Transcript Why would a Clinician be interested in Somantic

ICT expo Dublin 14th April 2005
Making E-Health work
Why would a clinician be interested in Somantic
Interoperability?
Jeremy R L Nettle
European Healthcare Director
Oracle Corporation UK Ltd
[email protected]
April 2005
The Interoperability Consortium
In November 2004, Oracle Corporation one of the eight
leading services and technology companies came together as
the Interoperability Consortium to respond to a request from
the newly-formed office of the National Coordinator for Health
Information Technology (ONCHIT) to submit information on
how the National Health Information Network (NHIN) could be
designed and deployed.
The Interoperability Consortium outlined an initial plan for
patient-centered health care delivery systems, secure and
private communications, open information exchange
standards and public-private financing
Making e-Health Work
Agenda
 Why deliver Integrated Healthcare
 The proliferation of non Integrated systems
 What do we mean by Integrated healthcare
 Understanding the architecture and standards to deliver interoperability
 A normalised clinical data repository model
 Why has Oracle entered this market?
The healthcare marketplace
Enabling the healthcare enterprise…
Suppliers
Pharmaceutical
Payers /
Regulators
Medical Eqpt
Distributor/
Wholesaler
Biotech
Employer
Other
Payer
Outpatient
Primary
Care
Hospitals
Physicians
Regulatory
Agency
Integrate
d
Networks
Providers
Patients
Why deliver integrated healthcare?
Reducing Medical Errors
 Between 50,000 and 100,000 deaths each year are attributable to
adverse drug events (ADEs).1
 Computerised Physician Order Entry can play a significant role
decreasing the number of ADEs.2
“The report (Audit Commission, Spoonful of Sugar) estimates that adverse drug
events might cost the NHS in the UK £1.1 billion per year. It also cites
evidence to suggest that improved information systems could avoid 78% of
transcription errors that lead to such adverse drug events.”
A Patient is at a higher risk of an ADE than of loosing their
luggage when travelling!
1 “To Err is Human”, Institute of Medicine, 1999
2 “Crossing the Quality Chasm”, Institute of Medicine, 2001
A Simple Case
 SP, a 38 year old businessman
 14/08 – donates blood; hematocrit 45
 21/08 – visits GP; obtains prescription for sulindac, an anti-inflammatory
agent
 10/10 – in traffic accident
– Visits emergency room
– hematocrit is 40
10% drop in Hematocrit could indicate gastro-intestinal bleeding….
Beginning a Transaction Chain
 As clinicians speak with and examine patients, they also begin to develop plans of
care.
.
?
I need a chest
X ray for
Mr Smith.
Following a Transaction Chain
 A clinical thought can spawn a series of clinical activities.
Schedule
chest x ray
Check room,
equipment
availability
Check
technician
availability
Perform
procedure
Order
chest x ray
Place image
in radiologist
work queue
I need a chest
x ray for
Mr Smith.
Report
result
Interpret
study
Following a transaction chain
 A clinical thought can spawn a series of clinical and business activities.
Schedule
chest x ray
Check room,
equipment
availability
Check
technician
availability
Perform
procedure
Submit
facilities
charge
Order
chest x ray
Verify insurance
coverage for
chest x ray
I need a chest
x ray for
Mr Smith.
Interpret
study
Report
result
Submit
professional
fee
Reimburse
providers
Creating an Transaction Entity
 When a clinical thought is entered in an EHR application as a part of a clinical
plan, a medical entity-attribute complex should be created.
Order for
chest x ray
Ordered by
James Miller, MD
prv 56647-9
I need a chest
x ray for
Mr Smith.
X-ray, chest
rt 3766207
12/04/05
0900.34.33
tr 334678898373
Ordered for
Marshall Smith
mpi 885757439
Standardising Transactions
 All clinical and business events need to reference all or part of the complex.
Schedule
chest x ray
Check room,
equipment
availability
Check
technician
availability
Perform
procedure
Order
chest x ray
Place image
in radiologist
work queue
I need a chest
x ray for
Mr Smith.
Report
result
Interpret
study
Work vs medical entities
Work Activities
Schedule
Draw
Order
FBC
Send
Order to
Lab
Medical Entities
Draw
Process
Specimen
Specimen
to Lab
Receive
Lab result
RBC
WBC
Hg
Done
Constructing the System
 A pervasive information model allows many parties to contribute to the EHR.
