendors
The singel information model is doomed to change as medical knowledge expands.
– Brilliant business model for information architects
– The model will collaps because of the complexity
– We will never acheive stable interoperable systems following these strategies
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My suggestion: Use Two-Level Modelling
“Separation of Information and Knowledge”
Business Logic
Knowledge Models
Information Models
Source: Rong Chen, Guest lecture at UiT, IFI, June 2008. Two level modelling and ‘future-proof’ information system
Defined by clinicians
Defined by informaticians
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Information
Information
Instances
Reference Model Archetype Model
Instances
Archetypes
Semantics of constraint
Runtime constraint
Knowledge
Source: Rong Chen, Guest lecture at UiT, IFI, June 2008. Two level modelling and ‘future-proof’ information system
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What can we do?My advises for the next ten years
• Let clinicains define the clinical information models in the EHR system, they know their domain
• Use the two level modelling method for EHR systems• => adopt the OpenEHR methodology
• Ban closed and proprietary systems in healthcare– We dont have time to evolve all systems into interoperability– We really need to know what is going on in the health service
• Let the vendors work on one common and open software repository for EHR software– They have the knowledge, experience and skills to do it
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We need interoperable systems
PHR - Personal health record (for patients)EPR - Electronic patient record (for GP’s)EMR - Electronic medical record (Hospitals)RR - Rehabilitation RecordsNHCR - Nursing Home Care RecordHCR - Home Care Record
PHR EPR EMR RR
NH
CR
HC
R
3-4 4-5 2 (3) 3 3Systems:
One shared and Open EHR system
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Conclusion
We don’t have time for evolution!
We must choose revolution!
Thank you for listening