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  • 1. Strategic Directions for Health Informatics Content Interoperability in NZ Professor Jim Warren Dr Douglas Kingsford, University of Ballarat
  • 2.
    • Need agreed strategic direction for interoperability standards
    • Report commissioned by HISAC
    • Objectives:
      • Identify current state of play
      • Framework for debate and policy formation
    Introduction
  • 3.
    • National Institute for Health Innovation University of Auckland
    • Collaborative Centre for e-Health University of Ballarat
    • Dr Douglas Kingsford
    • First step towards strategy formulation
    • Independent of HL7 Users Group
    Context
  • 4.
    • Quality of care delivered
    • Patient safety
    • Cost of care delivery
    • Shortage of skilled healthcare workers
    • Public health
    • Biomedical research
    Key Health IT Drivers
  • 5.
    • Substantial benefits from simple interventions:
      • Human readable EMR content, narrative documents
      • Clinical guidelines / care pathways
      • Medicines reconciliation
      • Simple workflow & decision support
      • Standardised medical terminology
    International Health IT Experience
  • 6.
    • Emerging trends:
      • Chronic disease management programmes
      • Personal health records
      • Complex workflow & decision support, genomics
      • Telemedicine, biosurveillance
    International Health IT Experience
  • 7.
      • Interfaces, message syntax, message structure
      • Interface engines, portals
      • HL7 v2.x, XML, ASN.1, Web Services
      • Negotiated exchange of information, inflexible
    Interoperability
      • Exchange without prior agreement
      • Rich meaning, context
      • Language: grammar + vocabulary
      • HL7 v3, CDA, openEHR, CEN13606
    Functional Interoperability Semantic Interoperability
  • 8. Semantic Requirements
      • Reference model
      • Vocabularies +/- other ontologies
    Common semantics
      • HL7 v2, HL7 v3, CEN, openEHR, ISO datatypes
    Equivalent formal datatypes
      • HL7 v3 Templates, openEHR/CEN13606 archetypes
    Means to define / constrain compositions
      • Syntax and grammar for messaging
      • HL7 v2, HL7 v3 XML ITS, CEN13606 Part 5
    Agreed interchange format
  • 9.
    • Messaging vs Persistence
      • Documents vs Transactions
      • Transient vs Persistent information
      • Simple transfer of information?
      • Workflow / business process management?
    Other Considerations
  • 10.
    • Implementation
      • Governance, creation / management of content
      • Tooling, reference implementations
      • Vendor support
    Other Considerations
  • 11. +++ (using RDF and OWL) ‏ +++ (as per v3 esp CD datatype)     +++ +++ +++ (v3 has richer structured datatypes that better support post-coordination) ‏ ++ Terminology/Ontology bindings + ++ +++ ++ - (neither v2 nor v3 are persistence specs) ‏ - EHR Persistence + ++ (it is a messaging spec) ‏ + (no messaging support beyond content) ++ +++ +++ Support messaging +++ +++ + +++ +++ +++ Institutionalisation & governance + + +++ + +++ +++ Embedded security - ++ +++ ++ +++ + Support for knowledge management - ++ ++ ++ ++ - RIM stability & consistency +++ +++ + - (no implementations) ‏ + +++ Reference implementations +++ (widespread use across IT) ‏ ++ + - (no implementations) ‏ + +++ Vendor interest & support +++ + ++ - ++ +++ Tools and components +++ +++ +++ + ++ +++ Accessibility to Standards and Specs - ++ (as in NHS CfH) ‏ ++ ++ +++ + Support for Decision Support    + (XPath) ‏ + +++ ++ (there are problems with it) ‏ +++ (assuming a RIM parser) ‏ + Intelligent querying    - +++ (as per v3) ‏ +++ ++ (weaker RM) ‏ +++ + Expressive power for clinical data         - ++ +++ ++ ++ + Coverage (i.e. to realise full EHR)         XML/Web Service CDA/CCD openEHR CEN HL7 v3 HL7 v2
  • 12. Comparison of Major Options This is a methodology rather than a technology solution. The technology is still CDA/v3 – this approach does not implement the openEHR reference model or datatypes, it just uses the archetyping methodology for content creation. There is currently little evidence for the ROI of a openEHR / HL7 v2 solution. openEHR may not offer the same opportunities for machine reasoning as HL7 v3. HL7 v3 is not a persistence standard. ROI for upgrading messaging systems would need to be established first. Cost of development using a relatively unstable RIM may be high. Limited semantic interoperability of messaging. Inability to express context of messages. Cons Archetyping appears to be gaining acceptance as a way of modelling clinical content. While not adopting a full openEHR solution, applying archetyping methodoloy to HL7 template creation would make CDA structured content more in line with clinical needs. openEHR offers a semanticaly standardised persistent storage solution within an organisation. openEHR content is easier for clinicians to understand than HL7 v3 content. Communicating with outside organisations using HL7v2 would offer a pragmatic solution to messaging as the integration infrastructure and skills already exists, so the total cost of ownership is low. Semantic messaging may offer a ROI where decision support and workflow tools are to be implemented that are capable of leveraging rich message content. Allows use of existing messaging infrastucture, minimising total cost of ownership. CDA would offer a persistent storage solution for structured content containing defined datasets. Some degree of interoperability due to the vocabulary bindings in coded message fields. Pros openEHR Archetyping Applied to HL7 Templates in CDA Documents HL7 v2 Messaging + openEHR HL7 v3 Messaging +/- CDA L3 HL7v2 Messaging +/- CDA L1
  • 13.
    • No clear winner for Semantic Interoperability
      • HL7 v3 and openEHR dominate ... but both have weaknesses
      • CDA offers incremental interoperability
      • HL7 v2 unable to deliver ... but can carry CDA, openEHR Archetypes
      • Significant ongoing harmonisation work ... HL7 v3, openEHR, CEN13606
      • Content creation & governance is crucial
    • Messaging, XML, web services are insufficient
    • Standard terminology is key – SNOMED CT
    Discussion
  • 14.
    • What are we trying to achieve?
    • Where are the biggest gains to be made in quality of care, patient safety, cost reduction?
    • What are our goals for workflow and decision support?
    • Do we need to sustain an open architecture?
    Further Debate
  • 15.
    • Involvement of key stakeholders:
      • clinicians, patients, vendors, researchers, health administrators
    • Determination of sector objectives
    • Fine-grained analysis of HL7 v3, openEHR, other standards relative to these objectives
    • New group to provide ongoing monitoring of international developments
    Next Steps