Standards and interoperability towards 2014 and the New Zealand e-health vision


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Standards and interoperability towards 2014 and the New Zealand national e-health vision - the not so unexpected journey towards core personal health information being available at all points of care

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  • We look at the standards and interoperability agenda, towards reaching the New Zealand health sector’s objective of shared personal health information by 2014National Health IT Board prioritiesClinical integration and the interoperability frontlineThe standards agenda
  • Be regional‘electrified health records’
  • Current headlines in Nov 2012Novopay a $30m horror showJackson scrambling to finish The Hobbit – one day out from premiereHowever, the first headline wrongly susposes the 2014 vision to be predicated on a national rollout of some monolithic system
  • This is the e-health destination as described by NHITBWith a further theme of sustainability in the health system
  • Different branches of the tree represent the different kinds of solution that will exist in the environment – from shared care systems at the top, for people with high needs, through systems that lubricate the wheels of healthcare in the community and the hospital, test results, reports and other objective health information in CDRs, and – at the base of the tree – demographics, allergies and alerts, enrolments/registrations
  • These are the National Health IT Board priority programmes for 2012-14 – the windowpanes Underpinned by work on infrastructure,connectivity, ICT organisational capability, standards
  • IFHCs will be able to offer access to a patient portal that presents a core set of personal health information and has functions like booking an appointment, requesting a repeat prescription and having email interaction with practitioners. Examples of nascent IFHCs include Midland Health Network, Canterbury Initiative, Island Bay medical centre, and Wairarapa and MidCentral PHOs.For patients with high needs around long term conditions, shared care systems will be in place enabling the involvement of a multi-disciplinary team. The frontline is now the community pharmacy, where we can expect to see shared care plans created for patients with high needs.Hospitals will have a clinical workstation and clinical data repository – common within the region, accessible by the community workforce as well as in the hospital. The R-CDR needs to present an inter-regional view.
  • GP2GP has been a success storyGP2GP 2.0 is in planning
  • Interconnected care solutions are in development that will enable information flows between all of the following: community pharmacy, general practice, community nursing, residential care, ambulance, ED
  • Community pharmacy referrals and assessmentsNZePS developed but not rolled outCCMS introduced as shared care solution Pharmacy Services Agreement for long term conditions New processes to support –Referrals into pharmacies Eligibility assessments by pharmaciesEnrolments for LTCSCreation of medications plansCommunication of medications plansOngoing clinical management by the pharmacistShared information within the care teamNZePS v2 has been successfully tested by the NZePS broker, one pharmacy vendor and three GP vendors, and paves the way for version two to be implemented in all pharmacy and GP systems as a precursor to national rollout. Work is underway on preparation for the rollout.The essential LTC Services a pharmacy must provide include, dispensing of pharmaceuticals, medicine reconciliation, synchronisation of medicines, reminder services (e.g. email, phone call) for collection of pharmaceuticals, regular screening of adherence to medicine regime, and regular engagement with the patient’s multidisciplinary care team.
  • Community Pharmacy Services Agreement opens the door to the introduction of shared care services between GPs and pharmacists with patients with high needs
  • This is care without walls – the ambulance has access to the patient’s past event information, including recent discharge summaries, via the regional CDRAmbulance might send an ECG as an attachment to the ePRF – presently an ECG can be sent via email, with patient consentePRF includes details of interventions, making it both a referral and an event summaryAmbulance ePRF use case illustrates very well the difficulty of having multiple non-interoperable referral systemsePRF phased rollout from July 201320% of ambulance calls are for people discharged within the past week70% of ambulance calls are medical as opposed to injuriesAmbulance particularly interested in discharge diagnoses from ED and discharge dispositionePRF portal will be made available to Accident and Medical centres, possibly also ED as a first stepAmbulance officers record meds found in the patient’s home – could scan barcodesAmbulance arrival board in ED
  • Having a SNOMED CT coded eDS would be like Xmas to GPsGlobal general practice reference set has ~3500 concepts (July 2013)Locally, all clinical systems SNOMED enabled from x date – 2015? A structured discharge summary will be importable into the GP PMS and shared care systems (which are accessible in the pharmacy), as well as being communicated via the R-CDR as an entry in the longitudinal recordDischarge Rx entered via SMT –Directed to the hospital dispensing systemOr to community pharmacies via the NZePSDischarge summary is a living document, continually updated from admission to discharge, and visible to all parties hospital and community through the hospital stay (this cannot be achieved very easily with a messaging model)
  • The conceptis of a managed list following the patient, reviewed and updated by the care teamIncludes allergies and alertsSitsalongside prescribing and dispensing information
  • A shared, repository-based information resourcePresented natively via existing point-of-care applications, loosely coupled to the repositoryQuestions the South Island e-medications workshop set out to address: What datasets are involved? How does the repository work? What are the interfacing requirements client-side? What is the interface to the eDS? What is the interface to eSCVR?
