Semantic Interoperability
of the Electronic Health Record:
Ambitions and realities
David Moner
damoca@upv.es
Biomedical In...
Semantic Interoperability
of the EHR
We talk about semantic
interoperability…
…but do we really know what we are
talking a...
Semantic Interoperability
of the EHR
Semantic
Interoperability
What?
Semantic Interoperability: ambitions and realities 5©...
What?
• Interoperability is the ability of two or more
heterogeneous systems to communicate
and share processes and data.
...
What?
• Edwin Smith Papyrus, 16th century B.C.
• It is as incomprehensible as current EHR!!!
© David Moner Semantic Intero...
What?
• SI of the Electronic Health Records (EHR)
– Share and semantically process EHR
information.
– Currently it is a ke...
Semantic Interoperability
of the EHR
Semantic
Interoperability
What?
Why?
Semantic Interoperability: ambitions and realiti...
Semantic Interoperability: ambitions and realities
Why?
• Our objective is the semantic interoperability of
clinical infor...
Why?
Semantic Interoperability: ambitions and realities 11
• 10813 kilometres
• Different languages
• Different treatments...
Why?
Semantic Interoperability: ambitions and realities 12
• Spain
• 17 autonomous regions
• 17 independent health systems...
Semantic Interoperability: ambitions and realities
EHR
server
EHR
server
EHR
server
EHR
server
EHR
server
EHR
server
EHR
s...
Semantic Interoperability: ambitions and realities
EHR
server
EHR
server
EHR
server
EHR
server
EHR
server
EHR
server
EHR
s...
Semantic Interoperability: ambitions and realities 15
Why?
© David Moner
Why?
Use case 1
© David Moner Semantic Interoperability: ambitions and realities 16
EHR History
Country A Country B
EHR
ξβ...
Why?
Use case 2
© David Moner Semantic Interoperability: ambitions and realities 17
Consultation
EHR
EHR
Why?
Use case 3
© David Moner Semantic Interoperability: ambitions and realities 18
EHR EHR EHR
Public health
EHR
EHR
EHR
Why?
• Many more use cases and benefits:
public-private health transitions, clinical
research, interaction with Personal H...
Semantic Interoperability
of the EHR
Semantic
Interoperability
What?
How?Why?
Semantic Interoperability: ambitions and rea...
EHR systems now
Semantic Interoperability: ambitions and realities 21© David Moner
The EHR systems we need
Semantic Interoperability: ambitions and realities 22
Rules Information Presentation Soft. Hardwar...
Semantic Interoperability: ambitions and realities
© Gerard Freriks
23
How?
© David Moner
We are moving
towards a
plug-and...
How?
Semantic Interoperability: ambitions and realities 24© David Moner
• Not only infrastructure is important, but
also i...
Model of Knowledge
Codes/terms
Model of
Documentation
Real use
Model of Meaning
general Use
Model of Meaning
specific Use
...
How?
Semantic Interoperability: ambitions and realities 26
SYSTEM A SYSTEM B
Health
information
Structure A
Semantic A
Lan...
How?
Terminologies
• We must implement and use medical
terminologies and ontologies.
– They are the interface between the ...
How?
Standards
• Adoption of standards for the
representation and communication of the
information contained at the EHR.
•...
How?
Standards
Keith Boone, Standards Geek for GE Healthcare.
© David Moner Semantic Interoperability: ambitions and reali...
How?
Standards
• Mistake: To look for homogenisation,
instead of cooperation and harmonisation.
Semantic Interoperability:...
How?
Detailed Clinical Models
• A Detailed Clinical Model (DCM) is an information model of a
discrete set of precise clini...
How?
Detailed Clinical Models
© David Moner Semantic Interoperability: ambitions and realities 32
Model of Knowledge
Codes...
33© David Moner Semantic Interoperability: ambitions and realities
How?
Detailed Clinical Models
ISO 13606
• How can we bring DCMs to a working
system?
