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Bridging patient summaries across the Atlantic

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1 Bridging patient summaries across the Atlantic
Catherine Chronaki, Robert H. Dolin, Marcello Melgara, Harold Solbrig, Jamie Ferguson, Dipak Kalra coming soon…

2 Structure and aims for today’s workshop
Objectives Briefly present the Trillium Bridge project Discuss use cases of transatlantic exchange of patient summaries Identify issues, interoperability assets and opportunities Recognize barriers and strategies to overcome them Engage the health informatics community as part of the solution Structure Four presentations Structured Discussion Collection of questionnaires Findings and next steps Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

3 The Speakers Catherine Chronaki Harold Solbrig Dipak Kalra
HL7 Foundation, coordinator of Trillium Bridge support action Introduction to Trillium Bridge Selecting the Grounds: Supporting EU/US initiatives & use cases Harold Solbrig Mayo Clinic, co-leader of the Interoperability assets work package (Building the Bridge) Building the Bridge: Interoperability assets Dipak Kalra Eurorec, Coordinator Semantic Healthnet, Leader Policy alignment, Standardization, Future sustainability Work package in Trillium Bridge Policy alignment The case of heart failure: “are we talking about the same disease?” Jamie Ferguson Kaiser Permanente, VP Health Information Technology Strategy & Policy The case of medication allergy avoidance Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

4 Bridging patient summaries across the Atlantic: Your input!
Q1: What are the compelling use cases for the transatlantic sharing of personal health information? Q2: What are the critical success factors to enable the Trillium Bridge project to succeed? Q3: What key barriers will Trillium Bridge need to address? Q4: Are there other important initiatives that we need to know about or liaise with? Q5: Which ONEs do you see as most important areas for investment in bridging patient summaries across the Atlantic?  Cross-vendor integration  Incentives  Standardization  Innovative Business models  Education  Clinical Research  Security and privacy Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

5 Policy context or what’s in a name?
Ensure sustainability of the healthcare system Unlock the market for innovation Deliver Quality Care - better care TB supports the transatlantic eHealth/health IT Cooperation MoU, Roadmap and DAE in achieving the triple win: ensure sustainability of the healthcare system, unlock the market for innovative solutions, deliver quality of care – better care. The world trillium in the name of the project, originates from this triple win relating it to the trillium flower used for pharmaceutical research. MoU highlights cooperation on topics directly pertaining to use and advancement of eHealth in pursuit of improved health and healthcare delivery as well as economic growth and innovation: TB will contribute to knowledge and interoperability assets, as well as policy alignment, standardization and sustainability. How? by establishing the foundations of an interoperability bridge for the meaningful exchange of patient summaries and EHRs among eu and us. Sharing of knowledge and information constrained in patient summaries. So what do we mean by patient summary? Practically we mean a Summary care record: a view to the patients’ relevant health information In this sense the work of TB is very much related to the IMIA traveler’s EHR which we hope to envigorate with Trillium Bridge. Copenhagen Aug 21, 2013

6 Objectives of Trillium Bridge
Build a bridge for EU/US patient summaries across the Atlantic Identify use cases of transatlantic exchange of patient summaries Compile gap analysis to identify barriers and easy wins Assemble Interoperability assets to support implementation Validate exchange of patient summaries Facilitate policy alignment, future standardization, and sustainability Develop feasibility study to guide future developments Why? Lower costs/barriers for transatlantic business engagement Reduce implementation/configuration costs Decrease standards development costs Accelerate convergence towards global standards Support the fundamental right of citizens to their health information First steps towards realizing the vision and implementing the Roadmap of the EU-US MoU on eHealth/Health IT cooperation Build a bridge for EU/US patient summaries to be exchnaged across the Atlantic Identify use cases of transatlantic exchange of patient summaries Compile gap analysis to identify barriers and easy wins Assemble Interoperability assets to support implementation effort Validate exchange of patient summaries and bestow an award Develop feasibility study to guide future developments Facilitate policy alignment, future standardization, and sustainability Why? Lower costs/barriers for transatlantic business engagement Reduce implementation/configuration costs Decrease standards development costs Accelerate convergence towards global standards Support the fundamental right of citizens to their health information First steps towards realizing the vision of the MoU Consider This: What does it take for a provider of a health information system that has been certified under MU-2 to configure it for the EU market? Have you any thoughts on the amount of this effort today? What should Trillium Bridge do to reduce it? Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

