Strategic Directions for Health Informatics Content Interoperability in NZ

Strategic Directions for Health Informatics Content Interoperability in NZ Professor Jim Warren Dr Douglas Kingsford, University of Ballarat

Need agreed strategic direction for interoperability standards

Report commissioned by HISAC

Objectives:

Identify current state of play

Framework for debate and policy formation

Introduction

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

Quality of care delivered

Patient safety

Cost of care delivery

Shortage of skilled healthcare workers

Public health

Biomedical research

Key Health IT Drivers

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

Emerging trends:

Chronic disease management programmes

Personal health records

Complex workflow & decision support, genomics

Telemedicine, biosurveillance

International Health IT Experience

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

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

Messaging vs Persistence

Documents vs Transactions

Transient vs Persistent information

Simple transfer of information?

Workflow / business process management?

Other Considerations

Implementation

Governance, creation / management of content

Tooling, reference implementations

Vendor support

Other Considerations

+++ (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

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