ICEGOV2009 - Tutorial 4 - E-Health Standards in Practice: Challenges and Opportunities
E-Health Standards in Practice:
Challenges and Opportunities
Chief Executive Officer, IHTSDO
Bogota, November 10-13, 2009
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
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)
Human response to disease, scientific knowledge, and technology
are also explosive in their rates of change
Health Information for the 21st Century
Respectful of privacy and secure
User-Friendly and accessible
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
Source: Commonwealth Fund Survey
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?
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A medical device is withdrawn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
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
Help clinicians and patients make better decisions
Reducing duplication and other inefficiencies
Centralized vs. Decentralized decisions
Engagement of the public
Engagement of clinicians
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
Nobody has it all solved ...
... But in many ways we share challenges & a vision
Common Themes Internationally (1)
Information to enable patient/client care, e.g.
Electronic health records (for professionals and individuals)
Clinical decision support
Access to care, chronic disease management, and similar
Integration with medical devices, telehealth, etc.
Common Themes Internationally (2)
Increasing use of information and communications technologies by
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
Ensuring privacy, confidentiality, and security
Common Themes Internationally (3)
Health system uses of information also matter, e.g.
Quality improvement & health policy • Research
Accountability • Public health
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
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
Information Challenges for Policy Makers:
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?
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
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?
Information enabling change ...
... with interoperability a key
Thinking About E-Health
Privacy, Confidentiality and Security
Applied Use Cases
Data & Tools
Source: Adapted from Canadian Institute for Health Information
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
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
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
To process payment, the insurance company needs to know
which patient was cared for
Create a form that would capture this information
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
How did you describe the reason for visit?
Two (of many) Possible Scenarios
Physician ID (numeric, 9 Patient name (free text, 60
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)
Different Types of e-Health Standards
Security, & access
Information Information architecture,
exchange Models, & structures
Standards Can Exist at Different Levels
within these Broad Domains
Another view: Interoperability & standards levels
Machine Transportability Communication
Agreed communication interfaces
Machine Readability Accessing info
Operational workflows focused
Machine interpretability Connecting systems
Secondary data users
Regional Connectivity & EHR.
Agreed structure and meaning
Co-operability Connecting people
Clinician Driven leading to agreed process, eg care planning
Source: MOHHoldings, Singapore
A Wide Range of Relevant Organisations
WONCA ICH MedDRA
ISO TC 215/
IUPAC HL7 CEN TC 251
The Vision for IHTSDO
To enhance the health of human-kind by facilitating better health
To contribute to improved delivery of care by clinical and social care
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
Terminology: SNOMED CT as an Example
Systematized Nomenclature of Medicine Clinical Terms (SNOMED
A comprehensive clinical terminology covering diseases, clinical
findings, and procedures
Represents the meaning of concepts using formal definitions
> 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
To a clinician, these are related. But what
about to a computer?
Infarction of heart
Enabling decision support: An Example
Influenza vaccination reminder
decision support program criterion:
chronic cardiorespiratory disorders
mild persistent asthma
Use in Clinical Environments
For capture, exchange, and use of clinical information
Specialist care Inside”
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
Use in Public Health, e.g.
Public health reporting (e.g. Notifiable diseases)
Track and analyze information about vaccinations, public health
Enabling research to understand factors that influence health
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
Thinking about a standards process for
Diverse standard users and use cases
Current and future
Importance of balance
What about governance?
Establishing criteria and mechanisms for consultation/consensus-
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
The Journey Ahead ...
How do we make it easier to use ehealth and ehealth standards than not to?