HL7 & Health Information Exchange
in Thailand
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospi...
2
A Bit About Myself...
2003 M.D. (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics...
3
Outline
• Needs for better information in healthcare
• eHealth as a health system's component
• Thailand's eHealth situa...
4
Needs for
Better Information
in Healthcare
5
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11...
6
Needs for Better Information
• Good information needed for quality care
– Past and present history
– Medication list
– P...
7
(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports
8
• Humans are not perfect and are bound to
make errors
• Highlight problems in U.S. health care
system that systematicall...
9
• Medication Errors
–Drug Allergies
–Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Fai...
10
Back to
something simple...
11
To treat & to
care for their
patients to their
best abilities,
given limited
time &
resources
Image Source: http://en.w...
12
The Question Becomes...
How do we deliver better
information, by supplementing
human clinicians with ICT, so that
they ...
13
Outline
Needs for better information in healthcare
• eHealth as a health system's component
• Thailand's eHealth situa...
14
eHealth as a
Health System
Component
15
15
WHO (2009)
Components of Health Systems
16
16
WHO (2009)
WHO Health System Framework
17
Use of information and communications
technology (ICT) for health; Including
• Treating patients
• Conducting research
...
18
 All components are essential
 All components should be balanced
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealt...
19
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Goal: Health Information Exchange
20
Outline
Needs for better information in healthcare
eHealth as a health system's component
• Thailand's eHealth situat...
21
Thailand’s
eHealth Situation
22
eHealth in Thailand: The current status. Stud Health Technol Inform
2010;160:376–80, Presented at MedInfo2010 South Afr...
23
 All components are essential
 All components should be balanced
Slide adapted from: Dr. Boonchai Kijsanayotin
Recall...
24Slide adapted from: Dr. Boonchai Kijsanayotin
Thailand: Unbalanced Development
25
 Silo-type systems
 Little integration and interoperability
 Mostly aim for administration and management
 40% of w...
26
eHealth Components
27
Nationwide survey on hospital IT
adoption conducted in 2011
THAIS: Thai Hospitals’ Adoption
of Information Technology
S...
28Pongpirul et al., 2004
Vendor/Product Distribution (2004)
29Theera-Ampornpunt, 2011
Vendor/Product Distribution (2011)
30
Estimate (Partial or Complete
Adoption)
Nationwide
Basic EHR, outpatient 86.6%
Basic EHR, inpatient 50.4%
Basic EHR, bo...
31
• High IT adoption rates
• Drastic changes in adoption landscape
• Adequate infrastructure for information
exchange
• N...
32
eHealth Components
33
Outline
Needs for better information in healthcare
eHealth as a health system's component
Thailand's eHealth situati...
34
Standards Are Everywhere
35
Standards: Why?
• The Large N Problem
N = 2, Interface = 1
# Interfaces = N(N-1)/2
N = 3, Interface = 3
N = 5, Interfac...
36
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Goal: Health Information Exchange
37
Objectives
• Interoperability
• Inter-operable
systems
Ultimate Goals
• Continuity of Care
• Quality
 Safety
 Timelin...
38
Levels of Interoperability
Functional
Semantic
Syntactic
39
Various Kinds of Standards
• Unique Identifiers
• Standard Data Sets
• Vocabularies & Terminologies
• Exchange Standard...
40
Functional
Semantic
Syntactic
How Standards Support Interoperability
Technical Standards
(TCP/IP, encryption,
security)...
41
Message Exchange
• Goal: Specify format
for exchange of data
• Internal vs. external
messages
• Examples
 HL7 v.2
 HL...
42
Messages
• Human Unreadable
• Machine Processable
Clinical Documents
• Human Readable
• (Ideally) Machine
Processable
E...
43
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Message Exchange
Message
Message
Message
Message
Message
44
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Clinical Document Exchange
Message containing
Referral Le...
45
Standards National
1. Core data set standards 12 & 18 files standards
2. Semantic standards Personal ID,
Provider ID
IC...
46
Standards National
1. Core data set standards Referral, Chronic Diseases
2. Semantic standards
Drug Terminology (TMT),
...
