1. The Medication Supply Registry Project & Demonstration in The Netherlands A co-production by NICTIZ – HL7 the Netherlands – IT industry Tom de Jong HL7 the Netherlands

2. What is NICTIZ? Not-for-profit organisation Founded by healthcare stakeholders: –Ministry of Healthcare –Organization of IT Vendors in HC –Dutch HC Insurers Organisation –Organisation of HC Providers –Patient representation groups Funding by Ministry of Health (for a 5-year ‘trial’ period)

3. Current developments in Dutch healthcare Shift from administration and billing processes to clinical care itself. Very little central coordination in the creation and application of standards Restructuring of healthcare (mergers). Shift from intra-institutional to inter-institutional cooperation and a resulting need to share information throughout the ‘chain of care’.

4. Care regions

5. One solution: Service Centres (e.g. in a hospital)

7. Regional Care Networks

8. Solutions One big EHR database with healthcare info for 16 million people Leave data at the source, but register a reference to it in a central repository (‘Act Registry’ in HL7 speak) A hybrid solution?

9. Features of the Care Information Broker (ZIM) Data itself it not copied in the registry Interested parties use a pull mechanism (query) instead of a proliferation of notification messages between systems. Advantages –Always the most recent data from the ‘virtual’ DB –No risk of inconsistencies due to duplication –No exponential growth in # of interactions Drawbacks –All interactions have to be standardised, which results in demands to vendors, providers, etc. –The ZIM itself will have to be built and maintained by either a central authority or a third party vendor

10. Care Information Broker functions Maintaining the Act Registry: –Process updates from HC systems –Process queries from HC systems Identification, Authentication (infrastructure & safe data transport are a requirement) Authorisation Logging

11. Virtual data warehouse

12. Linking ZIMs together…

13. Identification Schemes ZIN: Care Identification Number UZI: Unique Care Provider ID UZOVI: Unique Care Insurer ID

14. The first ‘ZIM-based’ project Obtain ‘proof of concept’ for: –Query and response for Medication Supply, based on HL7 version 3 models and messages –Use of an Act Registry (Care Information Broker) to share medication supply information transparently Demo at Dutch Medical IT Conference: –Representative selection of IT vendors –Implementation of abovementioned concepts –Near-complete, realistic and ‘live’ operation of V3 interfaces within infrastructure of conference network Some limitations were agreed upon: –No authentication, authorisation etc. –XML based on ‘simple’ TCP/IP protocol –All unique identifiers are assumed to be in place –Single vendor selected for implementation of Act Registry

15. Act Registry Notification (upload) of a medication supply to the Act Registry Two versions: –Light version –Extended version

16. R-MIM Act Registry Information concerning the ‘Act’ that is being ‘uploaded’ to the Act Registry 1 st participation is the patient. 2 nd participation is the care provider that is the source of the medication supply A common element (CMET) is used for the patient. A common element (CMET) is used for the care provider.

17. R-MIM Act Registry (Lite)

18. CMET R_PatientLite Zorg Identificatie nummer Patiënt naam

19. CMET R_AssignedEntity Unique Care Provider ID (UZI) Care provider can be a person or an organisation

20. Interaction scheme Act Registry Application roles – –Sender: Act Reference Notification Informer –Receiver: Act Reference Notification Tracker Set of related messages

21. Interaction Act Reference Lite Registry Entry Created (MFMT_IN100050NL) Sending Role Act Reference Lite Notification Informer MFMT_AR100007NL Receiving Role Act Reference Lite Notification Tracker MFMT_AR100008NL Trigger Event Activate Act Reference Lite MFMT_TE100050NL Message Type Act Reference Lite – Add MFMT_MT100300NL Wrapper Type Registry Act Wrapper MFMI_RM700700

22. Query and response Medication Supply What should the query result set be? –All medication supplies/dispenses (definition?) for/to a specific patient (within a certain interval). –Both a specific pharmacy and the Act Registry (as an information broker for a group of pharmacies and care providers) can be queried. Query implementation based on the generic query framework from HL7 version 3 –First (successful) practical application? Query response has similar (same?) payload as unsolicited Medication Supply message

23. The Medication Supply Message (I) Challenge: the Medication Information section of the V3 ballot was ‘frozen’; its status was unclear. Dutch work was based on parallel work in the UK (Hugh Glover et al), which was shared with us. Modified D-MIM (domain model) and message definition for Act Registry Upload and Medication Supply Query were developed within the task force. Feedback of results in the international standard is in progress and will lead to final harmonization. Minimal discussion with the IT vendors to ensure efficiency in preparing for the conference demo  evaluation and extension with care provider organizations and IT vendors will continue in 2004.

