This document summarizes a project called the Trillium Bridge, which aims to enable the exchange of patient summary data across the Atlantic between Europe and the United States. The project involves mapping and comparing EU and US electronic health record patient summary standards to identify interoperability assets. It also aims to inform standardization efforts and support the adoption of global standards. The methodology involves analyzing gaps, identifying terminology mappings, and developing proof of concept software to transform patient summary structures and semantics. The project has engaged stakeholders from several EU countries and the US to test and validate the approach.

1. www.trilliumbridge.eu
Crossing the Trillium Bridge: Transatlantic
Exchange of Electronic Health Record
Summaries
For the Trillium Bridge Consortium:
Catherine Chronaki (HL7 Foundation, Be),
Henrique Martins (SPMS, MoH Portugal, Pt),
Arturo Romero (MoH Spain, ES),
Harold Solbrig (Mayo Clinic, US),
Alexander Berler (Gnomon Informatics, GR)
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2. Trillium Bridge Project:
a feasibility study and builder perspective…
The problem The Solution
• What can we do to lower the cost of
transatlantic business engagement
in eHealth?
– Reduce barriers for transatlantic
coordination, health care, trade
– Decrease standards development
and implementation costs
– Accelerate convergence towards
global standards
– Support right of citizens to their
health data and safety
• Well, perhaps we could try building..
…a Transatlantic Bridge for
EHR summaries!
• Pragmatic Feasibility study on the
exchange of Patient Summaries
across the Atlantic
• Compare, analyze, and map
EU/US EHR patient summaries
starting with Meaningful Use 2 C-
CDA/CCD and EU patient
summaries (epSOS)
• July 2013 to June 2015
• Stellar consortium of EU member
state provider networks,
associations, SDOs
Trillium Bridge: where are we?

3. Trillium Bridge: methodology
Building the Transatlantic bridge for EHR patient summaries
• Complete Gap analysis
• User stories, use cases, business architecture, D2.2
• Identify interoperability Assets
– Established STS terminology
service associating EU/US terms, D3.1
– proof of concept transformer of EHR structures
and semantics, D3.2
• Inform and support standardization efforts
– ground work of an Intl EHR patient summary
– Aligning infrastructure, D4.1
• Refine assets, work on the puzzle through validation
– Test with EU countries and US providers, D4.2
– Set the tone and pace for interoperability
in the global eHealth ecosystem, D5.1, 5.2
Selecting
Grounds
Building
the
Bridge
Testing
the
Bridge
Policy
Alignment
We are
here
CTS-2
Trillium
transformer
Trillium Bridge: where are we?
Attain the vision and aims of EU-US of the
eHealth MoU and roadmap!

4. Under the Hood
CCD
CCD
EPSOSEPSOS
Structure
Transformation
Code
Mapping
Language
Translation
CTS-2
Transformer Components

5. Under the hood
Transformer Gateway Open Source Software

6. Patient Summaries in Spain
– In Spain, most Communities (regions) produce PS
• HCDSNS Project communicates individual community
PS
• Requirements of PS consolidation are being studied
• > 15 million citizens have PS available (April 2015)
• Source EHR coverage very high at Primary & Family
Care
• Source EHR coverage is less advanced in hospitals
– Trillium Bridge acts as a conceptual prototype for:
• Standards adoption
• Functional design (clinician-oriented & safety-aware)
• Technical implementation (messaging-oriented &
integrity)
• Actual communications still not feasible

7. 09/06/14 2
Citizen
Sections
Postal
Document: Bilingual
Organization
Items
1 2
3 4 5 6
Patient Summaries
in Spain

8. Future Prospects:
– Agreement levels: EU-USA, bilateral, patient led
– All-bilingual approach
– Multilingual terminologies go mainstream
– “Convincing” industry about business added value of PS will
require proof of feasibility and large-scale adoption
– Population coverage measuring will be essential
– Trillium Bridge documents may guide and teach
– Testing and validating requirements
– Automated generation for all citizens
– Stimulus for standards adoption
– Solving practical legal issues
– Complete semantic units approach
– Opportunities to innovate
Trillium Bridge fits eHealth Strategy:

9. THE PORTUGUESE BRIDGE...
The last American Census (2000) estimated a total of 1.173.691
Portuguese and luso-americans residing in USA
There are 95 Portuguese citizens/luso-americans in active political activity,
and more than 385 portuguese collectivities (cultural, recreational,
religious)*
* - Portuguese presidency website data
Portugal is fashionable in 1º Semester of 2014, American tourism in
Portugal was of about 227 million Euros, 47,8MEuros more than in 2013
(26,7% increase in 1 year). 156100 in 6 months individuals, which is
about 3548000 hotel nights (21,8% increase) tourists in Portugal *
Number of residents perhaps more than 5000?;
http://www.americansinportugal.org/
*- national institute of statistics/bank of portugal

10. Portugal (about 3,5/9 Million Patient Summaries
ready for exchange)
~ 10 million citizen
~ 50 Public Hospitals
~ 400 Primary Care Centres
~ 90% running SPMS ICT
solutions (ADT and EHR)
~ 60 ICT Solutions
(SPMS portfolio)
PT Ministry
of Health
DGS
Clinical
Guidance
ACSS
Financial
and ruler
SPMS
Technical
Implementation