• ISO 13606 – Communication of the EHR
– It has been designed speci...
ISO 13606
• Information: statements about specific entities.
– Represented by a Reference Model.
– For example, the statem...
• The archetype model is a formal framework to define high
level and semantically rich definitions of health concepts
(arc...
© David Moner Semantic Interoperability: ambitions and realities 37
25571000000103
(Discharge report)
SNOMED-CT
89100005
(...
© David Moner Semantic Interoperability: ambitions and realities 38
English German Spanish
http://www.linkehr.com/
ISO 136...
39© David Moner Semantic Interoperability: ambitions and realitieshttp://ehrflex.sourceforge.net/
© David Moner Semantic Interoperability: ambitions and realities 40
ISO 13606
http://www.linkehr.com/
• We can create
arch...
ISO 13606
• We can automatically convert an archetype
from one reference model to another.
© David Moner Semantic Interope...
DCM
Coding systems
Rules
Software
Tools
Services
Archetypes
Templates
© David Moner Semantic Interoperability: ambitions a...
How?
• Some projects in Europe:
– Spain. Generation and communication of a
common patient summary among all the
regions.
–...
Large Scale Pilot: epSOS
• European Patient Smart Open Services (epSOS)
– The project is co-financed by the European Commi...
Large Scale Pilot: epSOS
• The epSOS project cover three use cases:
– Communication of the Patient Summary, including aler...
Large Scale Pilot: epSOS
• Methodology:
1. Clinical specifications were developed by a
clinicians
2. A set of terminologie...
Semantic Interoperability: ambitions and realities
An epSOS pilot experience
• The semantic interoperability of the Patien...
© David Moner Semantic Interoperability: ambitions and realities 48
An epSOS pilot experience
Hospital de Fuenlabrada
Madr...
An epSOS pilot experience
• The LinkEHR Normalisation Platform is a multi-
standard system that helps to achieve the
Seman...
Semantic Interoperability: ambitions and realities
An epSOS pilot experience
1. Agree a concept definition and define the ...
Semantic Interoperability: ambitions and realities 51
An epSOS pilot experience
2. Map the archetype to original/legacy da...
Semantic Interoperability: ambitions and realities
An epSOS pilot experience
3. Deploy the transformation program in the E...
Semantic Interoperability: ambitions and realities 53© David Moner
Semantic Interoperability
of the EHR
Semantic
Interoperability
What?
How?
Who?
Why?
Semantic Interoperability: ambitions a...
Who?
• Clinicians
– Clinical users must be involved from the
beginning.
– They are responsible of defining their own
domai...
Who?
• Technicians
– Technical decisions must not modify the
clinical ones.
• Standardisation bodies
– They need more harm...
Semantic Interoperability
of the EHR
Semantic
Interoperability
What?
How?
When?Who?
Why?
Semantic Interoperability: ambiti...
When?
• To achieve SI is still a long way ahead.
• We have the tools, but we still need to use
them correctly.
• The big p...
Semantic Interoperability: ambitions and realities 59© David Moner
Semantic Interoperability: ambitions and realities 60© David Moner
Conclusion
• Clinicians must lead the process
– They must be aware of the benefits of SI for their daily
work.
• They keys...
Semantic Interoperability: ambitions and realities 62© David Moner
It always seems impossible
until its done
Nelson Mandel...
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Semantic Interoperabilityof the Electronic Health Record:Ambitions and realities

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Semantic interoperability of the Electronic Health Record (EHR) has been identified as a key objective of current and future Health Information Systems. But there is often a misunderstanding on what does semantic interoperability really means and requires and, at the same time, a limited view on which advantages it can provide to improve healthcare.

The adoption of appropriate standards for the representation and communication of the information contained at the EHR is only a first step. And a first mistake is to think that only one of them has the perfect solution or can cover all needs for every case of use. The harmonisation and combined use of many health standards is the correct path to success instead of the confrontation between them.

