The Lombardy Region Electronic Health Record

Milan, 18 November 2010

The Lombardy Region Electronic Health RecordThe Lombardy Region Electronic Health Record

Milan, 18 November 2010

Nicola ContardiSISS Department – Development Manager

Summary

The Lombardy Region

The SISS Program

The EHR

The Challenges

2

The Lombardy Region

The SISS Program

The EHR

The Challenges

Summary

3

Lombardy Region

• Is one of the twenty Italian Regions• About 16% of Italy’s citizens• Is one of the most populated Regions of Europe (more

populated than 14 EU member States)• Its GNP is about 20% of Italy’s GNP

4

The Lombardy Region

The SISS Program

The EHR

The Challenges

Summary

5

• 9.900.000 Citizens (99% of total)

• 150.000 Health & Social Care Operators

• 7.800 General Practitioners (97%)

• 2.600 Pharmacies (100%)

SISS in numbers

6

• 2.600 Pharmacies (100%)

• 35 Public Hospitals (100%)

• 15 Local Healthcare Units (100%)

• Over 2500 Private Healthcare Service Suppliers (15%)

ASL

Hospital

ASLASL

Hospital

The underlying philosophySISS is a Regional Healthcare Information Network ; the Citizen is its centre .All the data are gathered, organized and reported on the basis of the citizen’s clinical treatment within the Regional Healthcare Network.

Healthcare DataHealthcare Data

Administrative DataAdministrative Data

General Practiotioner

Practitioner

Healthcare Local Unit

Pharmacy

Healthcare DataHealthcare Data

Administrative DataAdministrative Data

General Practiotioner

Practitioner

Healthcare Local Unit

Pharmacy

Data WareHouseCluster of Patients

Electronic Health RecordVision per single Patient

Data WareHouseCluster of Patients

Electronic Health RecordVision per single Patient

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SISS – The Model

Electronic Health

Record

Services for the

Citizen

Dematerialization

System Governance

SISS PLATFORM

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Pharmacies

Care Homes

Private HC

GP

Hospitals

Others

LHU

SISS PLATFORMIntegration with HC Suppliers

The Lombardy Region

The SISS Program

The EHR

The Challenges

Summary

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• Give an integrated and contextualized vision of the health

history of a specific individual

• Increase the efficacy and efficiency of clinical actions

• Make information directly available to the citizen

The SISS EHR - Scope

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• Simplify the activities of health operators

• Interface administrative systems for secondary usage of

information

The SISS EHR: Architecture

Two-level architecture:

Level 1 (Lombardia Informatica):

•Index and “pointers”.

Level 2 (Hospitals/LHU):

HC Supplier

docClinical

HC Supplier

HC SupplierClinicaldoc

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Level 2 (Hospitals/LHU):

•Clinical documents.

Digital DocumentsLHU: Prescriptions, Patient Summary, Vaccination recordsHealth Suppliers: Test Results, Discharge letters, First-aid reports, Pathology Cards, Therapy Plans, …

ASLASLASL

LHU

Events Link

Electronic Health Record

PS

Clinicaldoc

Prescr.

Doctors

The SISS EHR: Content

ASL

Farmacie MMG/PLSEnti Erogatori

RE

P 1

RE

P 2

RE

P n

RE

P 1

RE

P 2

RE

P n

RE

P 1

RE

P 2

RE

P n

EE 1 EE 2 EE n

REPARTO VIRTUALE (Rete di patologia)

LHU

Pharmacies GPHospitals

War

d 1

War

d 2

War

d n

War

d 1

War

d 2

War

d n

War

d 1

War

d 2

War

d n

H 1 H 2 H n

VIRTUAL WARD (Pathology Network)

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PrescriptionsPatient Summary

Vaccinations

PrescriptionsResults“ER” ReportsDischarge Letters

Pathology ChartsDiagnostic Therapy Paths

Electronic Health Record

Patient-centric View

Each document is classified according to its typology (Radiology, Lab, ...), and is qualified by context attributes (date, ward, problem, ...).

The EHR manages documents both in textual and structured (HL7-CDA2) formats.