47
Thai Health Information Standards
Development Center
www.this.or.th
http://www.facebook.com/thishsri
this@this.or.th
St...
4848
eHealth & e-Transactions
49
• HL7 Certified Specialists
Kevin
Asavanant
HL7 V3 RIM (2009)
Supachai
Parchariyanon
HL7 CDA (2010)
Nawanan
Theera-Ampo...
50
URGES Member States:
(1) to consider, as appropriate, options to collaborate with
relevant stakeholders, including nati...
51
Outline
Needs for better information in healthcare
eHealth as a health system's component
Thailand's eHealth situati...
What is HL7?
• HL7 is an ANSI-accredited Standards
Development Organization (SDO)
operating in the healthcare arena.
• It ...
What is HL7? (Cont.)
• HL7 is an acronym for Health Level Seven
– Seven represents the highest, or “application”
level of ...
OSI Model
54
Slide adapted from: Dr. Supachai Parchariyanon
55
HL7 Standards
• HL7 V2.x
– Defines electronic messages supporting hospital
operations
• HL7 V3
• HL7 Clinical Document ...
56
HL7 V3 Standards
• A family of standards based on V3
information models and development
methodology
• Components
– HL7 ...
57
Sample HL7 v.2 Message (Lab Result)
OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml|
0-1.3|H||H|F|19980309…
58
Sample HL7 v.3 Message
(Patient Registration)
<?xml version="1.0" encoding="UTF-8"?>
<PRPA_IN101311UV02 xmlns="urn:hl7-...
59
HL7 Reference Information Model (RIM)
Source: HL7 CDA R2
60
Source: “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
61
HL7 V3 Messaging
• V3 provides messaging standards for
– Patient administration
– Medical records
– Orders
– Laboratory...
62
What Is HL7 CDA?
• “A document markup standard that
specifies structure & semantics of “clinical
documents” for the pur...
63
A Clinical Document (1)
• A documentation of clinical observations
and services, with the following
characteristics:
 ...
64
A Clinical Document (2)
• A documentation of clinical observations
and services, with the following
characteristics:
 ...
65
A Clinical Document (3)
• A CDA document is a defined & complete
information object that can include
 Text
 Images
 ...
66
CDA Releases
• CDA Release 1 (ANSI-approved in 2000)
– First specification derived from HL7 RIM
• CDA Release 2 (2005) ...
67
Key Aspects of CDA
• CDA documents are encoded in XML
 When alternative implementations are feasible,
new conformance ...
68
Scope of CDA
Lab Technician Physician
Lab Report
Create
document
Process &
Store
document
Transmit
document
CDA
69
CDA & HL7 Messages
• Documents complement HL7 messaging
specifications
• Documents are defined and complete information...
70
CDA & Message Exchange
• CDA can be payload (or content) in any kind of
message
– HL7 V2.x message
– HL7 V3 message
– E...
71
CDA & Message Exchange
Clinical Document
(Payload)
HL7 V3 Message
(Message)
HL7 V2 Message
(Message)
Source: Adapted fr...
72
CDA As Payload
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
73
CDA Model
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
74
A Closer Look at a CDA Document
<ClinicalDocument> ... CDA Header ...
<structuredBody> <section> <text>... Single
Narra...
75
Rendering CDA Documents (1)
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
76
Rendering CDA Documents (2)
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
77
Human Readability &
Rendering CDA Documents (3)
Source: HL7 CDA R2
<ClinicalDocument> ... CDA Header ...
<structuredBod...
78
Some Possible Use Cases of CDA
 Intra-institutional
 Exchange of parts of medical records (scanned or
structured elec...
79
Some Possible Use Cases of CDA
 Inter-institutional
 Referral letters
 Claims requests or reimbursement documents
 ...
80
Achieving Interoperability
 CDA is a general-purpose, broad standard
 Use in each use case or context requires
implem...
81
Outline
Needs for better information in healthcare
eHealth as a health system's component
Thailand's eHealth situati...
82
Back to Thailand’s
eHealth status: Workforce
83
eHealth Components
83
84
• Certificate & Diploma Level
• Undergraduate Level
• Graduate Level
84
Informatics Workforce Programs
85
Faculty of Medicine Ramathibodi Hospital, Mahidol University
http://med.mahidol.ac.th/has/85
Healthcare CIO Certificate...