A second requirement is the proper and intensive use of medical terminologies and ontologies. They provide the ideal interface between the daily health care language and a first level of formalisation that will be needed to achieve a complete semantic interoperability. Once again, the solution will not come from the use of a globally unique terminology, but from the correct combination of them all.

Finally, the last and most important requirement is to agree on which the domain concepts that we will use at the health domain are. This agreement, in the form of clinical and technical specifications such as templates, archetypes and detailed clinical models, is a key aspect for semantically interoperable systems, but it has been traditionally left out of the development efforts. Semantic interoperability will not be achieved only by using common syntaxes (standards) and common words (terminologies). It necessarily requires the agreement on the different concepts from the reality that we are going to use in our communication process. And this agreement can only be done with the participation of health professionals and not by technical decisions.

Semantic interoperability has a long-term roadmap that will require many efforts, but the benefits will clearly surpass any expectation. The ability of an information system to automatically share and understand information originated at any other different information system means not only the possibility of achieve a quality continuity of care for patients through the communication of their EHR. It also opens the door to new and exciting possibilities such as the interaction of the EHR with Personal Health Records and a seamless integration of telemedicine systems. Also, the convenient reuse of health information for public health and medicine research will improve the quality of life of people all over the world.

Publication:
David Moner. "Semantic Interoperabilityof the Electronic Health Record:Ambitions and realities". Keynote, Joint Conference on Medical Informatics in Taiwan, Taipei, 2010

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Semantic Interoperabilityof the Electronic Health Record:Ambitions and realities

  1. 1. Semantic Interoperability of the Electronic Health Record: Ambitions and realities David Moner damoca@upv.es Biomedical Informatics group - ITACA Institute Technical University of Valencia, Spain Joint Conference on Medical Informatics in Taiwan
  2. 2. Semantic Interoperability of the EHR We talk about semantic interoperability… …but do we really know what we are talking about? Semantic Interoperability: ambitions and realities 4© David Moner
  3. 3. Semantic Interoperability of the EHR Semantic Interoperability What? Semantic Interoperability: ambitions and realities 5© David Moner
  4. 4. What? • Interoperability is the ability of two or more heterogeneous systems to communicate and share processes and data. • Semantic Interoperability (SI) is the ability of sharing, aggregate, analyse and use external information automatically and in a meaningful way. Semantic Interoperability: ambitions and realities 6© David Moner
  5. 5. What? • Edwin Smith Papyrus, 16th century B.C. • It is as incomprehensible as current EHR!!! © David Moner Semantic Interoperability: ambitions and realities 7
  6. 6. What? • SI of the Electronic Health Records (EHR) – Share and semantically process EHR information. – Currently it is a key objective of Health Information Systems. – But is it really necessary at all places and levels? • Mistake: the SI for the sake of it. Semantic Interoperability: ambitions and realities 8© David Moner
  7. 7. Semantic Interoperability of the EHR Semantic Interoperability What? Why? Semantic Interoperability: ambitions and realities 9© David Moner
  8. 8. Semantic Interoperability: ambitions and realities Why? • Our objective is the semantic interoperability of clinical information. Alerts Current history Past history Medications And all the information we use and need 10© David Moner
  9. 9. Why? Semantic Interoperability: ambitions and realities 11 • 10813 kilometres • Different languages • Different treatments • Different healthcare systems The same illness! © David Moner
  10. 10. Why? Semantic Interoperability: ambitions and realities 12 • Spain • 17 autonomous regions • 17 independent health systems • 4 official languages • 46 million inhabitants • ~60 million tourists/year © David Moner
  11. 11. Semantic Interoperability: ambitions and realities EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server Why? 13© David Moner
  12. 12. Semantic Interoperability: ambitions and realities EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server EHR server 14 Why? © David Moner
  13. 13. Semantic Interoperability: ambitions and realities 15 Why? © David Moner
  14. 14. Why? Use case 1 © David Moner Semantic Interoperability: ambitions and realities 16 EHR History Country A Country B EHR ξβñç!
