ICEGOV2009 - Tutorial 4 - E-Health Standards in Practice: Challenges and Opportunities


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ICEGOV2009 - Tutorial 4 - E-Health Standards in Practice: Challenges and Opportunities

  1. 1. E-Health Standards in Practice: Challenges and Opportunities Jennifer Zelmer Chief Executive Officer, IHTSDO ICEGOV 2009 Bogota, November 10-13, 2009
  2. 2. Today’s Tutorial Why e-health? Workshop case: H1N1 Interoperabilty: key drivers for e-health standards Workshop case: reimbursement for physician consult Major types of e-health standards in use today Examples of standards in practice Lessons learned and key considerations
  3. 3. Information is key to health and health care
  4. 4. Complexity of the real world of health care The major reality of health and health care is driven by biological variability and human systems Biological variability is hugely diverse, dynamic, and uncontrolled emerging infections (e.g. HIV, H1N1) cancer Human response to disease, scientific knowledge, and technology are also explosive in their rates of change
  5. 5. Health Information for the 21st Century Person-oriented Respectful of privacy and secure High quality Relevant Inter-operable Flexible User-Friendly and accessible
  6. 6. Progress Made But Challenges Remain Of adults with health problems surveyed 1 in 2 had to tell same story to multiple providers 1 in 5 sent for duplicate tests by multiple providers 1 in 5 reported that records/tests didn’t reach office in time for appointment Source: Commonwealth Fund Survey
  7. 7. Just some of the challenges ... What is the patient’s problem list? Is a new drug safe to prescribe? What are the latest test results? Is recommended preventive care due? How long are patients waiting? Can I learn from others about how to improve care? How can we pay health care providers fairly and efficiently? How can we track resources and outcomes in a health system? etc.
  8. 8. What happens when ... You move, you travel ... and you still need healthcare A friend has a life-threatening allergy A family member’s doctor retires Clinicians in your hospital trained somewhere else or practice in more than one site A medical device is withdrawn A health region’s boundaries change You want to be able to select the best IT systems available globally
  9. 9. A Global Challenge
  10. 10. Shared Goals: Real & Lasting Change Safe, effective, and responsive health services Appropriate information sharing between providers and with patients/clients Better chronic disease management and public health surveillance Help clinicians and patients make better decisions Engaging patients Reducing duplication and other inefficiencies etc.
  11. 11. Approaches Vary Centralized vs. Decentralized decisions Organizational arrangements Funding mechanisms Engagement of the public Engagement of clinicians Etc.
  12. 12. As Do Areas of Focus/Progress Focus on administrative tools vs. enabling better care In clinical applications Primary vs. Secondary/Tertiary Care Degree of specialized systems (e.g. outbreak management or e- prescribing) vs. integrated solutions Extent of focus on telehealth, public health surveillance, etc. The challenge of renewal of legacy systems Engagement of, and support for, patients and citizens Quality improvement & accountability Etc.
  13. 13. Nobody has it all solved ... ... But in many ways we share challenges & a vision
  14. 14. Common Themes Internationally (1) Information to enable patient/client care, e.g. Electronic health records (for professionals and individuals) Knowledgebases Clinical decision support Access to care, chronic disease management, and similar services Integration with medical devices, telehealth, etc.
  15. 15. Common Themes Internationally (2) Increasing use of information and communications technologies by patients/clients To find information about health and health care To monitor health using medical devices To choose health care options and schedule appointments To communicate with health professionals To access and contribute to a personal health record etc. Ensuring privacy, confidentiality, and security
  16. 16. Common Themes Internationally (3) Health system uses of information also matter, e.g. Quality improvement & health policy • Research Accountability • Public health Funding Increasing the flexibility, integration, and use of information Growing international cooperation in health information Standards, systems, best practices, policies, etc. Building capacity – people, infrastructure, etc. Focus on benefits evaluation & best practices
  17. 17. A problem shared is a problem halved “In the highly interconnected and readily traversed ‘global village’ of our time, one nation’s problem soon becomes every nation’s problem” Source: Smolinski et al (2003) Microbial Threats to Health : Emergence, Detection and Response 17 22/04/2010
  18. 18. Workshop Case #1: H1N1 ?
  19. 19. Information Challenges for Policy Makers: Selected Examples How widespread is H1N1 in my jurisdiction? Who is most at risk? How severe are cases? How is my health system coping with cases? Who needs to be vaccinated? How do I reach them?
  20. 20. New Ways of Monitoring Outbreaks Model estimates for the mid-Atlantic region (black) vs.CDC- reported ILI percentages (red) J Source: Ginsberg et al. Nature 000, 1-3 (2008) doi:10.1038/nature07634
  21. 21. The Question of Vaccination: A Case Study Have there been cases of H1N1 in your country? Has your country begun or planned H1N1 vaccination? Is priority being given to certain groups in the population? Can your country systematically identify everyone under age 65 who has diabetes or asthma [...]? Can you contact them?