11. 09/06/14 11
• International Projects
• Represent the fastest and secure way to learn from experience and
lessons learnt. Belonging and actively participating in EU projects allow
our teams to learn from example and improve our technical & semantic
implementation skills.
• Trillium Bridge
• Represents the opportunity for explore possible solutions towards cross
Atlantic health information exchange, namely what concerns PS
structures and terminologies used. It also represents the right
opportunity to push forward unfulfilled gaps left by epSOS in what
concerns to PAC service (e.g. export and import, transformation EU-US)
• Piloted Uses Cases
• Provider Mediated
• Patient Mediated

12. Luxembourg
• Some facts
ca. 550.000 Inhabitants
Largest foreign national
community in EU (45%)
ca. 155.000 Commuters
(FR/BE/GE)
Three official languages
 Luxembourgish
 French
 German

13. Questions and Answers…
• How does Trillium Bridge fit with the eHealth strategy of your
country?
– By definition the eHealth Strategy of Luxembourg is cross border
enabled
– 45% of residents are expatriates
– Luxembourg hosts many EU institutions
• How do Patient Summaries and Trillium Bridge work in your country?
– Patient Summaries are part of the national strategy
– The size of Luxembourg make it a perfect reference implementation and
Large scale pilot
– Trillium provides guidance on solving legal and organizational issues
• What are the prospects you see for the future?
– Patient mobility will increase
– Patient engagement is part of EU and US strategies
– Trillium Bridge will enforce the patient role in his care both planned or
unplanned

14. Giving value to Trillium
scenarios
• Healthcare Provider Mediated Scenario
– Trillium Gateway is reference implementation that proves that
healthcare information exchange based on Standards is possible
– Patient summary is a valid start especially for unplanned care
– Trillium Bridge has worked on creating an international patient
summary dataset that can be populated by globally accepted
encounter reports.
• Patient Mediated Scenario
– Involving the patient is the first step to establish the Gateway
– Trillium Gateway would enable a “Blue Button enabled” strategy for
US expatriates to Europe and beyond
– Legal and organizational issues can be bypassed by the direct
consent of the patient.

15. Is there a Market?
Snapshots from EU-US market
 US is ranked 3rd as potential medical
tourism destination
• source: Economist Intelligence Unit
 US is already a treatment destination
 >150.000 Patients travel NOW to
the US for expert care
– Copyright © 2010 Treatment Abroad
 33% of European Healthcare
Travelers are coming to North America
– Copyright © 2009 Grail Research, LLC
 6.32 million Americans (excluding
military) live in 160-plus countries of
which 1,6 Million in Europe
– source AARO
 4,817,437 European citizen living in
the US
– source 2000 US census
Snapshots from a small
nation: Greece
• 30m€/yr spent now for non resident
episodes of care
• 2bn€/yr in 10 yrs (ranked 11th as a
potential medical tourism country)
• 21M tourists in 2014 and growing
• 300.000 EU expatriates in Greece
• 100.000 US citizen lived in Greece the
last 10 yrs
• 50.000 Greek students in the US
• >2.500 Greek Cancer Patient travel to
the US, spending >12M€
Source: Medical Tourism study, Min of Tourism

16. Having a global vision for
citizens on the move
• Accommodate new business models
– Create an interoperable “healthcare e-passport” service
– Establish a global encounter report format compliant to standard based patient
summaries
– Patient outsourcing
– Patient mobility –
• break the m-health information silos
– Focus on prevention
and information flow
• Technology is not a barrier
(i.e. Trillium Bridge)
Medical
Tourism
Second
Opinion
Disease
Management
Expatriate
Care
Chronic CareM-Health
Clinical Trial
Management
Trillium
Gateway
Enabled by
What’s next?

17. Check out our Demo:
South Building, Hall A, Booth 2084
Transformer
(CTS2)
IHE XCPD
IHE XCA
IHE ATNA
(epSOS)
IHE XCPD
IHE XCA
IHE ATNA
(eHealth)
Trillium Bridge Gateway
(epSOS Open NCP)
National Contact
Point

18. Thank you to an incredible
team and journey
HL7 Europe:
Catherine Chronaki
Giorgio Cangioli
IHE Europe:
Karima Bourquad
Charles Parisot
Eric Poiseau
Kaiser Permanente:
Jamie Ferguson
Kevin Isbell
Virginia John
Zachary Gillen
Mayo Clinc:
Harold Solbrig
Christopher Chute
Kevin Peterson
Gnomon:
Kostis Kaggelides
Alexander Berler
Kostas Karkaletsis
Spain:
Arturo Romero
Juan Pablo Martinez
Iciar Abad
Portugal:
Henrique Martins
Arlete Monteiro
Alexandra Cabral
Alexandre Santos
Licinio Kustra Mano
Rui Alves
Luxembourg:
Heiko Zimmerman
Herve Barge
Italy:
Marcello Melgara
Phast:
Nicolas Canu
Ana Estelrich
Franck Gener
Lantana:
Liora Alschuler
Russ Hamm
Sarah Gaunt
Zabrina Gonzaga
Eurorec:
Dipak Kalra
Smart EHR:
Elaine Blechman
Stephen Kay
Larry Garber