24. The Medication Supply Message (I) Information contents of V3 messages were checked with EDIFACT message currently in use between Dutch community pharmacies. Result: first (partial) mapping of EDIFACT pharmacy messages to HL7 v3 models. Comparison and mapping to HL7 v2 messages (used within hospitals) will follow. But there are even more ‘competitive’ standards that will have to be ‘harmonized’.

25. Medication supply Query & Response Query with query parameters is sent to a ‘query responder’ ‘Query responder’ collects medication supplies that answer to query parameters and sends the answer to ‘querying application’ Act Registry may be used, but the interactions are the same for direct communication between querying application (e.g. EHR) and query responder (i.e. source pharmacy).

26. R-MIM Medication Query Medication usage interval Medication supply interval Supply ID Query definition ID, status: New Preferred sort order ZIN; mandatory

27. R-MIM Query response

28. Interaction scheme Query & query response Application role – –Requester: Substance Supply Event Query Placer –Fulfiller: Substance Supply Event Query Fulfiller

29. Interactions Sending Role Substance Supply Event Query Fulfiller PORX_AR100020 Receiving Role Substance Supply Event Query Placer PORX_AR100010 Trigger Event Substance Supply Event Query Response PORX_TE100002 Message Type Substance Supply Query Response PORX_MT100400 Interaction Type Substance Supply Event Query Response QURX_IN100002 Wrapper Type Query response QUQI_RM120000 Substance Supply Event Query Response Sending Role Substance Supply Event Query Placer QURX_AR100010 Receiving Role Substance Supply Event Query Fulfiller QURX_AR100020 Trigger Event Substance Supply Event Query QURX_TE100001 Message Type Substance Supply Query. QURX_MT100401 Interaction Type Substance Supply Event Query QURX_IN100001 Wrapper Type QueryQUQI_RM020000 Substance Supply Event Query

30. Project context Start of project May 1 (announced late April). Parallel paths: –Creation of Implementation Guide for Act Registry Upload and Medication Supply Query & Response. –Bringing together a representative group of IT vendors; convincing them to invest and participate in the demo. Implementation guide delivered first week of July. After that, getting the interface specialists from the vendors involved turned out to create an excellent environment for active cooperation in the project.

31. The ICT vendors (I) Participating companies: –Community pharmacy systems: MicroBais, EuroNed (a special ‘OZIS gateway’ was developed to allow use of existing standards for querying the Act Registry; upload not yet possible) –Hospital pharmacy systems: Falcon –HIS/EHR vendors: ChipSoft, McKesson, 2Cure, Infocare –Act Registry was implemented by LifeLine Two GP systems were involved, but were allowed to send proprietary prescription messages to the ‘OZIS gateway’. Realization of interfaces between August and October: –HL7 Netherlands task force gave support where necessary –Intermediate communication was mainly handled by e-mail Interface realization was greatly expedited by use of XSLT scripts to transform from EDIFACT-XML to HL7 v3-XML.

32. The IT vendors (II) Integral test sessions on October 29/30 at NICTIZ (with all participating vendors & HL7 NL present). Atmosphere of energetic, enthusiastic cooperation (‘innovation can be fun’). NICTIZ took care of facilities and politics, HL7 task force handled message implementation Conclusions: –Implementation guide (almost) ensured plug-and-play –Quick-and-dirty coding could be done in one day –Act Registry concept and message interfaces worked!

33. The MIC demo NICTIZ had prepared all conference attendees as ‘patients’ (marketing instrument) Some ‘Murphy’s Law’ issues were corrected on the night before the conference started;-) Demo performed excellently at all vendor stands (visitors could follow a realistic route through the ‘simulated care chain’) Politicians and other ‘budget makers’ made this tour too and saw something that worked

34. Conclusions Great sense of enthusiasm (‘proof of concept’) Unique synergy between competing vendors (important to maintain and expand on this while it still exists) Breakthrough event for NICTIZ (important for its role as a catalyst in health IT innovation) Breakthrough event for HL7 NL and V3 (important for its role as a catalyst in interface standardization) Follow-up projects to build on this foundation: –Working on a complete interface specification with all parties involved (care providers and IT vendors) –Try to move from “I’ll join if you…” to “please, can I join” Important 1 st step towards goal of having a national medication record online by 2006.

35. Questions