HL7 & Health Information Exchange in Thailand

HL7 & Health Information Exchange in Thailand

Nawanan Theera-Ampornpunt, M.D., Ph.D.Faculty of Medicine Ramathibodi Hospital

Mahidol University, ThailandJune 24, 2014

www.SlideShare.net/Nawanan

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A Bit About Myself...2003 M.D. (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)2012 Certified HL7 CDA Specialist• Lecturer, Department of Community Medicine• Deputy Executive Director for Informatics

(CIO/CMIO), Chakri Naruebodindra Medical InstituteFaculty of Medicine Ramathibodi Hospital

nawanan.the@mahidol.ac.thhttp://groups.google.com/group/ThaiHealthIT

Research interests:• EHRs & health IT applications in clinical settings• Health IT adoption & eHealth development• Health informatics education & workforce development

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Outline

• Needs for better information in healthcare• eHealth as a health system's component• Thailand's eHealth situation• Standards & interoperability• HL7 standards• The road ahead for Thailand's eHealth

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Needs for Better Information

in Healthcare

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“Information” in Medicine

Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.

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Needs for Better Information

• Good information needed for quality care– Past and present history– Medication list– Problem list– Allergies– Lab & imaging results

• Information gaps prevalent in healthcare settings (e.g. Stiell A et al. CMAJ. 2003;169:1023-8.)

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(IOM, 2001)(IOM, 2000) (IOM, 2011)

Landmark IOM Reports

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• Humans are not perfect and are bound to make errors

• Highlight problems in U.S. health care system that systematically contributes to medical errors and poor quality

• Recommends reform• Health IT plays a role in improving patient

safety

IOM Reports Summary

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• Medication Errors

– Drug Allergies

– Drug Interactions

• Ineffective or inappropriate treatment

• Redundant orders

• Failure to follow clinical practice guidelines

Common Errors

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Back to something simple...

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To treat & to care for their patients to their best abilities, given limited time & resources

Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)

What Clinicians Want?

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The Question Becomes...

How do we deliver better information, by supplementing

human clinicians with ICT, so that they make less errors and

perform better?

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Outline

Needs for better information in healthcare• eHealth as a health system's component• Thailand's eHealth situation• Standards & interoperability• HL7 standards• The road ahead for Thailand's eHealth

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eHealth as a Health System

Component

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WHO (2009)

Components of Health Systems

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WHO (2009)

WHO Health System Framework

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Use of information and communications technology (ICT) for health; Including

• Treating patients• Conducting research• Educating the health workforce• Tracking diseases• Monitoring public health.

Sources: 1) WHO Global Observatory of eHealth (GOe) (www.who.int/goe)2) World Health Assembly, 2005. Resolution WHA58.28

Slide adapted from: Mark Landry, WHO WPRO & Dr. Boonchai Kijsanayotin

eHealth

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All components are essential All components should be balanced

Slide adapted from: Dr. Boonchai Kijsanayotin

eHealth Components: WHO-ITU Model

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Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Goal: Health Information Exchange

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Outline

Needs for better information in healthcareeHealth as a health system's component• Thailand's eHealth situation• Standards & interoperability• HL7 standards• The road ahead for Thailand's eHealth

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Thailand’s eHealth Situation

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eHealth in Thailand: The current status. Stud Health Technol Inform 2010;160:376–80, Presented at MedInfo2010 South Africa

Thailand’s eHealth: 2010

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All components are essential All components should be balanced

Slide adapted from: Dr. Boonchai Kijsanayotin

Recalling eHealth Components

24Slide adapted from: Dr. Boonchai Kijsanayotin

Thailand: Unbalanced Development

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Silo-type systems Little integration and interoperability Mostly aim for administration and management 40% of work-hours spent on managing reports and

documents Lack of national leadership and governance body Inadequate HIS foundations development

Boonchai Kijsanayotin et al. (2010)

Thailand’s eHealth Situation

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eHealth Components

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Nationwide survey on hospital IT adoption conducted in 2011

THAIS: Thai Hospitals’ Adoption of Information Technology Survey

Self-administered paper-based survey mailed to 1,298 hospitals in Thailand

Thailand’s Hospital IT Adoption

28Pongpirul et al., 2004

Vendor/Product Distribution (2004)

29Theera-Ampornpunt, 2011

Vendor/Product Distribution (2011)

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Estimate (Partial or Complete Adoption)

Nationwide

Basic EHR, outpatient 86.6%Basic EHR, inpatient 50.4%Basic EHR, both settings 49.8%Order entry of medications, outpatient

96.5%

Order entry of medications, inpatient 91.4%Order entry of medications, both settings

90.2%

Hospital IT Adoption Estimates

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• High IT adoption rates• Drastic changes in adoption landscape• Adequate infrastructure for information

exchange• Next question is on interoperability

THAIS: Discussion

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eHealth Components

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Outline

Needs for better information in healthcareeHealth as a health system's componentThailand's eHealth situation• Standards & interoperability• HL7 standards• The road ahead for Thailand's eHealth

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Standards Are Everywhere

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Standards: Why?