86Faculty of Tropical Medicine, Mahidol University86
Diploma & Master Graduates in Biomedical &
Health Informatics, First ...
87
• In January 2013, the Thai Medical
Informatics Association (TMI) approved
establishment of the “Biomedical and
Health ...
8888
TMI CIO Forum
89
• International Medical Informatics
Association (IMIA)
– MEDINFO & APAMI
• HIMSS AsiaPac
• Asia eHealth Information Net...
90http://www.aehin.org/Meetings/2013AeHINGeneralMeeting.aspx90
Participation in AeHIN
91
Outline
Needs for better information in healthcare
eHealth as a health system's component
Thailand's eHealth situati...
92
The Road Ahead for
Thailand’s eHealth
93
• Addressing
– Lack of national leadership & governance,
strategy & investment, policy & regulation
– Shortage of infor...
94Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/
The Journey Beyond
95
But We’ll Get There...
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HL7 & Health Information Exchange in Thailand

  1. 1. HL7 & Health Information Exchange in Thailand Nawanan Theera-Ampornpunt, M.D., Ph.D. Faculty of Medicine Ramathibodi Hospital Mahidol University, Thailand June 24, 2014 www.SlideShare.net/Nawanan
  2. 2. 2 A Bit About Myself... 2003 M.D. (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) 2012 Certified HL7 CDA Specialist • Lecturer, Department of Community Medicine • Deputy Executive Director for Informatics (CIO/CMIO), Chakri Naruebodindra Medical Institute Faculty of Medicine Ramathibodi Hospital nawanan.the@mahidol.ac.th http://groups.google.com/group/ThaiHealthIT Research interests: • EHRs & health IT applications in clinical settings • Health IT adoption & eHealth development • Health informatics education & workforce development
  3. 3. 3 Outline • Needs for better information in healthcare • eHealth as a health system's component • Thailand's eHealth situation • Standards & interoperability • HL7 standards • The road ahead for Thailand's eHealth
  4. 4. 4 Needs for Better Information in Healthcare
  5. 5. 5 “Information” in Medicine Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
  6. 6. 6 Needs for Better Information • Good information needed for quality care – Past and present history – Medication list – Problem list – Allergies – Lab & imaging results • Information gaps prevalent in healthcare settings (e.g. Stiell A et al. CMAJ. 2003;169:1023-8.)
  7. 7. 7 (IOM, 2001)(IOM, 2000) (IOM, 2011) Landmark IOM Reports
  8. 8. 8 • Humans are not perfect and are bound to make errors • Highlight problems in U.S. health care system that systematically contributes to medical errors and poor quality • Recommends reform • Health IT plays a role in improving patient safety IOM Reports Summary
  9. 9. 9 • Medication Errors –Drug Allergies –Drug Interactions • Ineffective or inappropriate treatment • Redundant orders • Failure to follow clinical practice guidelines Common Errors
  10. 10. 10 Back to something simple...
  11. 11. 11 To treat & to care for their patients to their best abilities, given limited time & resources Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen) What Clinicians Want?
  12. 12. 12 The Question Becomes... How do we deliver better information, by supplementing human clinicians with ICT, so that they make less errors and perform better?
