1. Development of a Regional Shared Electronic Health Record
Pablo Serrano Balazote
Planning Director. Hospital 12 Octubre. Madrid
May 2017 HL7 International Conference & Working Group Meeting. Madrid

2. Madrid Health Community
About SERMAS
Madrid Health Community
Third largest city and metropolitan area in Europe, with 6.3 Million citizens
Spain has a public health system, population based, decentralized in regions.
They are responsible of health care provision.
SERMAS is the Madrid regional health service, dependent of the Government.
Madrid Health Service (SERMAS)
Part of the Regional Healthcare Minister

3. 35 hospitals, 30 outpatient centers Mental health network
About SERMAS
Primary Care
265 centers & 163 offices
Specialized care
35 hospitals, 30 outpatient centers
Mental health network
Emergency services
Lab, transfusion and radiology central units
citizens
health professionals
IT users
Public funding, planning and provision
Population-based
Direct and indirect management
The Madrid Regional health service cover the care of more than 6 million people, with health care professionals.
The Regional Government finances and plans and the SERMAS provides health care.
The organization have a population base, with community Primary Care, gatekeeper of the system, and a reference Hospital.
There are a common emergency service and central support units.
Most of organizations are managed directly and 5 hospital are managed by private concessions.
2 Specialised data center
1 Contingency data center
+202 applications
1 Local data center per hospital (20 large CPD’s)
670 Connected centers
634 Servers
TBytes storage capacity
PCs
& printers
+50 IT services and products suppliers

4. Currently, IT is supporting: 100 % primary care patients with EHR
About SERMAS
Information Technology is a fundamental part of SERMAS, supporting all healthcare
Currently, IT is supporting:
100 % primary care patients with EHR
65 % hospital patients with EHR
100 % electronic process in emergency services, and laboratory, radiology and transfusions central units
Patients empowerment
+10 million appointments / PHR access
Currently, IT is supporting: all primary care patients with EHR
ˈpeɪʃənt hɛlθ
Two thirds of hospital with EHR
tuː θɜːd
all electronic records in emergency services, laboratory, radiology and transfusions central units
trænsˈfjuːʒən
and patient empowerment
ɪmˈpaʊəmənt
ICT Main goals
Meet the needs of citizens and professionals
A more efficient model
Empower clinical professionals
Innovation
Clinical collaboration

5. Main healthcare information systems
National document repository HCD SNS
Regional view layer, professional HORUS and personal
Specialized care
EHR
HIS
SELENE
HCIS
IMDH F
They are the currently main healthcare information systems: health records in all care levels, order manager and repositories. We will briefly describe them and their integrations.
Mandate. Delay. Appointment
e prescription
EHR Primary Care
AP Madrid
Population information Cibeles

6. Main healthcare information systems
Population information
unique regional patient identification
demographic repository
Primary care
unique EHR
multidisciplinary
longitudinal and problem oriented
ISO accordant
high degree of structured data
start 25 years, normalized and unified 10 years
We have a population information system Cibeles, who provide unique regional patient identification and demographics data for all the systems. In Primary care there are a unique EHR “AP Madrid”, multidisciplinary, longitudinal and problem oriented, ISO conformant, with a high degree of structured data. It began more than 25 years ago and was normalized and unified ten years ago. The electronic prescription is integrated with pharmacy offices and is currently fully implemented and is interoperable at the national level. In order to communicate levels of care, two systems was deployed to appointment and to communicate referrals and diagnostic requests from family physicians to hospitals.
Electronic prescription
integrated with pharmacy offices
currently fully implemented
interoperable at the national level
Mandate. Appointment
to communicate levels of care,
referrals and diagnostic requests from family physicians to hospitals

7. Main healthcare information systems
Specialized care
1997 first hospital EHR
13 hospitals started with EHR
2009-
convert conventional into digital
10 implemented EHR currently
remainder planned in next 3 years
Hospitals HIMSS EMRAM stage 6
2 native, 1 transformed.
4 different EHR system,
with heterogeneous information models
a broad scope:
inpatient, outpatient centers and mental health centers
2 EHR to emergency services and palliative care
Central units
laboratory, radio diagnostic and transfusion systems
At the specialized care, the EHR implementation began 20 years ago, and was driven in the last decade with the opening of a set of 13 hospitals that started with EHR.
In the lasts five years we are deploying two programs to convert conventional hospitals into digital ones. Currently has been implemented the EHR in 10 centers and we planned the remainder in the next three years. The implementation level has recognize with HIMSS EMRAM stage 6 for 2 new hospitals and one transformed.
They are 4 different EHR system, with heterogeneous information models. These EHRs has a broad scope: inpatient, outpatient centers and mental health centers. In emergency services and palliative care there are other two EHR

8. Main healthcare information systems
Regional repository
share clinical information across all centers
view layer above the systems
access to structured summary patient data in the primary care EHR
index clinical reports in the EHR hospitals and emergency services
retrieve documents
images links to PACS of the centers
PHR “carpeta personal”
patient can access to his personal records
National repository
HCD SNS
integrated with the national document repository of Digital Health Record.
Ten years ago to share clinical information across all centers we developed a view layer above the systems. This system access to structured summary patient data in the primary care EHR and index a set of clinical reports in the EHR hospitals and emergencies, that can be retrieve like documents. For to images the system links to PACS of the centers. Since two years the patient can access to his personal records with the same content.
The document repository is integrated with the national document repository.

