This is a presentation of 19 case studies on the coexistence of standards carried out by the eStandards project. More at www.estandards-project.eu

1. Solutions for the Co-Existence of
eHealth Standards:
Lessons Learned
Dr. Marco Eichelberg
OFFIS-Institute
for Information Technology

2. Introduction
• Selecting the appropriate set of standards for achieving
interoperability is a major challenge for all eHealth
deployment projects:
– No single standard would cover all needs of a project
– A multitude of overlapping and, partly, competing standards for
• document formats,
• terminology,
• communication protocols
• etc.
– International consensus unlikely to be achieved anytime soon
• Projects need to address the coexistence between
competing or overlapping standards
– How do they do this?
– What can we learn from their experience?
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3. Introduction
• The eStandards project has published a collection of
19 “case studies” covering concepts and solutions
– in the research domain
– in large-scale eHealth deployment
• eStandards Deliverable 4.1: Solutions for a
Coexistence of eHealth Standards, January 2016.
– 240 pages
– Online: http://bit.ly/1YCuSmA
• The document also summarizes the most important
lessons learned and recommendations from the
experience described in the case studies.
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4. Co-Existence of eHealth Standards: Case Studies
International R&D Projects
• 01: SemanticHealthNet
• 02: Semantic Mediation in ARTEMIS, RIDE and SALUS
• 03: IHE Cross-Community Profiles
• 04: X-Paradigm
• 05: DICOM SR to HL7 CDA Imaging Report Transformation Guide
• 06: Trillium Bridge – Bridging Patient Summaries across the Atlantic
eHealth Deployment Projects
• 07: eHealth Cross-Border Patient Summary and ePrescription /
eDispensation Services: epSOS, EXPAND, and e-SENS
• 08: Nation-wide EHR System in Romania
• 09: National eHealth network in Denmark
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5. Co-Existence of eHealth Standards: Case Studies
eHealth Deployment Projects (continued)
• 10: “Documentation at the Source” Programme in the Netherlands
• 11: EHR Interoperability in Italy
• 12: Delivering 21st Century IT to the English NHS
• 13: Greek National Patient Summary Design
• 14: Spanish Implementation of the EU Patient Summary
• 15: e-SENS ePrescription and Patient Summary pilot for Greece
• 16: Electronic Prescription of Drugs and Pharmaceutical Products
• 17: LIGHt – Local Integration Gateway for eHealth
• 18: Portuguese eHealth National Contact Point
• 19: Portuguese National Broker
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6. The Case Studies
• We asked each project:
– What is the project
about? (Overview)
– What is your approach
to interoperability
(e. g. standards and
profiles used), by layer?
– Where does concurrent use of standards play a role in the
project, and how did you address this?
– What is the governance structure for continuous
maintenance of specifications developed by the project?
– What are the main lessons learned from your project
(successes, pitfalls and remedies)?
– Has your project published resources that could be useful
for future projects?
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7. Coverage of Interoperability Layers, by Case Study
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Antilope Layer
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19
SemanticHealthNet
ARTEMIS,RIDEandSALUS
IHECross-CommunityProfiles
X-Paradigm
DICOMSRtoHL7CDA
TrilliumBridge
Cross-BorderPSandePrescription
Nation-wideEHRSystemRO
eHealthNetworkDK
"DocumentationattheSource"NL
EHRInteroperabilityinItaly
EnglishNHS
GreekNationalPatientSummary
SpanishPatientSummary
e-SENSPilotforGreece
ePrescriptioninPT
eHealthIntegrationGatewayinPT
PTeHealthNationalContactPoint
PTNationalBroker
Legal and Regulatory
Policy
Care Process (x) (x) (x) X (x) X (x) X X (x) (x) (x) (x)
Information X X (x) X X X (x) X (x) X X X (x) (x) (x) (x) X
Applications X X X X (x) X (x) X (x) X (x) X (x) (x) (x) (x)
IT Infrastructure (x) (x) (x) (x) X (x) X (x) X X X
Case Study

8. Results: Competing and Overlapping Standards
• In the „real-world“ eHealth deployment projects, we
found little use of competing / overlapping standards
other than terminology mapping:
– International Classification for Primary Care (ICPC)
and ICD-10 (DK)
– ICD-10 and SNOMED-CT (NL)
– National and regional EHR terminology (IT)
– ICD-10 Procedure Coding System (PCS) and SNOMED-CT
procedures (ES)
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9. Results: Competing and Overlapping Standards
• epSOS developed an elaborated concept for
converting between
– a document in the sending country’s format and
language,
– a document in the receiving country’s format and
language,
– based on a “pivot document”, an intermediate
format for which a mapping from and to each
national format has to be defined.
• Document types: patient summary,
ePrescription / eDispensation, patient consent
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10. Results: Competing and Overlapping Standards
• In R&D projects, we found several elaborated
algorithms for converting between different
equivalent representations of messages or clinical
documents
• These can be classified into 3 approaches that
complement each other:
– Gateway based
– Semantic mediation based
– Model driven
• No “magic bullet”, all approaches have strengths
and weaknesses
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11. Three Approaches to Converting between Formats
• Gateway-based approaches define the access
protocol, but not how a conversion between content
format takes place
• Model driven approaches define an abstract clinical
information model and map this into different
representations, which can be converted due to their
shared information model
• Semantic mediation uses a semantic (ontology
based) representation of clinical information,
together with reasoners, to convert between
different iso-semantic representations of the same
information
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12. Lessons Learned: Starting from the State of the Art
• Do not reinvent the wheel. There are many eHealth standards, architectures
and tools available. Try to understand the existing standards and tools before
re-inventing your own.
• Several case studies confirmed the importance of selecting and using good
software tools. One of the success factors of epSOS was the decision to
develop an Open Source reference implementation.
• There are useful components developed outside the eHealth community.
Topics such as
– electronic identification,
– end point detection,
– non-repudiation,
– the use of electronic signatures,
– trust establishment
are not eHealth specific. Mature solutions have been developed outside the
field of eHealth, and these are readily available for use in eHealth projects.
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13. Lessons Learned: eHealth Network Architecture
• Think big, start small. It is better to start with a small system and grow over
time, than to aim for the perfect solution immediately. Look for the “low-
hanging fruit.
• Develop your architecture layer by layer. Separate between the layers of
interoperability, create the architecture within each layer, define the
relationship between the layers.
• Decouple components by defining clear interfaces (such as gateway
protocols). This makes it easier to separate responsibilities for parts of the
overall system and can help to “hide” parts of the overall system complexity.
Furthermore, it simplifies the development of system components.
• IT Security is hard, and cannot be successfully retro-fitted into an existing IT
architecture. Furthermore, security mechanisms should built on top of robust
standardized solutions.
• Make sure that more than one end user application can be built as edge
system for the eHealth network (e. g. for accessing and visualizing
information), catering for different user needs and user preferences.
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14. Summary and Conclusion
• No „magic bullet“ to address coexistence of
overlapping/competing standards found
– (but nobody really expected this)
• Three fundamental approaches: gateways, model driven
and semantic mediation
• Terminology mapping (and Security) remain “hard”
problems
• Lots of experience and tools available that others can
learn from!
• Next step in eStandards: Condense the experiences and
recommendation into a practical “cookbook”
– to be published in October 2016.
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15. Thank you for
your attention
www.estandards-project.eu
http://bit.ly/1YCuSmA
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