1. Through functional harmonisation to Interoperability of EHR systems ISHEP Zagreb, September 16, 2010 Dr. Jos Devlies, EuroRec

2. Topics addressed The EuroRec Institute Interoperability and Quality…. Functionality as prerequisite for Quality EuroRec Functional Criteria EuroRec Seal HITCH project Conclusions

3. The EuroRec Institute Not-for-profit Federation of National Centres To promote the use of high quality EHR systems Main activities: –Research –Product Conformance

4. Why do we need interoperability? Efficiency in care: –sharing available patient information with authorised ‘users’ –knowledge explosion  more decentralised care decisions on more centralised data Patient-focused information management –complete record = patient lifetime (at least) -beyond life the HC Professionals -applications ‘disappear’

5. What is Interoperability? So many definitions: just one of IEEE “The ability of two or more systems or components to exchange information and to use the information that has been exchanged” Focus on the “use” More than exchangeability More than being “human understandable”  exchangeability is a “low level of interoperability”. Remark: We are only addressing “clinical systems”

6. (Re)use is the issue Interoperability means the ability to (re)use content –by different applications –outside the context of origin –without new / complementary encoding Is exchangeability / understandability enough for (re)use? Everything depends on the quality…

7. Garbage in... Garbage out

8. Exchangeable Garbage is still Garbage

9. Health data need to be Correct at “conception” Comprehensive regarding context: –Who, when, circumstances and role of the author regarding the patient (on duty service, regular GP consult, multidisciplinary conclusion of a hospital stay)… –Co-morbidity / absence of co-morbidity Precise and granular –“Other disease of genito-urinary tractus” –Staging and severity –Certainty

10. Quality problems ? Enormous “quality” gap at data entry –professional inconsistency in labelling clinical conditions using “standards” (if used…) –functionalities of systems insufficiently used –systems with poor functionality Lack of domain-validated “info-structure”: –what are now the correct attributes in order to capture a complete description of a type II diabetes, of blood pressure, a medication administration? –where are the standard expressions for some of these attributes? Even more regarding environmental, behavioural, hereditary and professional context

11. Also at application level Systems need to be able to produce / to collect and to share those “high quality data” with authorised Healthcare Professionals. Examples: –Staging of diseases –Complex dosing schemes for medicinal products –Distinguish a confirmed diagnosis from a nursing diagnosis or from a hypothesis –Monitor real-time alerts for allergies or specific health conditions –Manage prevention and immunisations –Implement Good Practice Guidelines and specialised Care Protocols –Device connectivity… Defining the needs is defining EHR functional requirements.

12. Functional Requirements Without functionalities no content, nothing to exchange… Systems with the same / similar functionalities will produce roughly the same data (more specifically when using the same standards or based on the same requirements). There are hundreds, thousands of requirements to be met –Some by all the systems –Some (domain specific) only by some applications The actual EuroRec repository of functional descriptive statements contains over 1.600 statements / criteria. Partially translated in 19 languages.

13. The EuroRec Functional Requirements

14. Countries of origin Belgium (1999-2006-2010) CCHIT (USA) Alberta (Canada) Ireland France (LAP) Denmark Meaningful use (USA) Clinical research (eClinical Forum) Austria (Lab results)

15. Medicinal decision support related statements….

17. In Croatian

18. How to reach functional quality? Someone defines an agreed “quality” level. What and how a system should behave. Who? –The users… surely, ideally a professional consensus –Also the authorities, as they: have different / additional priorities want consistency between the systems Translated in system / functional requirements Issuing requirements is not enough, they should be “verified”  conformance testing Will result in systems with similar (not identical!) functionality  harmonisation

19. Two ways to favour functional harmonisation? National / Regulatory way: –Can be very detailed / comprehensive. –May address one specific user group. Cross-Border: needs to be more generic EuroRec issued two “Seals” –Seal Level 1 : 20 mainly generic statements –Seal Level 2 : 50 criteria also addressing security and confidentiality management. http://www.eurorec.org/consortium_intern/seal/index. cfmhttp://www.eurorec.org/consortium_intern/seal/index. cfm Available in all the languages

20. Composition of the seal NumberIndexIndex Title 12A00EHR Data Entry related 9A02EHR Content related 8A03EHR Structuring Data 22A04EHR Display 1A05EHR Data Exchange Services and Record Interfaces 14A09EHR Generic Data Properties 7A10Medication Management 3A11Clinical Statements Management 3A14Shared Care 2A15Clinical Decision Support: alerts, reminders 7A22Demographic Services 1A32Laboratory Services 4A6Health Information System management 23A7Privacy and Accountability Services 6A8Technical Security Services

21. Is that enough to guarantee quality? Having good systems is one step. This includes the function of sharing / exchanging patient information. Getting them used properly is another issue –Using the rod or whip does not work –Let the market do his job… –Incentives….for using those systems (meaningful use in the USA) –Education and training are essential as well … 25 years after the first PCs still…

22. How to match Functional Testing (EuroRec,…) and Interoperability Testing (IHE Europe) ?

23. Support Action within 7 Th Framework. Aim of the project is to define “A roadmap to establish a foundation for the Interoperability Conformance Testing of information systems in Healthcare” Partners: INRIA, IHE Europe, OFFIS, ETSI, MEDCOM and EuroRec.

24. Overlap functionality and interoperability testing

25. Conclusions Quality of the content is a prerequisite to interoperability. Quality of the content depends on functional ability of the system to produce those data and on the effective use by the HC Professional. Systems meeting the same / similar functional criteria evolve to a degree of functional harmonisation, favouring interoperability. Conformance testing is an important step to realise quality as well as interoperability.

26. Thank you www.eurorec.org jos.devlies@eurorec.org