• The Large N ProblemN = 2, Interface = 1

# Interfaces = N(N-1)/2

N = 3, Interface = 3

N = 5, Interface = 10

N = 100, Interface = 4,950

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Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Goal: Health Information Exchange

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Objectives• Interoperability• Inter-operable

systems

Ultimate Goals• Continuity of Care• Quality Safety Timeliness Effectiveness Equity Patient-Centeredness

Efficiency

Why Health Information Standards?

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Levels of Interoperability

Functional

Semantic

Syntactic

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Various Kinds of Standards

• Unique Identifiers• Standard Data Sets• Vocabularies & Terminologies• Exchange Standards

– Message Exchange– Document Exchange

• Functional Standards• Technical Standards

– Data Communications, Encryption, Security

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Functional

Semantic

Syntactic

How Standards Support Interoperability

Technical Standards (TCP/IP, encryption,

security)

Exchange Standards (HL7 v.2, HL7 v.3 Messaging, HL7 CDA,

DICOM)

Vocabularies, Terminologies, Coding Systems (ICD-10, ICD-9,

CPT, SNOMED CT, LOINC)

Information Models (HL7 v.3 RIM, ASTM CCR, HL7 CCD)

Standard Data Sets

Functional Standards (HL7 EHRFunctional Specifications)

Some may be hybrid: e.g. HL7 v.3, HL7 CCD

Unique ID

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Message Exchange

• Goal: Specify format for exchange of data

• Internal vs. external messages

• Examples HL7 v.2 HL7 v.3 Messaging DICOM NCPDP

Document Exchange

• Goal: Specify format for exchange of “documents”

• Examples HL7 v.3 Clinical Document

Architecture (CDA) ASTM Continuity of Care

Record (CCR) HL7 Continuity of Care

Document (CCD)

Exchange Standards

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Messages

• Human Unreadable• Machine Processable

Clinical Documents

• Human Readable• (Ideally) Machine

Processable

Exchange Standards

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Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Message Exchange

Message

Message

Message

Message Message

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Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Clinical Document ExchangeMessage containing

Referral Letter

Message containing Claims Request

Message containing Lab Report

Message containing Patient Visit Summary

Message containing Communicable Disease Report

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Standards National

1. Core data set standards 12 & 18 files standards

2. Semantic standards Personal ID, Provider ID

ICD-10-TM, ICD-9-CM3. Syntactic standards X

4. Security and privacy standards X

Slide adapted from: Dr. Boonchai Kijsanayotin

Existing Standards in Thailand

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Standards National

1. Core data set standards Referral, Chronic Diseases

2. Semantic standardsDrug Terminology (TMT),

SNOMED-CTLab Code (LOINC)

Providers IDs

3. Syntactic standards HL7 Messaging, CDA

4. Security and privacy standards X

Standards Being Explored/Developed

Slide adapted from: Dr. Boonchai Kijsanayotin

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Thai Health Information Standards Development Center

www.this.or.thhttp://www.facebook.com/thishsrithis@this.or.th

Standards Development Organization

Slide adapted from: Dr. Boonchai Kijsanayotin

4848

eHealth & e-Transactions

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• HL7 Certified Specialists

Kevin Asavanant

HL7 V3 RIM (2009)

SupachaiParchariyanonHL7 CDA (2010)

NawananTheera-Ampornpunt

HL7 CDA (2012)

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SireeratSrisiriratanakul

HL7 V3 RIM (2013)

Capacity Building on Standards

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URGES Member States:(1) to consider, as appropriate, options to collaborate with

relevant stakeholders, including national authorities, relevant ministries, health care providers, and academic institutions, in order to draw up a road map for implementation of ehealth and health data standards at national and subnational levels;

(2) to consider developing, as appropriate, policies and legislative mechanisms linked to an overall national eHealthstrategy, in order to ensure compliance in the adoption of ehealthand health data standards by the public and private sectors, as appropriate, and the donor community, as well as to ensure the privacy of personal clinical data;... http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf

World Health Assembly Resolution WHA66.24 (2013) on eHealth Standardization & Interoperability

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Outline

Needs for better information in healthcareeHealth as a health system's componentThailand's eHealth situationStandards & interoperability• HL7 standards• The road ahead for Thailand's eHealth

What is HL7?