  • The need in many DHBs to upgrade their pharmacy management systems, such as in Midland region where all DHB pharmacies will share a single application instanceHospitals will also adopt prioritisation standardsThere will be a national agreement on e-prescribing, which will provide DHBs with an off-the-shelf waiver under the Medicines Act to permit e-prescribingThis will all build on pilot work at Taranaki, Southern, Waitemata and Counties Manukau DHBsNational implementation will begin mid 2013, following a hardening exercise on the recommended solution‘Going for Platinum’DHBs implementing new/updated ePM systems for dispensing and pharmacy management – predominantly CSC ePharmacyCSC ePharmacy interfaces to MedChart for medication ordersAlso has interfaces to suppliers’ systems, FMIS, PyxisMidland has plans to create a single-instance regional solution:single instance of the back endlocal deployment of the client-side applicationmulti-tenanted, but with a common configurationintegration with district level PAS and FMIS
  • Hospital medications management is also topicalThis slide shows how My List of Meds relates to the hospital medications chart – used as an input to medicines reconciliation on admission, and updated out of the discharge summaryMedical oncology solutions will tend to be different to the ePA solution for the rest of the hospital, and will also cater to both inpatients and outpatientsA combined view will be presented somehow, in the portal if not the wider hospital ePA solution
  • EMR Adoption Model (EMRAM) for uptake of HIT within the hospital. There are 8 stages, with the topmost being a fully paperless environment. Below this, physician documentation / charting (structured templates), full CDSS and closed loop medication administration environment are fully implemented.Electronic Medical Record Adoption Model – a structured assessment developed by HIMSS Analytics to measure hospital progress towards full electronic system rollout.NHITB will coordinate EMRAM assessments that benchmark New Zealand hospitals against similarly sized hospitals globally. All hospitals in the US, along with most Canadian and European hospitals, have completed EMRAM assessments. DHBs are keen to participate, and results available to date indicate New Zealand hospitals compare well globally.To progress from one stage of adoption to the next, a hospital must have implemented everything at the preceding levelScores go to 4 decimal places, depending on achievements at higher levels (which makes big jumps possible)
  • The first of three examples of the emerging class of interoperable shared care solutionsComprehensive care assessments with the sector’s interRAI application, hosted nationallyAssessments are created and stored in one system, but used in others – for care planning, by the GP, on admission to hospitalDeveloping this capability is an incremental taskCurrently, the application can present PDF-formatted assessment reports within an application sessionBuilding on this, CDA level 1 can be used to attach metadata to the report and it can be conveyed via web services to portal usersFinally, when an XDS infrastructure is in place, and we have a suitable set of templates, we can move to CDA level 3 content shared out of an XDS-enabled repository
  • Porous regional boundaries and centres of excellenceCentral Region is Region Central
  • There is plenty of locked-up clinical data that DHBs would like to make available via the R-CDRXDS seems to offer a robust way of doing this – we hope cost effectiveHIE community policy?
  • We need the new standard to drive the repository-based information sharing described by the National Health IT Plan.Solution scope options for NHITB/healthAlliance pioneering work on R-CDRsAn important use case is shared care system access to repository-held records, such as test results, discharge summaries and My List of MedicinesThere is also the ‘after hours’ use caseThere is an interesting comparison with the implementation of Australia’s PCEHR, which has the following features:Single national XDS registry (XCA not required)Registry and repositories implement XDS and ATNAPatient privacy consents (non BPPC) based on Practitioner-Role-Organisation and Organisation-Patient-Document relationships (with opt-outs)Eight CDA document types in circulation – a mix of levels 1, 2 and 3Registry vendor supportive of PIXV3 (though not implemented)
  • SPaCE programme likely to have chosen a vendor by Xmas
  • What standards do we need to reach the 2014 goal?Of these, HISO 10040 is an interim standard (awaiting trial implementation)Transfer of Care Standard is scheduled to be released for public comment in the first half of 2013, ePharms (necessary for the NZePS) after thatThe Comprehensive Care Assessment Document will be a standardised interRAI extractWe will also have refreshed health identity standards