  13. 13. 13 Outline Needs for better information in healthcare • eHealth as a health system's component • Thailand's eHealth situation • Standards & interoperability • HL7 standards • The road ahead for Thailand's eHealth
  14. 14. 14 eHealth as a Health System Component
  15. 15. 15 15 WHO (2009) Components of Health Systems
  16. 16. 16 16 WHO (2009) WHO Health System Framework
  17. 17. 17 Use of information and communications technology (ICT) for health; Including • Treating patients • Conducting research • Educating the health workforce • Tracking diseases • Monitoring public health. Sources: 1) WHO Global Observatory of eHealth (GOe) (www.who.int/goe) 2) World Health Assembly, 2005. Resolution WHA58.28 Slide adapted from: Mark Landry, WHO WPRO & Dr. Boonchai Kijsanayotin eHealth
  18. 18. 18  All components are essential  All components should be balanced Slide adapted from: Dr. Boonchai Kijsanayotin eHealth Components: WHO-ITU Model
  19. 19. 19 Hospital A Hospital B Clinic C Government Lab Patient at Home Goal: Health Information Exchange
  20. 20. 20 Outline Needs for better information in healthcare eHealth as a health system's component • Thailand's eHealth situation • Standards & interoperability • HL7 standards • The road ahead for Thailand's eHealth
  21. 21. 21 Thailand’s eHealth Situation
  22. 22. 22 eHealth in Thailand: The current status. Stud Health Technol Inform 2010;160:376–80, Presented at MedInfo2010 South Africa Thailand’s eHealth: 2010
  23. 23. 23  All components are essential  All components should be balanced Slide adapted from: Dr. Boonchai Kijsanayotin Recalling eHealth Components
  24. 24. 24Slide adapted from: Dr. Boonchai Kijsanayotin Thailand: Unbalanced Development
  25. 25. 25  Silo-type systems  Little integration and interoperability  Mostly aim for administration and management  40% of work-hours spent on managing reports and documents  Lack of national leadership and governance body  Inadequate HIS foundations development Boonchai Kijsanayotin et al. (2010) Thailand’s eHealth Situation
  26. 26. 26 eHealth Components
  27. 27. 27 Nationwide survey on hospital IT adoption conducted in 2011 THAIS: Thai Hospitals’ Adoption of Information Technology Survey Self-administered paper-based survey mailed to 1,298 hospitals in Thailand Thailand’s Hospital IT Adoption
  28. 28. 28Pongpirul et al., 2004 Vendor/Product Distribution (2004)
  29. 29. 29Theera-Ampornpunt, 2011 Vendor/Product Distribution (2011)
  30. 30. 30 Estimate (Partial or Complete Adoption) Nationwide Basic EHR, outpatient 86.6% Basic EHR, inpatient 50.4% Basic EHR, both settings 49.8% Order entry of medications, outpatient 96.5% Order entry of medications, inpatient 91.4% Order entry of medications, both settings 90.2% Hospital IT Adoption Estimates
  31. 31. 31 • High IT adoption rates • Drastic changes in adoption landscape • Adequate infrastructure for information exchange • Next question is on interoperability THAIS: Discussion
  32. 32. 32 eHealth Components
  33. 33. 33 Outline Needs for better information in healthcare eHealth as a health system's component Thailand's eHealth situation • Standards & interoperability • HL7 standards • The road ahead for Thailand's eHealth
  34. 34. 34 Standards Are Everywhere
  35. 35. 35 Standards: Why? • The Large N Problem N = 2, Interface = 1 # Interfaces = N(N-1)/2 N = 3, Interface = 3 N = 5, Interface = 10 N = 100, Interface = 4,950
  36. 36. 36 Hospital A Hospital B Clinic C Government Lab Patient at Home Goal: Health Information Exchange
  37. 37. 37 Objectives • Interoperability • Inter-operable systems Ultimate Goals • Continuity of Care • Quality  Safety  Timeliness  Effectiveness  Equity  Patient-Centeredness  Efficiency Why Health Information Standards?