The SISS EHR: Sources of Data

Preparation and signature of documentsThe specific departmental

Archiving of clinical documents in hospital repository

Publication in EHR

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The specific departmental system (e.g. LIS or RIS) generates the clinical document and submits it for digital signature

repository The system archives the

document, along with the consultation authorisation

The hospital repository publishes the document to the SISS

• Healthcare Episodes (e.g. hospitalisations, “ER”)

• Specialist Consultations: Pathology Networks, Diagnosti c and TherapeuticPaths

• Discipline (cardiology, hematology, ...)

The SISS EHR: Consultation

The EHR permits various routes of interrogation for both doctors and the patient:

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• Discipline (cardiology, hematology, ...)

• Graphical interface (e.g. integrated clinical history over time)

• Clinical document attributes (document type, author, date, hospital, …)

New consultation methods are being studied: problem-oriented consultation, “search engine” for free text searches

75 million Prescriptions (+10%)

5.8 million active EHR

SISS in numbers for 2010 (forecast)

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14 million Electronic Clinical Documents (+18%)

Around 1.2 million Consultations of Clinical

Documents by GP’s (+47%)

Pathology

Networks

Pathology

Networks

Hospital Specialists

Hospital Specialists

EHR Data Sharing

Patient

Summary

Patient

Summary

Diagnostic

and Therapeutic

Paths

Diagnostic

and Therapeutic

Paths

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Hospital Specialists

GP

GP

Hospital Specialists

Regional Social Regional Social Healthcare PlanHealthcare Plan

(PSSR)(PSSR)

Annual DecreeAnnual Decree

Regional Regional DecreeDecree

• Indicators for the level of regional programming and the definition of the implementation of the PSSR• Verify state of implementation• Monitor epidemiological activity• Verify state of implementation of primary and secondary prevention

“Technical Scientific Support”

Commission

“Technical Scientific Support”

Commission

Defines:

EHR Data Sharing: the Lombardy Region program

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Annual DecreeAnnual Decree

Definition of new pathology

networks

� Objectives� Organisation� Components of

experimentation� Resources available

• Guide Lines Proposals• Approriateness indicators definition

• Improvment pathways definition

• Learning modules proposal

• Technical Scientific support to Lombardy Region for pathology health policies

Technical Analysis Group (GAT)

Defines:

Pathology NetworksPathology NetworksTechnical and organisational network consisting of

hospitals and operators active in the cure and assistance of patients in the various phases of illness, with the primary objective of optimising the

assistance of the patient by activating homogeneous care policies throughout the region.

Pathology Networks

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Pathology ArchivesPathology Archives

� Level: Regional� Data: Anonymous

Pathology RegistersPathology Registers

� Level: National� Data: Patient centric

Pathology Network SpecialisationsSCOPE: Gather data with epidemiological ends, to ob tain an in-depth study of the pathology, to define better c are paths

and a better appropriateness of cure .

� ROL – Lombardy Oncology Network� REL – Lombardy Hematological

Network� Hearing Disorder Network� Epilepsy Network� EUOL – Emergency/Urgency

� PMA – Medically Assisted Procreation� TIN – Neonatal Intensive Care� CAV – Anti-venom network� SIDS – Sudden Infant Death Syndrome

PATHOLOGY NETWORKSPATHOLOGY NETWORKS

Pathology Networks: State of the Art and Evolution

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Pathology ArchivesPathology Archives

�IMA – Acute Heart Attack�Stroke Archive

Pathology Pathology RegistriesRegistries

�Rare diseases� Nephrology

The Objective of Diagnostic Therapeutic Paths is to implement Continuity of Assistance according to the Chronic Care Model

An activity of convergence between Pathology Networks and Diagnostic

Therapeutic Paths is

Diagnostic Therapeutic Paths (PDT)Diagnostic Therapeutic Paths (PDT)

GP SPECIALISTS HC OPERATORS PATIENTS

AUTHORISATION MANAGEMENTVERTICAL APPLICATION (e.g. Cardiac Decompensation)

TEXT MESSAGENOTIFICATION NOTIFICATION NOTIFICATION

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First usage of PDT for cardiac decompensation in the Monza/Brianza and Como areas

WIP: Oncological PDT

Therapeutic Paths is under way

NOTIFICATIONSARCHIVE

VERTICAL APPLICATION (e.g. Cardiac Decompensation)

PDT ARCHIVE(documents and

activities)

DOCUMENT TEMPLATE ARCHIVE

NOTIFICATIONS SCHEDULEDOCUMENT ARCHIVE

MANAGEMENT

As defined by the committee of GP’s

Patient SummaryPatient Summary

“An electronic clinical document, digitally signed and published in the EHR, containing the summary of the clinical history and current state of the patient. It is created and updated by the GP each time there are significant variations in the clinical history of the citizen. It contains a

predefined set of clinical data in case of emergency”.