  • The diagram shows the CDA solar system, with the blue planets representing sets of templates and document types we use locally, deriving from international specifications (green)We are strongly internationally influenced, reusing wherever the fit to requirements is better than we could hope to achieve by ourselvesThe Continuity of Care Record (CCR) – although not itself CDA – is the origin of our conceptual data model for information exchangeThe other document types shown are: Consolidated CDA (CCDA) developed by the US’s ONC for Health IT; Continuity of Care Document (CCD); local GP2GP; local e-discharge summary (eDS); local e-prescription document; local transfer of care – generic referral/discharge document
  • HIT is a creative industry to be working in
  • Standards and interoperability towards 2014 and the New Zealand e-health vision

    1. Standards and Interoperability Towards 2014 27 November 2012
    2. HINZ Nov 2012 Privacy breaches Disruptive innovation Fabula, syuzhet, syzygy 2014 trees data as an actor personalised medicine 2
    3. In the newsNovopay a $30m horror show‘… such rush-jobs are all too common … [thegovernment] may be setting the stage for futurehorrors with its stated policy of getting a nationalpatient-record system in place by 2014’Sunday Star Times, 25/11/12
    4. The destination is … Person-centred, integrated health care Clinicians, consumers and IT people working in co-production Providers having the confidence to invest in new solutions 4
    5. This tree represents the solution space 5
    6. National priorities to 2014eMedicines programme Regional information platforms Pharmacy clinical integration  eReferral and eDS eMR, ePA  CDRs, CWS, ED solution NZULM, NZ Formulary  PACS  LIS, pharmacy  PASNational solutions Clinical integration Cancer information  LTC shared care Cardiac health  Maternity and well child Comprehensive clinical assessment  Patient portal Health identity platform  View of primary health info FMIS, procurement, supply chain  Urgent and unplanned care 6
    7. Top priorities for the next twelve months Offered by IFHCs CWS Common regional Patients with LTCs and Personal health info and CDR high needs Appointments hospital Accessible both Multidisciplinary input Repeat prescriptions and community Email consultations Inter-regional view 7
    8. GP2GP50% of GPs are users5500 transfers alongside 36,000 e-referrals per monthFiles over 5 MB have to be sent the old fashioned way5500 (Nov) 8
    9. The continuum of care 9
    10. Pharmacy clinical integration eRx via NZePS  eReferral via (eg) ERMS  Assess eligibility Centrally register Create medications plan Pharmacy desktop  Dispensing system  Assessment tool  Shared care system 10
    11. The strategy SHARED CARE 11
    12. Emergency care Ambulance accesses primary care info and any discharge summary Ambulance shares ePRF (as an event summary, but also a kind of referral) with hospital EDCommon ED solution basedon hospital PAS and CWS eDS shared via R-CDR 12
    13. Discharge summary SNOMED coded presenting complaint, diagnoses, procedures Continually updated during hospital stay Discharge Rx via NZePS eDS shared via R-CDR 13
    14. My List of Medicines eDS shared via R-CDR 14
    15. My List of Medicines 15
    16. eMR and ePA in all wardsGoing for Gold programme Shared medications lists Transition to eMR and ePA Standardised paper based eMR and medications charts CHALLENGES  eMR system separate to ePA  Outdated pharmacy systems  Shelves versus drawers versus robots  Medical oncology ePA 16
    17. End-to-end medications management Community ------------------------- Hospital 17
    18. Paperless hospitals 18
    19. Comprehensive clinical assessments Home care assessment Long term care assessment 19
    20. Comprehensive clinical assessments PDF (current) XDS (August 13) CDA + PDF CDA level 3 (March 12) 20
    21. Regional information platformsRegional PACS archiveRegional CWSRegional CDRRegional PASRegional ED solutionRegional RIS+Regional ePharmacy… 21
    22. Regional CDRs (and national too)4 DHB regions plus 5th nationally10, 20, … repositories?One registry? 22
    23. Regional CDRs 23
    24. Clinical integrationeSCRV sources information from GPs,pharmacy, community nursing andhospitalsERMS is the regional electronic requestmanagement system (8,000 referralsper month)Health Pathways has 400+ treatmentplans and pathways (74,000 page viewsper month)Shared Care Systems for patientswith long term conditions 24
    25. SPaCE programme Supporting Patients and Integrate primary care and Clinicians Electronically hospital workflow Incrementally replace eight Streamline the patient systems across five DHBs journey Go well beyond replacing the incumbent systems 25
    26. Orders and resultsCommunity lab and radiology test ordering solutions are appearing(with decision support and order tracking functions)Laboratory information standards review – NZPOCS overhaul HL7 v2.4 messaging implementation Judicious coding Message integrity between sender and receiver 26
    27. CDA HL7 v2 27
    28. New standards development …… An unexpected(-ly long)journey … 2010 Midland ‘core clinical dataset’ GP2GP HISO 10040 HIEs HISO 10041 – 2013 Q1/2 28
    29. HISO standards for 2014 29
    30. From: Bob DolinSent: Tuesday, November 29, 2011 12:55 PMTo: Rishel,Wes; Pratt, Douglas (H USA); robert worden;Structured Documents WGSubject: RE: CDA or greenCDAHi Wes,What is CCDA?Thanks,Bob 30
    31. Our family of CDA-based standards 31
    32. 32