  15. 15. Why? Use case 2 © David Moner Semantic Interoperability: ambitions and realities 17 Consultation EHR EHR
  16. 16. Why? Use case 3 © David Moner Semantic Interoperability: ambitions and realities 18 EHR EHR EHR Public health EHR EHR EHR
  17. 17. Why? • Many more use cases and benefits: public-private health transitions, clinical research, interaction with Personal Health Records, seek of a reduction of costs… • There is a need to share health information. • There is a wish to improve healthcare. © David Moner Semantic Interoperability: ambitions and realities 19
  18. 18. Semantic Interoperability of the EHR Semantic Interoperability What? How?Why? Semantic Interoperability: ambitions and realities 20© David Moner
  19. 19. EHR systems now Semantic Interoperability: ambitions and realities 21© David Moner
  20. 20. The EHR systems we need Semantic Interoperability: ambitions and realities 22 Rules Information Presentation Soft. Hardware EHR Instructions Ingredients Moulds Kitchen machines Oven Pastry TechnologyKnowledge © David Moner
  21. 21. Semantic Interoperability: ambitions and realities © Gerard Freriks 23 How? © David Moner We are moving towards a plug-and-play services world
  22. 22. How? Semantic Interoperability: ambitions and realities 24© David Moner • Not only infrastructure is important, but also infostructure. – An infrastructure refers to the physical substrate which must be laid down in order to provide a service. – An infostructure isn’t anything physical. It is the layout of information in a manner such that it can be organised, navigated and used.
  23. 23. Model of Knowledge Codes/terms Model of Documentation Real use Model of Meaning general Use Model of Meaning specific Use Encyclopaedia Dictionary Syntaxis Paper/Document Generic Phrase Specific Phrase © David Moner Semantic Interoperability: ambitions and realities 25 How? The semantic stack Data Model
  24. 24. How? Semantic Interoperability: ambitions and realities 26 SYSTEM A SYSTEM B Health information Structure A Semantic A Language A Structure B Semantic B Language B Context A Context B ? © David Moner Reference Model Clinical models Terminology
  25. 25. How? Terminologies • We must implement and use medical terminologies and ontologies. – They are the interface between the daily health care language and a first level of formalisation. • Mistake: The solution will not come from the use of a unique terminology, but from the correct combination of many of them. Semantic Interoperability: ambitions and realities 27© David Moner
  26. 26. How? Standards • Adoption of standards for the representation and communication of the information contained at the EHR. • Mistake: To think that only one standard will exist covering all needs for every case of use. Semantic Interoperability: ambitions and realities 28© David Moner
  27. 27. How? Standards Keith Boone, Standards Geek for GE Healthcare. © David Moner Semantic Interoperability: ambitions and realities 29 Red arrows are Joint work products. Blue arrows are MOUs. Green arrows are Memberships. Purple arrows are Liaison Relationships. Yellow connections are between SCO Summit Organizations Orange connections are between JIC Organizations
  28. 28. How? Standards • Mistake: To look for homogenisation, instead of cooperation and harmonisation. Semantic Interoperability: ambitions and realities 30© David Moner
  29. 29. How? Detailed Clinical Models • A Detailed Clinical Model (DCM) is an information model of a discrete set of precise clinical knowledge. – In other words, a formal definition of the structure and meaning of a clinical concept. • We must agree on which DCMs we will use at our application domain. • This agreement, in the form of clinical and technical specifications such as archetypes and templates, is a key aspect for semantically interoperable systems – Must be done with the participation of health professionals and not by technical decisions. Semantic Interoperability: ambitions and realities 31© David Moner