Ancillary results
Clinician orders and
observations
v o
Devices
c a
v o c a
b
u l
b u l
a
a
r
y
r y
Patient
input
Interoperability is more than exchange
HL7 Mission Statement:
“Develop specifications for and that support interoperability in
healthcare, i.e. “computer systems exchanging information in
the healthcare space will predictably compute on the exchanged
information based on an agreed upon set of specifications
defining the structure and meaning of the exchanged
information.”
Enforcing interoperability
 Interoperability
“Ability
of two or more systems or
components to exchange information and
to use the information that has been
exchanged”
Semantic
interoperability
IEE Standard Computer Dictionary, IEE, 1990
Functional
interoperability
Syntax and Semantics
– Syntax vs Semantics
• Syntax  structure
• Semantics  meaning
–
–
–
–
Time flies like an arrow.
Fruit flies like a banana. (no meaning)
Give pain medication.
Give medication for pain.
different syntaxes can have same meaning
What is Interoperability?
– Interoperability:
• “The ability of one or more systems to exchange
data/information and to be able to utilise the exchanged
information. ” (IEEE, 1990)
– Exchange information  syntactic interoperability
• Systems recognize the structure of the data
– Utilise information  semantic interoperability
• Systems understand the meaning of the information
– “Healthcare is a business in which information exchange is
the norm, not the exception.”
(Bob Herbold, Microsoft COO)
What is the HL7 RIM?
 The RIM (Reference Information Model) is
documentation of information from the healthcare
domain.
 It is used as a common reference for the data content of
all HL7 version 3 standards.
 The RIM has graphical expression and an
accompanying data dictionary.
 It is expressed using the Unified Modeling Language
notation.
Why Build a Reference Information Model?
Healthcare Interoperability  The Electronic Health Record
• ‘A cradle-to-grave collection of all of a person’s
healthcare transactions’
• ‘The integration of clinical, administrative, and financial
information’
• ‘Converting from sickness care to health maintenance’
• ‘Evidence-based healthcare’
• ‘Outcomes-based healthcare’
• ‘Providers assuming the risk for healthcare’
• ‘Patients receive healthcare services at a number of
points in time and space’s
Why Build a Reference Information Model?
– To achieve any / all of these goals, we must have a set of
standards that enable healthcare system interoperability at both
the functional (syntactic) and operational (semantic) level.
– The RIM is a structural standard
• Defines Concepts
• Defines Attributes of Concepts
• Defines Relationships between Concepts
– Semantic interoperability ?
• V2.x: In principle but not in fact
• No standard structures to facilitate reuse across multiple
healthcare domains
• No formal interface to external terminologies
• ‘Bottom-up’ message development process
The RIM’s Value Proposition
 The RIM is ‘more than just the basis for a messaging model’
 It is also a knowledge repository containing
 Concepts
 Relationships
 Cross-domain knowledge
 World-wide depth and breath of input
 An emerging ANSI and ISO standard in and of itself (i.e. separate from
the V3 messaging standard per se)
 The RIM is increasingly being used as a source set of abstractions
and relationships around which to build logical data models which
can, in turn, support real-work healthcare information systems from
both a clinical and/or an administrative/financial perspective.
Core concepts of RIM
 Every happening is an Act
• Procedures, observations, medications, supply, registration,
etc.
 Acts are related through an Act_relationship
• composition, preconditions, revisions, support, etc.
 Participation defines the context for an Act
• author, performer, subject, location, etc.
 The participants are Roles
• patient, provider, practitioner, specimen, healthcare facility
etc.
 Roles are played by Entities
• persons, organizations, material, places, devices, etc.