7 Milestones to success Policy Alignment: Testing the Bridge:
Selecting the Grounds: Pilot Use Cases Business Architecture Gap Analysis Building the Bridge: Aligning Structure & Terminology Trust Agreements Interoperability assets Testing the Bridge: Testing Tools, Data Sets Validation Reports Policy Alignment: eIdentification, Security & Privacy Legal / Regulatory Interoperability Feasibility Analysis Cross-vendor integration Incentives Standardization Innovative Business models Education Clinical Research Security and privacy So how are we going to build this transatlantic bridge for EHRs? Well, first we will Select the grounds, identify the most promising areas/the low hanging fruits, by comparing patient summary specifications for gap analysis and by selecting key use cases. Then, we will Build the bridge: assemble interoperability assets, mappings of terminology data sets, translations, etc. Next we will Test the bridge: configure testing tools and validate patient summary exchange But for our efforts to persist and be result oriented, we will also contribute to policy alignment, standardization, sustainability of resources. We will address seven key areas: education, cross-vendor integration, incentives, standardization, innovation, research, security & privacy, Policy briefs will be developed by thought leaders at the two ends of the Atlantic and our findings and lessons learned and recommendations will be reported In our feasibility study to guide future calls for proposals to inspire and drive investment in new initiatives and products. Our feasibility study will be based on validation reports by leading providers in the EU and US. These include in the US Kaiser Permanente and Atrius Health (a gp network in Ma) and member states (Prt, Spain, It) that have committed to implementing the epSOS patient access service. Copenhagen Aug 21, 2013

8 Patient-driven questions and needs
EU citizen going to the US How can European citizens or residents request and receive their epSOS patient summary and, with their consent, have it delivered to a cloud service or health app that would translate it to a form that can be understood, trusted, and incorporated in the EHR of a US provider? EU citizens receiving care in the US How can European Citizens or residents receiving the services of a US provider while travelling in the US, have a care summary delivered to them or safely uploaded into a PHR or provider’s portal in a format that is compatible with epSOS? US citizens going to Europe How can members of US-based health networks receive an MU-2 certified care summary in a format and language that epSOS providers will be able to understand and use? US citizens receiving care in the EU How can members of US-based health networks, upon receiving the services of an epSOS provider translate and transfer the encounter report to the EHR system of US providers? But let’s pause for a minute and think through the Trillium Bridge strategy. Does it make sense? Trillium Bridge builds on important initiatives in the EU and US and extends them across the Atlantic. Here are some examples: How can European citizens or residents request and receive their epSOS patient summary and, with their consent, have it delivered to a cloud service or health app that would translate it to a form that can be understood, trusted, and incorporated in the EHR of a US provider? How can European Citizens or residents receiving the services of a US provider while travelling in the US, have a care summary delivered to them or safely uploaded into a PHR or provider’s portal in a format that is compatible with epSOS? How can members of US-based health networks receive an MU-2 certified care summary in a format and language that epSOS providers will be able to understand and use? How can members of US-based health networks, upon receiving the services of an epSOS provider translate and transfer the encounter report to the EHR system of US providers? Can we do it? What are the main issues or barriers that TB should attach? What are some easy wins? What do we need to be careful about? Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