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• Hospitalisation: Information from GP to Specialist

• Emergency Room

• Home care

• GP change

Usage

HL7-CDA2

Digital Signature - PKCS#11

Smart Card

SOA

Standards

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National Standards:

SPCoop

CNS

ICAR - INF.1 e INF.3

HL7 is the chosen standard.It’s adoption is gradual according to the specific level of

consolidation. • Lombardy Region has decided to promote its adoption:

�Step 1: intra-hospital integration;

�Step 2: integration over the SISS Extranet.

Digital documentation: standards (1/2)

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�Step 2: integration over the SISS Extranet.

• Documents currently available are text (PDF) and structured(HL7-CDA2).• Each document in the EHR has a relative electronically signedPDF (PKCS#11).

• Objective: semantic interoperability, i.e.:

� clinical documents structured and encoded in conformancewith HL7-CDA2 standards;

� “import” of structured documents into clinical applications.

• Documents managed : discharge letters and out-patient

Digital documentation: standards (2/2)

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• Documents managed : discharge letters and out-patientreports (pathology networks), patient summary.

• Short-term Evolution : generic discharge letters, “ER” reports,therapy plans, rehabilitation plans, anatomical pathology.

The definition of the lab-test report

(“Implementation Guide” ) in CDA2

format was published by HL7 in 2009.

Since then, Lombardy Region has launched a program such

that all Lombardy HC providers generate HL7-CDA2 lab-test

reports..

- 2 Hospitals generate HL7-CDA2reports.

From 2011 gradual extension over all

Digital documentation: Lab-test reports

EXPERIMENTATION 2010

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Lombardy Region has published a further document, available on the Internet, such that lab-test reports

prpduced conform to:

• Structured in compliance withHL7-CDA2;• “Entry”-level encoding (level 3);• Minimum dataset encodingaccording to LOINC standard.

reports.

- 100 GP’s receive the reports andimport data into personal GP SW.

- 2 SWH for LIS and 4 SWH for GP SW.

The GP SW imports automatically andarchives at least the LOINC-encodedparts, taking into account that eachsingle test could be associated withmore than one LOINC code due todifferent test methodologies, ....

Lombardy.

• “Personal zone” for the citizen in his EHR – creationof an area for the insertion of clinical data by the citizenhim/herself (Personalized Health Information – PHI)

• Diagnostic & Therapeutic plans in the graphicalclinical history interface

Electronic Health Record - Evolution

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• Hospital patient chart management

• Extensive use of structured documents

• DICOM Image consultation

The Lombardy Region

The SISS Program

The EHR

The Challenges

Summary

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1. Involvement of Doctors• Ensure participation in

the decision processes• Ensure benefits for the

doctors

1. Involvement of Doctors• Facilitate dialogue between specialists, GP’s and

citizens (pathology networks, Patient Summary, ...)

• On-the-road services• Active involvement of stake-holders (Medical

Experts Group, Hospital Coordination Group, ...)

Challenge Response

Organisational Challenges and the SISS response (1/2)

2. Involvment of Citizens• In the area of health,

citizens entrust themselves to doctors, not public administration

• Privacy and data security• Contribution of the citizen

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2. Involvement of Citizens• A system for the healthy too• Personal Health Record• Interface revision with user groups• Simple functions with short Time-to-Market• Bidirectional communication services (Text

messages, outbound call centre, email, ...)

3. Supplier Management• Balance between risks

and gain• Careful monitoring of

aggregations

3. Supplier Management• Competition/Cooperation• Creation of an ecosystem of partners

cooperating in the construction of the system

4. Ensure an effective governance

Challenge Response

Organisational Challenges and the SISS response (2/2)

4. Ensure an effective governance

• Leadership, political involvement, financing

• Balance between decisions made above and proposals from the operative level

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4. Ensure an effective governance• Data gathering, organising, and

processing of citizen-centric data (EHR, Citizen Registry, DWH, ...)

• Evolution of mechanisms (electronic prescriptions, ...)

Thank you

Nicola [email protected]

Lombardia Informatica S.p.a .