  38. 38. 38 Levels of Interoperability Functional Semantic Syntactic
  39. 39. 39 Various Kinds of Standards • Unique Identifiers • Standard Data Sets • Vocabularies & Terminologies • Exchange Standards – Message Exchange – Document Exchange • Functional Standards • Technical Standards – Data Communications, Encryption, Security
  40. 40. 40 Functional Semantic Syntactic How Standards Support Interoperability Technical Standards (TCP/IP, encryption, security) Exchange Standards (HL7 v.2, HL7 v.3 Messaging, HL7 CDA, DICOM) Vocabularies, Terminologies, Coding Systems (ICD-10, ICD-9, CPT, SNOMED CT, LOINC) Information Models (HL7 v.3 RIM, ASTM CCR, HL7 CCD) Standard Data Sets Functional Standards (HL7 EHR Functional Specifications) Some may be hybrid: e.g. HL7 v.3, HL7 CCD Unique ID
  41. 41. 41 Message Exchange • Goal: Specify format for exchange of data • Internal vs. external messages • Examples  HL7 v.2  HL7 v.3 Messaging  DICOM  NCPDP Document Exchange • Goal: Specify format for exchange of “documents” • Examples  HL7 v.3 Clinical Document Architecture (CDA)  ASTM Continuity of Care Record (CCR)  HL7 Continuity of Care Document (CCD) Exchange Standards
  42. 42. 42 Messages • Human Unreadable • Machine Processable Clinical Documents • Human Readable • (Ideally) Machine Processable Exchange Standards
  43. 43. 43 Hospital A Hospital B Clinic C Government Lab Patient at Home Message Exchange Message Message Message Message Message
  44. 44. 44 Hospital A Hospital B Clinic C Government Lab Patient at Home Clinical Document Exchange Message containing Referral Letter Message containing Claims Request Message containing Lab Report Message containing Patient Visit Summary Message containing Communicable Disease Report
  45. 45. 45 Standards National 1. Core data set standards 12 & 18 files standards 2. Semantic standards Personal ID, Provider ID ICD-10-TM, ICD-9-CM 3. Syntactic standards X 4. Security and privacy standards X Slide adapted from: Dr. Boonchai Kijsanayotin Existing Standards in Thailand
  46. 46. 46 Standards National 1. Core data set standards Referral, Chronic Diseases 2. Semantic standards Drug Terminology (TMT), SNOMED-CT Lab Code (LOINC) Providers IDs 3. Syntactic standards HL7 Messaging, CDA 4. Security and privacy standards X Standards Being Explored/Developed Slide adapted from: Dr. Boonchai Kijsanayotin
  47. 47. 47 Thai Health Information Standards Development Center www.this.or.th http://www.facebook.com/thishsri this@this.or.th Standards Development Organization Slide adapted from: Dr. Boonchai Kijsanayotin
  48. 48. 4848 eHealth & e-Transactions
  49. 49. 49 • HL7 Certified Specialists Kevin Asavanant HL7 V3 RIM (2009) Supachai Parchariyanon HL7 CDA (2010) Nawanan Theera-Ampornpunt HL7 CDA (2012) 49 Sireerat Srisiriratanakul HL7 V3 RIM (2013) Capacity Building on Standards
  50. 50. 50 URGES Member States: (1) to consider, as appropriate, options to collaborate with relevant stakeholders, including national authorities, relevant ministries, health care providers, and academic institutions, in order to draw up a road map for implementation of ehealth and health data standards at national and subnational levels; (2) to consider developing, as appropriate, policies and legislative mechanisms linked to an overall national eHealth strategy, in order to ensure compliance in the adoption of ehealth and health data standards by the public and private sectors, as appropriate, and the donor community, as well as to ensure the privacy of personal clinical data; ... http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf World Health Assembly Resolution WHA66.24 (2013) on eHealth Standardization & Interoperability
  51. 51. 51 Outline Needs for better information in healthcare eHealth as a health system's component Thailand's eHealth situation Standards & interoperability • HL7 standards • The road ahead for Thailand's eHealth
  52. 52. What is HL7? • HL7 is an ANSI-accredited Standards Development Organization (SDO) operating in the healthcare arena. • It is a non-profit organization made up of volunteers – providers, customers, vendors, government, etc. 52 Slide adapted from: Dr. Supachai Parchariyanon
  53. 53. What is HL7? (Cont.) • HL7 is an acronym for Health Level Seven – Seven represents the highest, or “application” level of the International Standards Organization (ISO) communications model for Open Systems Interconnection (OSI) networks. 53 Slide adapted from: Dr. Supachai Parchariyanon
  54. 54. OSI Model 54 Slide adapted from: Dr. Supachai Parchariyanon
  55. 55. 55 HL7 Standards • HL7 V2.x – Defines electronic messages supporting hospital operations • HL7 V3 • HL7 Clinical Document Architecture (CDA) Releases 1 and 2 • HL7 Arden Syntax – Representation of medical knowledge • HL7 EHR & PHR Functional Specifications • Etc.