• HL7 is an ANSI-accredited Standards Development Organization (SDO) operating in the healthcare arena.

• It is a non-profit organization made up of volunteers – providers, customers, vendors, government, etc.

52Slide adapted from: Dr. Supachai Parchariyanon

What is HL7? (Cont.)

• HL7 is an acronym for Health Level Seven– Seven represents the highest, or “application”

level of the International Standards Organization (ISO) communications model for Open Systems Interconnection (OSI) networks.

53Slide adapted from: Dr. Supachai Parchariyanon

OSI Model

54Slide adapted from: Dr. Supachai Parchariyanon

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HL7 Standards

• HL7 V2.x– Defines electronic messages supporting hospital

operations• HL7 V3• HL7 Clinical Document Architecture

(CDA) Releases 1 and 2• HL7 Arden Syntax

– Representation of medical knowledge• HL7 EHR & PHR Functional Specifications• Etc.

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HL7 V3 Standards

• A family of standards based on V3information models and development methodology

• Components– HL7 V3 Reference Information Model (RIM)– HL7 V3 Messaging– HL7 Development Framework (HDF)

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Sample HL7 v.2 Message (Lab Result)

OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml|0-1.3|H||H|F|19980309…

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Sample HL7 v.3 Message (Patient Registration)<?xml version="1.0" encoding="UTF-8"?><PRPA_IN101311UV02 xmlns="urn:hl7-org:v3"

xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" ITSVersion="XML_1.0" xsi:schemaLocation="urn:hl7-org:v3../schemas/PRPA_IN101311UV02.xsd">...<name use="SYL" >

<given>นวนรรน</given><family>ธรีะอมัพรพนัธุ</family>

</name><name use="ABC">

<given>Nawanan</given><family>Theera-Ampornpunt</family>

</name><administrativeGenderCode code="M"/>

...</PRPA_IN101311UV02>

Message source adapted from Ramathibodi HL7 Project by Supachai Parchariyanon, Kavin Asavanant, Sireerat Srisiriratanakul & Chaiwiwat Tongtaweechaikit

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HL7 Reference Information Model (RIM)

Source: HL7 CDA R2

60Source: “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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HL7 V3 Messaging

• V3 provides messaging standards for– Patient administration– Medical records– Orders– Laboratory– Claims & Reimbursement– Care provision– Clinical genomics– Public Health– Etc.

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What Is HL7 CDA?

• “A document markup standard that specifies structure & semantics of “clinical documents” for the purpose of exchange” [Source: HL7 CDA Release 2]

• Focuses on document exchange, not message exchange

• A document is packaged in a message during exchange

• Note: CDA is not designed for document storage. Only for exchange!!

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A Clinical Document (1)

• A documentation of clinical observations and services, with the following characteristics: Persistence - continues to exist in an

unaltered state, for a time period defined by local and regulatory requirements Stewardship - maintained by an organization

entrusted with its care Potential for authentication - an assemblage

of information that is intended to be legally authenticated Source: HL7 CDA R2

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A Clinical Document (2)

• A documentation of clinical observations and services, with the following characteristics: Context - establishes the default context for its

contents; can exist in non-messaging contexts Wholeness - Authentication of a clinical

document applies to the whole and does not apply to portions of the document without full context of the document Human readability - human readable

Source: HL7 CDA R2

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A Clinical Document (3)

• A CDA document is a defined & complete information object that can include Text Images Sounds Other multimedia content

Source: HL7 CDA R2

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CDA Releases

• CDA Release 1 (ANSI-approved in 2000)– First specification derived from HL7 RIM

• CDA Release 2 (2005) - Current Release– Basic model essentially unchanged from R1

• Document has a header & a body• Body contains nested sections• Sections can be coded using standard vocabularies and can

contain entries

– Derived from HL7 RIM Version 2.07

Source: HL7 CDA R2

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Key Aspects of CDA

• CDA documents are encoded in XML When alternative implementations are feasible,

new conformance requirements will be issued• CDA documents derive their machine

processable meaning from HL7 RIM and use HL7 V3 Data Types

• CDA specification is richly expressive & flexible Templates can be used to constrain generic