Reference Information Model
Class Diagram
Language_communication
language_cd : CE
mode_cd : CE
proficiency_level_cd : CE
preference_ind : BL
Entity
class_cd : CS
determiner_cd : CS
id : SET<II>
cd : CE
communicates_withqty : SET<PQ>
nm : BAG<EN>
1 desc : ED
status_cd : SET<CS>
existence_time : IVL<TS>
telecom : BAG<TEL>
risk_cd : CE
1..n handling_cd : CE
importance_status_txt : ED
serves
used_by
0..n
plays
is_played_by
0..1
scopes
0..n
is_scoped_by
0..1
1
Role
class_cd : CS
id : SET<II>
cd : CE
negation_ind : BL
addr : BAG<AD>
telecom : BAG<TEL>
status_cd : SET<CS>
effective_time : IVL<TS>
certificate_txt : ED
qty : RTO
position_nbr : LIST<INT>
0..n
0..n
is_target_for
1
Role_link
has_target type_cd : CS
0..n
effective_time : IVL<TS>
is_source_for
has_source
Participation
type_cd : CS
function_cd : CD
context_control_cd : CS
sequence_nbr : INT
note_txt : ED
time : IVL<TS>
mode_cd : CE
awareness_cd : CE
has_as_participant
signature_cd : CS
signature_txt : ED
0..n
for
has
0..n
1
Participation
participates_in
1
Managed_participation
id : SET<II>
status_cd : SET<CS>
Act
class_cd : CS
mood_cd : CS
id : SET<II>
cd : CD
negation_ind : BL
txt : ED
status_cd : SET<CS>
effective_time : GTS
activity_time : GTS
availability_time : TS
priority_cd : SET<CE>
confidentiality_cd : SET<CE>
repeat_nbr : IVL<INT>
interruptible_ind : BL
context_lock_ind : BL
independent_ind : BL
reason_cd : SET<CE>
language_cd : CE
is_source_for
has_source
1
0..n
is_target_for
has_target
1
0..n
Act_relationship
type_cd : CS
inversion_ind : BL
context_control_cd : CS
sequence_nbr : INT
priority_nbr : INT
pause_qty : PQ
checkpoint_cd : CS
split_cd : CS
join_cd : CS
negation_ind : BL
conjunction_cd : CS
originates_in_context_of
1..*
Living_subject
administrative_gender_cd : CE
birth_time : TS
deceased_ind : BL
deceased_time : TS
multiple_birth_ind : BL
birth_order_nbr : INT
organ_donor_ind : BL
0..*
Entity_heir
Organization
addr : BAG<AD>
standard_industry_class_cd : CE
Entity
Material
form_cd : CE
Manufactured_material
lot_nm : ST
expiration_time : TS
stability_time : IVL<TS>
Place
mobile_ind : BL
addr : AD
directions_txt : ED
position_txt : ED
gps_txt : ST
Person
addr : BAG<AD>
marital_status_cd : CE
education_level_cd : CE
ambulatory_status_cd : CE
disability_cd : CE
living_arrangement_cd : CE
religious_affiliation_cd : CE
special_accommodation_cd : SET<CE>
race_cd : SET<CE>
ethnic_group_cd : SET<CE>
Non_Person_living_subject
taxonomic_classification_cd : CE
breed_cd : CE
strain_txt : ED
gender_status_cd : CE
euthanasia_ind : BL
Device
manufacturer_model_nm : ST
software_nm : ST
local_remote_control_state_cd : CE
alert_level_cd : CE
last_calibration_time : TS
Container
capacity_qty : PQ
height_qty : PQ
diameter_qty : PQ
cap_type_cd : CE
separator_type_cd : CE
barrier_delta_qty : PQ
bottom_delta_qty : PQ
Imaging_modality
pixel_intensity_relationship_cd : CE
spacial_resolution_qty : PQ
pixel_padding_qty : PQ
Role_heir
Employee
job_cd : CE
job_title_nm : ST
job_class_cd : CE
salary_type_cd : CE
salary_qty : MO
hazard_exposure_txt : ED
protective_equipment_txt : ED
Certified_entity
recertification_time : TS
Guarantor
credit_rating_cd : CE
Role
Patient
confidentiality_cd : CE
very_important_person_cd : CE
Access
approach_site_cd : CD
target_site_cd : CD
gauge_qty : PQ
Schedulable_resource
slot_size_increment_qty : PQ
served_by
Enitites
Device_task
parameter_value : LIST<ANY>
Referral
authorized_visits_qty : REAL
Roles
Infrastructure (Structured
documents)
Control_event
: II
Transmission
creation_time : TS
id : II
is_contained_by security_txt : ST
0..*
Infrastructure (Message
control)
–persons
–organizations
–material
–places
–devices
–Etc.