  56. 56. 56 HL7 V3 Standards • A family of standards based on V3 information models and development methodology • Components – HL7 V3 Reference Information Model (RIM) – HL7 V3 Messaging – HL7 Development Framework (HDF)
  57. 57. 57 Sample HL7 v.2 Message (Lab Result) OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml| 0-1.3|H||H|F|19980309…
  58. 58. 58 Sample HL7 v.3 Message (Patient Registration) <?xml version="1.0" encoding="UTF-8"?> <PRPA_IN101311UV02 xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" ITSVersion="XML_1.0" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/PRPA_IN101311UV02.xsd"> ... <name use="SYL" > <given>นวนรรน</given> <family>ธีระอัมพรพันธุ</family> </name> <name use="ABC"> <given>Nawanan</given> <family>Theera-Ampornpunt</family> </name> <administrativeGenderCode code="M"/> ... </PRPA_IN101311UV02> Message source adapted from Ramathibodi HL7 Project by Supachai Parchariyanon, Kavin Asavanant, Sireerat Srisiriratanakul & Chaiwiwat Tongtaweechaikit
  59. 59. 59 HL7 Reference Information Model (RIM) Source: HL7 CDA R2
  60. 60. 60 Source: “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  61. 61. 61 HL7 V3 Messaging • V3 provides messaging standards for – Patient administration – Medical records – Orders – Laboratory – Claims & Reimbursement – Care provision – Clinical genomics – Public Health – Etc.
  62. 62. 62 What Is HL7 CDA? • “A document markup standard that specifies structure & semantics of “clinical documents” for the purpose of exchange” [Source: HL7 CDA Release 2] • Focuses on document exchange, not message exchange • A document is packaged in a message during exchange • Note: CDA is not designed for document storage. Only for exchange!!
  63. 63. 63 A Clinical Document (1) • A documentation of clinical observations and services, with the following characteristics:  Persistence - continues to exist in an unaltered state, for a time period defined by local and regulatory requirements  Stewardship - maintained by an organization entrusted with its care  Potential for authentication - an assemblage of information that is intended to be legally authenticated Source: HL7 CDA R2
  64. 64. 64 A Clinical Document (2) • A documentation of clinical observations and services, with the following characteristics:  Context - establishes the default context for its contents; can exist in non-messaging contexts  Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without full context of the document  Human readability - human readable Source: HL7 CDA R2
  65. 65. 65 A Clinical Document (3) • A CDA document is a defined & complete information object that can include  Text  Images  Sounds  Other multimedia content Source: HL7 CDA R2
  66. 66. 66 CDA Releases • CDA Release 1 (ANSI-approved in 2000) – First specification derived from HL7 RIM • CDA Release 2 (2005) - Current Release – Basic model essentially unchanged from R1 • Document has a header & a body • Body contains nested sections • Sections can be coded using standard vocabularies and can contain entries – Derived from HL7 RIM Version 2.07 Source: HL7 CDA R2
  67. 67. 67 Key Aspects of CDA • CDA documents are encoded in XML  When alternative implementations are feasible, new conformance requirements will be issued • CDA documents derive their machine processable meaning from HL7 RIM and use HL7 V3 Data Types • CDA specification is richly expressive & flexible  Templates can be used to constrain generic CDA specifications Source: HL7 CDA R2
  68. 68. 68 Scope of CDA Lab Technician Physician Lab Report Create document Process & Store document Transmit document CDA
  69. 69. 69 CDA & HL7 Messages • Documents complement HL7 messaging specifications • Documents are defined and complete information objects that can exist outside of a messaging context • A document can be a MIME-encoded payload within an HL7 message Source: “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  70. 70. 70 CDA & Message Exchange • CDA can be payload (or content) in any kind of message – HL7 V2.x message – HL7 V3 message – EDI ANSI X12 message – IHE Cross-Enterprise Document Sharing (XDS) message • And it can be passed from one kind to another Source: “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  71. 71. 71 CDA & Message Exchange Clinical Document (Payload) HL7 V3 Message (Message) HL7 V2 Message (Message) Source: Adapted from “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  72. 