Standards and interoperability: Towards 2014


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Alastair Kenworthy
Ministry of Health
(Wednesday, Interoperability Workshop)

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  • This slide set presents a state of the nation in the pursuit of New Zealand’s eHealth directives, and in particular progress towards the 2014 vision.
  • This is the e-health destination as described by NHITBWith a further theme of sustainability in the health system
  • These are the National Health IT Board priority programmes for 2012-14Underpinned 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.
  • 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)
  • What have we solved so far?
  • 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
  • Connected 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.
  • 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
  • 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 NZePS
  • 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.
  • 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 excellence
  • HIT is a creative industry to be working in
  • Standards and interoperability: Towards 2014

    1. 1. Standards and interoperability Towards 2014 7 November 2012 PREPARED BY
    2. 2. 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 2
    3. 3. National priorities 2012-14eMedicines 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 3
    4. 4. Realising the 2014 vision 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 4
    5. 5. Repository-based information sharing 5
    6. 6. GP2GPCurrently about 4000 medical records transfers per monthAbout 50% of GPs are usersFiles over 5 MB have to be sent the old fashioned way (a future upgradewill allow files to be sent in pieces) 6
    7. 7. The solution space 7
    8. 8. Connected care 8
    9. 9. 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 9
    10. 10. SHARED CARE 10
    11. 11. Emergency care Ambulance sends ePRF (as a kind of referral, but also an event summary) to hospital ED Ambulance accesses primary care info and previous discharge summaries Presenting complaint, diagnoses etc are SNOMED codedCommon ED solution basedon hospital PAS and CWS eDS shared via R-CDR 11
    12. 12. Discharge and follow ups Discharge Rx via NZePS  eDS shared via R-CDR 12
    13. 13. My List of Medicines 13
    14. 14. My List of Meds – a repository-based application 14
    15. 15. 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 15
    16. 16. Medications management Community ------------------------- Hospital 16
    17. 17. Paperless hospitals 17
    18. 18. Comprehensive clinical assessments Home care assessment Long term care assessment 18
    19. 19. Comprehensive clinical assessments PDF (current) XDS (August 13) CDA + PDF CDA level 3 (Mar 12) 19
    20. 20. CRISP (Central DHBs)Regional PACS archiveRegional CDRRegional PASRegional clinical workstationRegional ED solutionRegional RIS 20
    21. 21. South Island initiativeseSCRV 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) 21
    22. 22. South Island SPaCE programme Support 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 22
    23. 23. 23
    24. 24. Lab test orders and resultsCommunity lab and radiology test ordering solutions are appearing(with decision support and order tracking functions)Lab information standards review – NZPOCS overhaul HL7 v2.4 messaging implementation Judicious coding Message integrity between sender and receiver 24
    25. 25. 25
    26. 26. Baltimore Fire 1904 … 26
    27. 27. Baltimore FHIR 2012 (HL7 WG) 27
    28. 28. 28