  22. 22. The Results ...
  23. 23. Information enabling change ... ... with interoperability a key
  24. 24. Thinking About E-Health Health Privacy, Confidentiality and Security Information Governance Applied Use Cases Data & Tools Standards Infrastructure Source: Adapted from Canadian Institute for Health Information
  25. 25. Capture once, use many times (in a privacy sensitive manner) For direct client/patient care At the point of care By the client/patient Same provider, different time Different provider(s)
  26. 26. Capture once, use many times (in a privacy sensitive manner) For direct client/patient care For public health surveillance For health outcomes analysis For informing health policy For accountability and public reporting For costing and funding For clinical research For health services research For ...
  27. 27. Without Standards…
  28. 28. Standards-based Interoperability STANDARDS
  29. 29. Workshop Case #2: Paying for Care ?
  30. 30. The scenario John Smith visits his doctor because he has a bad eye infection. His doctor is entitled to bill the insurance plan for the consultation at a standard rate. To process payment, the insurance company needs to know which patient was cared for when by whom for what Create a form that would capture this information
  31. 31. Discussion Questions What was the first field on your form? How did you identify the patient? How did you identify the doctor? What form did you use for the date? Did you include the consultation time? How did you describe the reason for visit?
  32. 32. Two (of many) Possible Scenarios Physician ID (numeric, 9 Patient name (free text, 60 digits) char) Patient ID (alphanumeric, Patient address 12 digits) Physician name (free text, Date of consult 60 char) (YYYYMMDD) Date of consultation Reason for visit (SNOMED (DDMMMYYYY) encoded term for main Reason for visit (free text, problem) 200 char)
  33. 33. E-Health Standards in Use Today
  34. 34. Different Types of e-Health Standards Governance & organizational Technical (e.g. Privacy, confidentiality, for devices) Security, & access Information Information architecture, exchange Models, & structures Content Identifiers
  35. 35. Standards Can Exist at Different Levels within these Broad Domains Grouping Classification Terminology
  36. 36. Another view: Interoperability & standards levels Machine Transportability Communication Agreed communication interfaces Machine Readability Accessing info Technology based, Operational workflows focused Machine interpretability Connecting systems Engagement Clinician, Secondary data users Technology implementers Regional Connectivity & EHR. Agreed structure and meaning Co-operability Connecting people Clinician Driven leading to agreed process, eg care planning Policy driven Source: MOHHoldings, Singapore
  37. 37. A Wide Range of Relevant Organisations OpenEHR DICOM WONCA ICH MedDRA ICN IEEE LOINC IHTSDO Continua CDISC OHT ISO TC 215/ IUPAC HL7 CEN TC 251 WHO
  38. 38. The Vision for IHTSDO To enhance the health of human-kind by facilitating better health information management To contribute to improved delivery of care by clinical and social care professions To facilitate the accurate sharing of clinical and related health information, and the semantic interoperability of health records Member-driven organization, pooling resources for shared benefit 38
  39. 39. Terminology: SNOMED CT as an Example Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) A comprehensive clinical terminology covering diseases, clinical findings, and procedures Represents the meaning of concepts using formal definitions Language independent > 315,000 active concepts, ~ 806,000 descriptions, ~ 1M defining relationships in international release Helps to structure and computerize health records allowing for a consistent way of indexing, storing, retrieving and aggregating clinical data
  40. 40. To a clinician, these are related. But what about to a computer? Myocardial infarction Myocardial infarct MI AMI Heart attack Infarction of heart Cardiac infarction ...
  41. 41. Enabling decision support: An Example Influenza vaccination reminder decision support program criterion: chronic cardiorespiratory disorders patient record: mild persistent asthma 41
  42. 42. Using Standards in Practice Selected Examples
  43. 43. Use in Clinical Environments For capture, exchange, and use of clinical information Primary care ”Standards Specialist care Inside” Tertiary care Health systems
  44. 44. Use by Patients and Families For example for use in personal health history application and in personal health records Use usually transparent to user but intended to facilitate interoperability, data exchange, and decision support
  45. 45. Use in Public Health, e.g. Public health reporting (e.g. Notifiable diseases) Biosurveillance Track and analyze information about vaccinations, public health investigations, etc. Cancer registries Enabling research to understand factors that influence health Etc.
  46. 46. Use in Support of Public Policy Frequently need to combine information from many different sources to track trends or compare results using health indicators Requires standards for data capture, information exchange, identifiers, analysis, and more
  47. 47. The Challenge – and Opportunity – Ahead
  48. 48. Thinking about a standards process for ehealth … Diverse standard users and use cases Current and future Importance of balance What about governance? Establishing criteria and mechanisms for consultation/consensus- building How to ensure quality and sustainability of the process? Links with related activities in other jurisdictions & industries Facilitating adoption of standards – what are the levers? Compliance testing – opportunities and challenges Implications for implementation and evaluation
  49. 49. The Journey Ahead ... How do we make it easier to use ehealth and ehealth standards than not to?