  30. 30. How? Detailed Clinical Models © David Moner Semantic Interoperability: ambitions and realities 32 Model of Knowledge Codes/terms Model of Documentation Real use Model of Meaning general Use Model of Meaning specific Use Data Model DCM DCM Model/Ontology ISO 13606 Archetypes HL7 v3 Templates
  31. 31. 33© David Moner Semantic Interoperability: ambitions and realities How? Detailed Clinical Models
  32. 32. ISO 13606 • How can we bring DCMs to a working system? • ISO 13606 – Communication of the EHR – It has been designed specifically to achieve the semantic interoperability of the EHR. – It is prepared to work with formal clinical concepts in the form of archetypes. – Based on a dual model approach. © David Moner Semantic Interoperability: ambitions and realities 34
  33. 33. ISO 13606 • Information: statements about specific entities. – Represented by a Reference Model. – For example, the statement “Gina Smith (2y) has an atrial septal defect, 1 cm x 3.5 cm” is a statement about Gina Smith, and does not apply to other people in general. • Knowledge: statements which apply to all entities of a class. – Represented by an Archetype Model. – For example, “the atrial septum divides the right and left atrial chambers of the human heart”. © David Moner Semantic Interoperability: ambitions and realities 35
  34. 34. • The archetype model is a formal framework to define high level and semantically rich definitions of health concepts (archetypes) • Properties – Defines constraints over data structures – Defines semantic descriptions of concepts – It is automatically computable – It is multilingual – It can evolve and change to new requirements – It can be defined by clinicians and shared – It can generate screen forms automatically © David Moner Semantic Interoperability: ambitions and realities 36 ISO 13606
  35. 35. © David Moner Semantic Interoperability: ambitions and realities 37 25571000000103 (Discharge report) SNOMED-CT 89100005 (Final diagnosis - discharge) 85097005 (Secondary diagnosis ) … ISO 13606 http://www.linkehr.com/
  36. 36. © David Moner Semantic Interoperability: ambitions and realities 38 English German Spanish http://www.linkehr.com/ ISO 13606
  37. 37. 39© David Moner Semantic Interoperability: ambitions and realitieshttp://ehrflex.sourceforge.net/
  38. 38. © David Moner Semantic Interoperability: ambitions and realities 40 ISO 13606 http://www.linkehr.com/ • We can create archetypes for any reference model. – Ex. HL7 CDA archetype
  39. 39. ISO 13606 • We can automatically convert an archetype from one reference model to another. © David Moner Semantic Interoperability: ambitions and realities 41http://miuras.inf.um.es:9080/PoseacleConverter/
  40. 40. DCM Coding systems Rules Software Tools Services Archetypes Templates © David Moner Semantic Interoperability: ambitions and realities 42 How?
  41. 41. How? • Some projects in Europe: – Spain. Generation and communication of a common patient summary among all the regions. – Sweden. Roadmap towards an ISO 13606 native system for all the country. – United Kingdom. National implementation of a Logical Record Architecture (ISO 13606) and a spine for communications (HL7 v3) © David Moner Semantic Interoperability: ambitions and realities 43
  42. 42. Large Scale Pilot: epSOS • European Patient Smart Open Services (epSOS) – The project is co-financed by the European Commission and member states with EUR 22.000.000. – epSOS was launched on July 1, 2008 and will finish on June 30, 2011 Semantic Interoperability: ambitions and realities 44© David Moner – It is a Europe-wide project organized by 27 beneficiaries representing twelve EU- member states, including ministries of health, national competence centres and numerous companies.