72. 72 CDA As Payload Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  73. 73. 73 CDA Model Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  74. 74. 74 A Closer Look at a CDA Document <ClinicalDocument> ... CDA Header ... <structuredBody> <section> <text>... Single Narrative Block ...</text> <observation>...</observation> <substanceAdministration> <supply>...</supply> </substanceAdministration> <observation> <externalObservation>... </externalObservation> </observation> </section> <section> <section>...</section> </section> </structuredBody> </ClinicalDocument> Source: HL7 CDA R2 Human Readable Part Machine Processable Parts
  75. 75. 75 Rendering CDA Documents (1) Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  76. 76. 76 Rendering CDA Documents (2) Source: From “What is CDA R2? by Calvin E. Beebe at HL7 Educational Summit in July 2012
  77. 77. 77 Human Readability & Rendering CDA Documents (3) Source: HL7 CDA R2 <ClinicalDocument> ... CDA Header ... <structuredBody> <section> <text>... Single Narrative Block ...</text> <observation>...</observation> <substanceAdministration> <supply>...</supply> </substanceAdministration> <observation> <externalObservation>... </externalObservation> </observation> </section> <section> <section>...</section> </section> </structuredBody> </ClinicalDocument> Text to be rendered
  78. 78. 78 Some Possible Use Cases of CDA  Intra-institutional  Exchange of parts of medical records (scanned or structured electronic health records)  Lab/Imaging requests & reports  Prescriptions/order forms  Admission notes  Progress notes  Operative notes  Discharge summaries  Payment receipts  Other forms/documents (clinical or administrative)
  79. 79. 79 Some Possible Use Cases of CDA  Inter-institutional  Referral letters  Claims requests or reimbursement documents  External lab/imaging reports  Visit summary documents  Insurance eligibility & coverage documents  Identification documents  Disease reporting  Other administrative reports
  80. 80. 80 Achieving Interoperability  CDA is a general-purpose, broad standard  Use in each use case or context requires implementation guides to constrain CDA  Examples  Operative Note (OP)  Consultation Notes (CON)  Care Record Summary (CRS)  Continuity of Care Document (CCD)  CDA for Public Health Case Reports (PHCRPT)  Quality Reporting Document Architecture (QRDA)
  81. 81. 81 Outline Needs for better information in healthcare eHealth as a health system's component Thailand's eHealth situation Standards & interoperability HL7 standards • The road ahead for Thailand's eHealth
  82. 82. 82 Back to Thailand’s eHealth status: Workforce
  83. 83. 83 eHealth Components 83
  84. 84. 84 • Certificate & Diploma Level • Undergraduate Level • Graduate Level 84 Informatics Workforce Programs
  85. 85. 85 Faculty of Medicine Ramathibodi Hospital, Mahidol University http://med.mahidol.ac.th/has/85 Healthcare CIO Certificate Program
  86. 86. 86Faculty of Tropical Medicine, Mahidol University86 Diploma & Master Graduates in Biomedical & Health Informatics, First Batch
  87. 87. 87 • In January 2013, the Thai Medical Informatics Association (TMI) approved establishment of the “Biomedical and Health Informatics Education Special Interest Group” within TMI (BHI-ED-SIG) 87 Informatics Education SIG
  88. 88. 8888 TMI CIO Forum
  89. 89. 89 • International Medical Informatics Association (IMIA) – MEDINFO & APAMI • HIMSS AsiaPac • Asia eHealth Information Network (AeHIN) • American Medical Informatics Association (AMIA) 89 Internationalization
  90. 90. 90http://www.aehin.org/Meetings/2013AeHINGeneralMeeting.aspx90 Participation in AeHIN
  91. 91. 91 Outline Needs for better information in healthcare eHealth as a health system's component Thailand's eHealth situation Standards & interoperability HL7 standards • The road ahead for Thailand's eHealth
  92. 92. 92 The Road Ahead for Thailand’s eHealth
  93. 93. 93 • Addressing – Lack of national leadership & governance, strategy & investment, policy & regulation – Shortage of informatics workforce – Accelerating standards development – Harmonizing applications – Facilitating local research in informatics 93 The Road Ahead
  94. 94. 94Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/ The Journey Beyond
  95. 95. 95 But We’ll Get There...
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