9 Who is part of Trillium Bridge?
Before we proceed let me introduce the TB consortium From the US side: There is Lantana with Bob Dolin and Liora Alschuler lead inventors of the HL7 Clinical Document Architecture SmartPHR a small company building novel personal health apps for mobile users Atrius Health a physician network in Massachusetts Mayo maintaining a value set resources for the national library of medicine value set authority (Harold will speak to that next Kaiser Permanente (one of the lead providers in the US) In the European Side: We have the scouts led by Marcello and Bob leading the WP on selecting the grounds, comparing patient summaries We have the builders led Phast with Ana Esterlich and Harold Solbrig leading the WP on building the bridge, Interoperability assets We have the testers led IHE with Karima, Charles Parisot leading the WP on testing the bridge and and validation – going across the bridge We have the policy makers led Eurorec with Dipak Karla and Bob Dolin leading the effort on Policy Alignment, Future Standardization and Sustainability In this way we are confident that our efforts will not be in vain and others will follow along our the path we open with new inspired innovative projects. Ministries of health with Patient Access pilot Community of knowledge, interoperability assets, policy alignment Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

10 EU/US Community of Knowledge
Providers Beth Israel Deaconess MC, US University Hospitals Genève, CH Duke Center Health Informatics, US National programs NHS – Connecting for Health, UK Agence eSanté Luxemburg, LU French Ministry of Health, FR Spanish Ministry of Health, ES MedCom, Dk KELA, Fi European Federation for Medical Informatics (EFMI) Travel EHR initiative (IMIA) European Patients Forum Validation sites Kaiser Permanente, US Italian Ministry of Health, IT & Lombardia Atrius Health, US Slovenia, SI Portuguese Ministry of Health, Pt Industry Indizen , Spain IBM research labs, Il CISCO Marand, Slovenia Marketplace ECHAlliance and the EU-US Marketplace SDO advisory forum IHTSDO, GS1, CDISC, CEN, NEN, EN13606 Association, Health Story Here is a view of the environment in which TB will operate. I would like to thank Patrick, Christian and Anne and EFMI for the letter of support, their input and encouragement at the proposal preparation phase.

11 Bridging patient summaries across the Atlantic European Perspective based on epSOS
Marcello Melgara Skype: marcello.melgara Phone: office: ; mob.:

12 epSOS in Pils epSOS Consortium is composed by 48 beneficiaries from 26 States: Austria, Belgium, Croatia, Czech rep., Denmark, Estonia, Finland, France, Greece, Hungary, Germany, Italy, Latvia, Luxembourg, Malta, Netherland, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom, Turkey + Industry Team (~45) 15 Observers: Bulgaria, Iceland, Lithuania, Serbia,, … + USA, Canada = Total 40+ Nations Coordinator: SALAR (Swedish Association of Local Authorities and Regions) From to (6 month extension under discussion) Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

13 Goals and Challenges In preparation and application of:
EU Directive on Patient Cross-border Mobility (April 2011) Goal for the epSOS eHealth Project: “to develop a practical eHealth framework and ICT infrastructure [based on existing national infrastructures] that will enable secure access to patient health information, particularly with respect to a basic patient summary and ePrescription, between European health care systems” To define normative specifications for EU level cross border interoperability Without interfering with National/Regional policies, strategies and implementation of National/Regional EHR / PHR (e.g. no specs on how EHR/PHR is managed, or documents returned from the Country of treatment are handled) Challenges to get there: harmonize 26 Health Care systems Legal Interoperability Organisational Interoperability Semantic Interoperability Technical Interoperability Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

14 epSOS Use Cases Patient Summary (PS):
while abroad, a patient seeks unexpected care. The Health Professional, after having identified and checked the consent confirmation, requests the PS from the Country of Affiliation. The PS is shown mapped in the epSOS pivot format, with coded data translated in Country of Treatment language Health Care Encounter Report (HCER): while abroad, a patient seeks unexpected care. The Health Professional, after having received the PS, generates a CDA L3 document as Encounter Report. The document is transferred, mapped and translated to the Country of Affiliation Medication Related Overview (MRO): A pharmacist, who cannot access the PS, requests the medication summary and list of allergies (frequently derived from the PS) Patient Access: A patient while in the Country of Affiliation, may request his PS mapped and translated in one of the epSOS languages This is the basis for Trillium Bridge Patient Mediated Interoperability Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