CDA specificationsSource: HL7 CDA R2

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Scope of CDA

Lab Technician Physician

Lab Report

Create document

Process & Store

document

Transmit document

CDA

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CDA & HL7 Messages

• Documents complement HL7 messaging specifications

• Documents are defined and complete information objects that can exist outside of a messaging context

• A document can be a MIME-encoded payload within an HL7 message

Source: “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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CDA & Message Exchange

• CDA can be payload (or content) in any kind of message– HL7 V2.x message– HL7 V3 message– EDI ANSI X12 message– IHE Cross-Enterprise Document Sharing (XDS)

message

• And it can be passed from one kind to another

Source: “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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CDA & Message Exchange

Clinical Document (Payload)

HL7 V3 Message (Message)

HL7 V2 Message (Message)

Source: Adapted from “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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CDA As Payload

Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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CDA Model

Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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A Closer Look at a CDA Document

<ClinicalDocument> ... CDA Header ...<structuredBody> <section> <text>... Single Narrative Block ...</text> <observation>...</observation> <substanceAdministration> <supply>...</supply> </substanceAdministration> <observation> <externalObservation>... </externalObservation> </observation> </section> <section> <section>...</section> </section> </structuredBody> </ClinicalDocument>

Source: HL7 CDA R2

Human Readable Part

Machine Processable Parts

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Rendering CDA Documents (1)

Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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Rendering CDA Documents (2)

Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012

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Human Readability & Rendering CDA Documents (3)

Source: HL7 CDA R2

<ClinicalDocument> ... CDA Header ...<structuredBody> <section> <text>... Single Narrative Block ...</text> <observation>...</observation> <substanceAdministration> <supply>...</supply> </substanceAdministration> <observation> <externalObservation>... </externalObservation> </observation> </section> <section> <section>...</section> </section> </structuredBody> </ClinicalDocument>

Text to be rendered

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Some Possible Use Cases of CDA

Intra-institutional Exchange of parts of medical records (scanned or

structured electronic health records) Lab/Imaging requests & reports Prescriptions/order forms Admission notes Progress notes Operative notes Discharge summaries Payment receipts Other forms/documents (clinical or administrative)

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Some Possible Use Cases of CDA

Inter-institutional Referral letters Claims requests or reimbursement documents External lab/imaging reports Visit summary documents Insurance eligibility & coverage documents Identification documents Disease reporting Other administrative reports

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Achieving Interoperability

CDA is a general-purpose, broad standard Use in each use case or context requires

implementation guides to constrain CDA Examples Operative Note (OP) Consultation Notes (CON) Care Record Summary (CRS) Continuity of Care Document (CCD) CDA for Public Health Case Reports (PHCRPT) Quality Reporting Document Architecture (QRDA)

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Outline

Needs for better information in healthcareeHealth as a health system's componentThailand's eHealth situationStandards & interoperabilityHL7 standards• The road ahead for Thailand's eHealth

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Back to Thailand’s eHealth status: Workforce

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eHealth Components

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• Certificate & Diploma Level• Undergraduate Level• Graduate Level

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Informatics Workforce Programs

85Faculty of Medicine Ramathibodi Hospital, Mahidol University

http://med.mahidol.ac.th/has/85

Healthcare CIO Certificate Program

86Faculty of Tropical Medicine, Mahidol University86

Diploma & Master Graduates in Biomedical & Health Informatics, First Batch

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• In January 2013, the Thai Medical Informatics Association (TMI) approved establishment of the “Biomedical and Health Informatics Education Special Interest Group” within TMI (BHI-ED-SIG)

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Informatics Education SIG

8888

TMI CIO Forum

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• International Medical Informatics Association (IMIA)– MEDINFO & APAMI

• HIMSS AsiaPac• Asia eHealth Information Network (AeHIN)• American Medical Informatics Association

(AMIA)

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Internationalization

90http://www.aehin.org/Meetings/2013AeHINGeneralMeeting.aspx90

Participation in AeHIN

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Outline

Needs for better information in healthcareeHealth as a health system's componentThailand's eHealth situationStandards & interoperabilityHL7 standards• The road ahead for Thailand's eHealth

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The Road Ahead for Thailand’s eHealth

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• Addressing– Lack of national leadership & governance,

strategy & investment, policy & regulation– Shortage of informatics workforce– Accelerating standards development– Harmonizing applications– Facilitating local research in informatics

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The Road Ahead

94Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/

The Journey Beyond

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But We’ll Get There...