  43. 43. Large Scale Pilot: epSOS • The epSOS project cover three use cases: – Communication of the Patient Summary, including alerts, medical problems (past and current), list of medications… – ePrescription, a medical professional decides to prescribe medicine to a visiting patient from another country. – eDispensation, allowing a pharmacist to electronically access the prescription from the same eHealth interface used for prescriptions ordered in the local country. © David Moner Semantic Interoperability: ambitions and realities 45
  44. 44. Large Scale Pilot: epSOS • Methodology: 1. Clinical specifications were developed by a clinicians 2. A set of terminologies was selected, from international sources or as an own development. 3. Technical specifications in HL7 CDA and ISO 13606 were defined following the clinical specifications. 4. Pilot tests are being implemented. © David Moner Semantic Interoperability: ambitions and realities 46
  45. 45. Semantic Interoperability: ambitions and realities An epSOS pilot experience • The semantic interoperability of the Patient Summary is being tested between the Hospital General Universitario in Valencia (HGUV) and the Hospital de Fuenlabrada in Madrid. – Based both on the Spanish and epSOS definition of the contents of the Patient Summary. – The information is communicated using the ISO 13606 norm. 47© David Moner
  46. 46. © David Moner Semantic Interoperability: ambitions and realities 48 An epSOS pilot experience Hospital de Fuenlabrada Madrid Hospital General Universitario Valencia Communication of standardized ISO 13606 informationEHR Server EHR Server
  47. 47. An epSOS pilot experience • The LinkEHR Normalisation Platform is a multi- standard system that helps to achieve the Semantic Interoperability of existing EHR systems. • The methodology is based on three steps: 1. Definition of clinical archetypes. 2. Normalisation of legacy EHR systems. 3. Communication of EHR extracts. http://www.linkehr.com Semantic Interoperability: ambitions and realities 49© David Moner
  48. 48. Semantic Interoperability: ambitions and realities An epSOS pilot experience 1. Agree a concept definition and define the archetype • We used two different definitions – Spanish National Patient Summary – epSOS Patient Summary • They can be easily edited or modified with open source archetype editors such as LinkEHR. 50© David Moner
  49. 49. Semantic Interoperability: ambitions and realities 51 An epSOS pilot experience 2. Map the archetype to original/legacy data • With these mappings we can automatically generate transformation programs for the EHR system. XML Existing EHR systems © David Moner
  50. 50. Semantic Interoperability: ambitions and realities An epSOS pilot experience 3. Deploy the transformation program in the EHR server • Set up a standard ISO 13606 extract server in both hospitals to generate and communicate the standardized information – Transformation is applied on demand – Web-service based – Includes a standard ISO 13606 web viewer EHR Server XML ISO 13606 Standard Information Mapped Archetype CHGUV HIS HF HIS EHR Server Mapped Archetype 52© David Moner
  51. 51. Semantic Interoperability: ambitions and realities 53© David Moner
  52. 52. Semantic Interoperability of the EHR Semantic Interoperability What? How? Who? Why? Semantic Interoperability: ambitions and realities 54© David Moner
  53. 53. Who? • Clinicians – Clinical users must be involved from the beginning. – They are responsible of defining their own domain (DCMs, archetypes). – They must share and reuse this knowledge. • A global DCM/archetype governance is needed. © David Moner Semantic Interoperability: ambitions and realities 55 http://www.openehr.org/knowledge/
  54. 54. Who? • Technicians – Technical decisions must not modify the clinical ones. • Standardisation bodies – They need more harmonisation and coordination efforts. © David Moner Semantic Interoperability: ambitions and realities 56
  55. 55. Semantic Interoperability of the EHR Semantic Interoperability What? How? When?Who? Why? Semantic Interoperability: ambitions and realities 57© David Moner
  56. 56. When? • To achieve SI is still a long way ahead. • We have the tools, but we still need to use them correctly. • The big problem still to be solved: to compute the EHR semantically. – How can a machine correctly use the semantic information to behave correctly? © David Moner Semantic Interoperability: ambitions and realities 58
  57. 57. Semantic Interoperability: ambitions and realities 59© David Moner
  58. 58. Semantic Interoperability: ambitions and realities 60© David Moner
  59. 59. Conclusion • Clinicians must lead the process – They must be aware of the benefits of SI for their daily work. • They keys are agreements and harmonisation: – Agree on using common and generic DCMs. – There will always exist several standards and terminologies, and each of them can be adequate for a specific duty. © David Moner Semantic Interoperability: ambitions and realities 61
  60. 60. Semantic Interoperability: ambitions and realities 62© David Moner It always seems impossible until its done Nelson Mandela David Moner damoca@upv.es

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