15 What epSOS Patient Summary is
A clinical document with medical/legal value, to assure continuity of care for unexpected/ emergency situations Requested by the physician, after patient authorization Generated by the National Contact Point (NCP) of Country of affiliation as a structured and coded HL7 CDA V2 L3 document. Original PS is transferred as PDF embedded in a CDA V2 L1 document Translated in the local language by the NCP of the Country of Treatment Visualized by the physician using a specific CDA display tool The Heath Care Encounter Report (HCER), with the same structure, can be generated and returned to the Country of Affiliation Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

16 What epSOS Patient Summary is:
A team of clinical experts from epSOS Countries defined the contents of the PS, according to: Relevance to cope with unexpected/emergency situations Availability of (coded) information in the EU Country PS’s Compliance to CCD /PCC and CDA V2 L3 specifications Basic mandatory sections are: Header info to identify the patient, date & document creator, PS nature Allergies and medical alerts Active problems Recent surgical procedures List of current medicines (posology is optional) Medical devices and implants Patient data, document creator data, creation date cannot be Null Basic clinical info sections must be present, but null flavor is allowed Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

17 What epSOS Patient Summary is:
Extended optional sections are: Header: Insurance information, contact info/persons/institutions Vaccinations Resolved problems Surgical procedures, not older than 6 months Treatment recommendations Autonomy/Invalidity Social history observations (smoke, alcohol,..) Pregnancy /date of expected delivery Physical findings. Vital signs – blood pressure (only) Diagnostic tests. Blood group (only) Extended sections can be omitted, if not relevant Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

18 What epSOS PS is: terminology
For each section/subsection a standard coding system is identified A specific Value Set allows transcoding and translation FIELD TERMINOLOGY CHOSEN Field Labels LOINC Problem list ICD 10 (3 digit code) Medication list ATC + EDQM + UCUM Allergies SNOMED Surgical procedures Medical devices Country and languages ISO Professional role ISCO Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

19 What epSOS PS is not: Hospital discharge letter
Detailed document for specialist second opinion request Pathology specific / rare disease medical reports Why? Missing non-surgical procedures Laboratory test results Limited details in describing problems When limits will be overcome? epSOS is evaluating the adoption of the full ICD10 Extensions of the Value Sets and introduction of new sections is in the scope of CIP/PSP Expand Project (2014–2016). Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

20 epSOS Use Cases How the document is trasformed into Pivot HL7 CDA L3, trascoded and translated epSOS Central Reference Terminology Service: Master Value Set Catalogue: [MVC,] Subset of International Coding Systems (WHO ICD10, ATC; SNOMED-CT, EDQM, UCUM, HL7, IHE, ISCO)+ Master Translation/Transcoding Catalogue [MTC] 20 Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

21 epSOS setting sails First dispensation: eP Lombardy: Athens 11/2011
Pilots with real patients (since 4/2012): PS: AT, CH, ES, FR, IT, PT, (CZ) eP: IT (Country A), GR (Country B) Next PNs ready to pilot: PS: EE, MT, SI eP: DK, ES, FI, SE PNs in Pre-Production Testing: PS: HU, LU, DE*, TR* eP: HU, HR (*: legal constraints)

22 From epSOS Patient Access (PAC) to Trillium Bridge services
Some epSOS Countries plan to provide their citizens with epSOS Patient Access Service: The citizen may request his PS, in epSOS format, translated into any epSOS language Trillium will extend the service by providing the export in the selected format to allow: Patient mediated access: English document handed/showed to the US physician Structured document provided through secure media/mail/clouds Provider mediated access: The US physician requests the document to the EU healthcare institution (more difficult to implement) Providing ways of importing TO EU citizen PHR/EHR PS generated in US Providing services to EU physician to read/access to US citizen PS Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

23 Bridging Patient Summaries across the Atlantic US perspective
Bob Dolin Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