Billboard produced by:
Rochester Outdoor Advertising
Public_health_case
detection_method_cd : CE
transmission_mode_cd : CE
disease_imported_cd : CE
Act_heir
Financial_act
net_amt : MO
Account
nm : ST
currency_cd : CE
interest_rate_qty : RTO<MO,PQ>
allowed_balance_qty : IVL<MO>
Financial_contract
payment_terms_cd : CE
provides_context_for
Act_context
level_cd : CE
Invoice_element
modifier_cd : CE
unit_qty : PQ
unit_price_amt : RTO<MO,PQ>
factor_nbr : REAL
points_nbr : REAL
coverage_source_cd : CE
notify_subject_ind : BL
Financial
Acts
Financial_transaction
credit_exchange_rate_qty : REAL
debit_exchange_rate_qty : REAL
interest_rate_qty : RTO
1
0..n
is_communicated_as
Attention_line
key_word_txt : ST
: ST
may_have 1
can_include can_accompany
value
Query_event
query_id : II
0..1
Batch
nm : ST
reference_control_id : II
batch_total_nbr : SET<INT>
batch_comment : SET<ST>
transmission_qty : INT
Context_structure
local_id : ST
response_cd : CS
1..*
1
Clinical_document
set_id : II
version_nbr : INT
completion_cd : CE
storage_cd : CE
copy_time : TS
has_payload
Sort_control
element_nm : ST
sequence_nbr : INT
direction_cd : CS
is_for
0..n
1
is_acknowledged_by
Query_ack
query_response_cd : CS
message_query_cd : CE
result_total_qty : INT
result_current_qty : INT
result_remaining_qty : INT
Query_spec
execution_and_delivery_time : TS
initial_qty : INT
has
initial_qty_cd : CE
message_query_cd : CE
1
modify_cd : CS
response_modality_cd : CS
response_priority_cd : CS
response_element_group_id : SET<II>
acknowledges
0..*
Acknowledgement
type_cd : CS
note_txt : ED
error_detail_cd : CE
expected_sequence_nbr : INT
is_part_of
Parameter
has
nm : ST
is_parameter_of
id : II
0..n
0...
–patient
–provider
–Practitioner
–Specimen
–Etc.
0..n
may_contain
0..1
Parameter_list
Query_by_parameter
Parameter_item
value : ANY
semantics_txt : ST
Query_by_selection
Table_structure
halign : CS
char : ST
charoff : ST
valign : CS
local_id : ST
1
Table
rules : CS
cellspacing : ST
cellpadding : ST
summary : ST
width : ST
border : INT
frame : CS
Local_attr
name : ST
value : ST
Query_continuation
continuation_qty : INT
start_result_nbr : INT
•Roles participate in Acts
occurs_with
0..1
occurs_with
0..1
0..n
Message
accept_ack_cd : CS
application_ack_cd : CS
attachment_txt : ED
interaction_id : II
processing_cd : CS
processing_mode_cd : CS
profile_id : SET<II>
sequence_nbr : INT
version_id : ST
Acts (Clinical)
Acts (Financial)
Diagnostic_image
subject_orientation_cd : CE
0..1 structure_type_id
executed_by
executes
has
•Entities play roles
Observation
value : ANY
interpretation_cd : SET<CE>
method_cd : SET<CE>
target_site_cd : SET<CD>
derivation_expr : ST
Infrastructure (Structured documents)
Communication_function
type_cd : CS
telecom : TEL
contains
Working_list
ownership_level_cd : CE
Substance_administration
route_cd : CE
approach_site_cd : SET<CD>
dose_qty : IVL<PQ>
rate_qty : IVL<PQ>
dose_check_qty : SET<RTO>
max_dose_qty : SET<RTO>
potency_qty : PQ
substitution_cd : CE
Clinical
Acts
Procedure
method_cd : SET<CE>
approach_site_cd : SET<CD>
target_site_cd : SET<CD>
Assigned_entity
position_cd : CE
primary_care_ind : BL
0..n
Version reflects RIM changes through Harmonization on
03/07/2002 that were approved for implementation following the
release of the second committee-level ballot of Version 3.