24 Consolidated CDA Overview of Meaningful Use
Overview of Consolidated CDA Consolidated CDA Use Cases Trillium Bridge Considerations Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

25 Overview of MU2 Meaningful Use Stage 2 sets “criteria” for EHRs
EHRs meeting those criteria are MU2-certified Providers using certified EHRs are eligible for incentive payments Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

26 CDA in MU2 § Content exchange standards and implementation specifications for exchanging electronic health information. (a)(3) Consolidated CDA (C-CDA): Standardized representation of the Consult Note, Diagnostic Imaging Report, Discharge Summary, History and Physical, Operative Note, Procedure Note, Progress Note, and Continuity of Care Document (CCD). (h) CDA Guide for Quality Reporting Document Architecture, Category I (QRDA-I): Standardized representation of quality data for an individual patient. Data in a QRDA-I report can be consumed by a calculation engine to determine if the patient met the numerator or denominator criteria for a given quality measure. (i) CDA Guide for Reporting to Central Cancer Registries: Standardized cancer registry reporting format. (k) CDA Guide for Quality Reporting Document Architecture, Category III (QRDA-III): Standardized representation of aggregate quality data (e.g. number of patients meeting the numerator criteria for a given quality measure). Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

27 Consolidated CDA Many different kinds of documents:
CCD Consultation Note Diagnostic Imaging Report Discharge Summary H&P Operative Note Procedure Note Progress Note Unstructured Document A bucket of reusable templates Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

28 CCD (Summary Document)
Sections Payers Advance Directives Support Functional Status Problems (R) Family History Social History Allergies (R) Medications (R) Medical Equipment Immunizations Vital Signs Results (R) Procedures (R) Encounters Plan of Care Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

29 Consolidated CDA Use Cases
Narrative Interoperability Basic CDA functionality 3rd Party Data Aggregation E.g. registry Data Integration HARD Often achieved via clinician-assisted data reconciliation Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

30 Trillium Bridge Considerations
“Harmonization” and “Internationalization” (as opposed to “Transformation”) Vendors want global standards Decrease standards development effort Decrease realm localization requirements Mapping is HARD, and not sustainable Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

31 Trillium Bridge Considerations
Compare data structures Sections, CDA entry-level templates SECTION (O/R) epSOS C-CDA Demographics R Allergies Problems Procedures Medications Devices O Results Social History Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

32 Trillium Bridge Considerations
Compare vocabularies FIELD epSOS TERMINOLOGY C-CDA TERMINOLOGY Field Labels LOINC Problem list ICD 10 (3 digit code) SNOMED Medication list ATC + EDQM + UCUM RxNorm Allergies ATC (active ingr. SNOMED (subst.) SNOMED (react.) RxNorm (substance) SNOMED (reaction) Surgical procedures Medical devices ?? Country and languages ISO Professional role ISCO NUCC Copenhagen Aug 21, 2013 Trillium Bridge: Bridging Patient Summaries across the Medinfo2013

33 Summary Trillium Bridge will carry out a feasibility study with validation reports of EU/US Patient summary exchange, reusable interoperability assets and policy work to: Lower costs/barriers for transatlantic business engagement Reduce implementation/configuration costs Decrease standards development costs Accelerate convergence towards global standards That would be concrete steps towards realizing the EU/US MoU vision for transatlantic cooperation “to improve patient health and health care delivery, enable economic growth and nurture innovation.” Trillium Bridge: Bridging Patient Summaries across the Medinfo2013 Copenhagen Aug 21, 2013

34 Why don’t you join us to build the Trillium Bridge?
In conclusing Trillium Bridge conducts a feasibility study based on validation reports based reusable interoperability assets and pilot sites that: Lower costs/barriers for transatlantic business engagement Reduce implementation/configuration costs Decrease standards development costs Accelerate convergence towards global standards That would be concrete steps towards realizing the MoU vision for transatlantic cooperation “to improve patient health and health care delivery, enable economic growth and nurture innovation.” US Health Care Providers epSOS National Bodies with Patient Access pilot SMEs European Standardization


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