Diet
energy_qty : PQ
carbohydrate_qty : PQ
Message Control
0..*
HEALTH LEVEL 7
REFERENCE INFORMATION MODEL
VERSION 1.15 (RIM_0115)
Supply
qty : PQ
expected_use_time : IVL<TS>
Patient_encounter
acuity_level_cd : CE
admission_source_cd : CE
birth_encounter_ind : BL
discharge_disposition_cd : CE
length_of_stay_qty : PQ
pre_admit_test_ind : BL
referral_source_cd : CE
special_courtesies_cd : SET<CE>
urgency_cd : CE
valuables_desc : ED
valuables_location_desc : ED
Link_html
title : ST
name : ST
href : ED
rel : SET<CE>
rev : SET<CE>
•Participation defines •Acts are everything
that happens
the context of an Act
0..n
is_for
has_ex pression
Relational_expression
element_nm : ST
value : ST
relational_operator_cd : CS
Table_cell
rowspan : INT
colspan : INT
abbr : ST
axis : ST
headers : SET<ED>
scope : CS
1
Selection_expression
has_right_side
1
has_left_side
is_lhs_for
is_rhs_for
0..n
–Author
–Performer
–Subject
–Location
–Etc.
0..n
Logical_expression
relational_conjunction_cd : CS
Table_column_structure
span : INT
width : ST
Local_markup
ignore_cd : CS
descriptor : ST
render : ST
–Procedures
–Observations
–Medications
–Registration
–Etc.
Deriving the RIM Backbone
The Essential Structures of Healthcare
• A Healthcare Action can be the source of zero-to-many
Healthcare Relationships, each of which relate the source
Healthcare Action to one-and-only one other Healthcare Action
(the target action).
AR:
“is supported
by”
ACT:
Dx Pneumonia
is source for
AR:
“is supported
by”
AR:
“is supported
by”
has target
ACT:
Temp 101F
has target
ACT:
Abnormal
CXR
has target
ACT:
Elevated
WBC
A Simple Case
 SP, a 38 year old businessman
 14/08 – donates blood; hematocrit 45
 21/08 – visits GP; obtains prescription for sulindac, an anti-inflammatory
agent
 10/10 – in traffic accident
– Visits emergency room
– hematocrit is 40
10% drop in Hematocrit could indicate gastro-intestinal bleeding….
A normalised clinical data repository model
Any clinician, with appropriate authorization from the patient and
permissions from the system, can view clinical data
Viewing
Application
?
Rules
Engine
?
R EA L
•
•
•
•
Centralized
Data
Repository
DATA
Message Processing
Person Management
Terminology Management
Security, authentication
CDR
10/10
14/08
21/08
Blood bank
Local
Systems
Notification
GP office
21/08
Pharmacy
10/10
10/10
ER
Radiology
Lab
A normalised clinical data repository model
Viewing
Application
Any clinician, with appropriate authorization from the patient and
permissions from the system, can view clinical data
Notification
Consent
R EA L
•
•
•
•
Centralized
Data
Repository
Blood bank
Local
Systems
DATA
Security
Check
Message Processing
Person Management
Terminology Management
Security, authentication
GP office
Pharmacy
CDR
ER
Radiology
Lab
Why has Oracle entered this market?






Oracle has the fundamental infrastructure
Growing need for electronic health records (EHR)
Regulations for data standards, security, confidentiality
Growing awareness of the need to re-use clinical data
HL7 standards movement
The other guys cannot do it
The implications of our approach:




Evolve Oracle’s database functionality into a health care platform
Deploy the ideal model for multi-centered systems, including those with
regional, and national responsibilities
Occupy the center of the clinical data re-use, data exchange and
warehouse business
Offer the most efficient solutions for dealing with legacy systems
Scalability and performance
A foundation for healthcare
 Enables interoperability and meaningful data integration
 Built to support large, complex healthcare communities as
well as single hospitals
 Standards-based, open architecture
 Adaptive development, integration and operation platform
 Leverages Oracle’s core expertise and products
 Global platform
Healthcare Transaction Base (HTB)
Making E-Health work
“Knowledge of what is possible is the
beginning of happiness”
George Santayana (1863 - 1952)
US (Spanish-born) philosopher
Jeremy R L Nettle
European Healthcare Director
Oracle Corporation UK Ltd
[email protected]
April 2005
The Healthcare Transaction Base
QUESTIONS
ANSWERS