9. Regional integrations
National document repository
HL7 CDA
Departments systems
Regional view layer
One of the health integration standards used in SERMAS is HL7. We have the following success stories:
For the integration of demographic data between Cibeles and hospitals systems.
Within each hospital, integration between EHR and departmental systems is performed using HL7 messaging for sending requests and returning results (radiology, laboratory, ...) , and for prescription with pharmacy
With National document repository (HCDSNS), for submission of clinical reports using HL7 CDA.
Mandante , for request (ORM), appointment (ADT) and return of results (ORU).
HL7 2.x
HL7 2.x
EHR Primary Care
EHR hospital
Mandates
HL7 2.x
Population information

10. Hospital integrations
Regional view layer
XML
Delays. Appointments
Population information
The core of the integration platform is a corporate engine within the SERMAS.
The standard messaging used for integration between the HIS / EHR Hospital and the remains information systems is the HL7 2.6 Integration with the Corporate Patient Teacher Information System (CIBELES) uses standard HL7 2.5 messaging.
Integration with the Corporate Document Manager (HORUS), based on an integration in XML format (No CDA).
with the Corporate delays information (RULEQ) and multincenter appointment management (MULTICITA), in XML format.
The rest of departmental information systems are based on this standard and use integration engines in different versions of MirthConnect (Pharmacy Management System, RIS, HER Emergency, Endoscopic Imaging System, Functional Testing System ...), Orion Rhapsody , Cardiac Image System) or own developments (LIS).
Except for integrations with the Central Services Information Systems (SERMAS), the management and maintenance of integrations is carried out by HUDO's own staff.
HL7 2.6
Departments systems
HL7 2.5
HL7 2.6
Departments systems
EHR

11. Development of a Regional Shared Repository
Progress in share clinical information to facilitate continuity of care
Use existing EHR systems in primary care, hospitals and electronic prescriptions
The new shared system must evolve current regional and national repositories based on document
towards the organizational and semantic interoperability
The Madrid Region wants to progress in the electronic health record (EHR) to facilitate continuity of care, based on existing EHR systems in primary care, hospitals and electronic prescription. The new shared system must evolve current regional -Horus- and national -HCD SNS- repositories based on document towards the organizational and semantic interoperability.

12. Development of a Regional Shared Repository
Apply the lessons learned with ISO in advanced platforms (UPV LinkERH and ISCIII) about:
normalize heterogeneous EHR
communicate to other systems
persist in sharable data repository based on the dual model
We apply the lesson learned in the advanced research platforms (LinkERH UPV, ISCIII) about normalize heterogeneous EHR systems, communicate to other systems and persist in sharable data repository with dual model.
To do this architecture is required a common information model, corporate for the regional health system, transversal to care levels and providers, and cumulative longitudinal in time, allowing continuity of care and patient-centered.
They has to cover high organizational concepts, reference model, clinical data structures and terminology.
Need a common and corporate information model, transversal to care levels and providers, and cumulative longitudinal in time
They has to cover high organizational concepts, reference model, clinical data structures and terminology

13. Methodology to define the model
Concurrent used
health informatics ISO advanced standards
ISO for the concepts of continuity of care
ISO reference model for clinical information
Sequence
organization information model with the intersection of the standards: organizational concepts and processes, and the clinical record context
clinical detailed information models: editing archetypes and binding terminology
Heterogeneous concepts of current systems have been matched through a correspondence schema based on the ISO and ISO reference model.
ISO 13940
Healthcare organizational concepts
ISO part 1 RM
Information management
ISO part 2 archetypes
Clinical information models
SNOMED CT
Terminology binding
To the define the information model we have used a methodology for the application of advanced ISO standards developed from the CEN working group named "concurrent use".
From abstract to concrete concepts and from the enterprise viewpoint to information view. The modelling has followed this sequence: first the definition of the organization information model with the intersection of the standards: organizational concepts, workflows and processes, and the reference of the clinical record context , and then in a second step the definition of clinical detailed information models with the binding of archetypes and terminology.
The heterogeneous concepts of current systems have been matched through a correspondence schema based in the model of ISO and ISO reference model.

14. Clinical information models
Adopt the CIMI approach,
base on convergence and abstraction
modeling formalism : archetypes
terminology: SNOMED CT
reuse and align existing models
HL7 FHIR, openEHR
Specialize the current Spanish ISO archetypes for HCD SNS
Define clinical records components -compositions, entries, elements- and their relationships (links)
Matched concepts in the current systems through a correspondence schema with the model to be instantiated with legacy data
To define the clinical information models we adopt the CIMI approach:
archetypes like modeling formalism and SNOMED CT like terminology.
And reuse and aligned existing models, with the main standards openEHR, HL7 FHIR, and specialize the spanish ISO archetypes for HCD SNS
We have define Clinical records components -compositions, entries, items- and their relationships (links).
We have matched concepts in the current systems through a correspondence schema with the model to be instantiated with legacy data .

15. Methodology to define the model
Example models for Healthcare planning
CONCEPT
MODEL
Care plan
Care Plan
openEHR-EHR-INTRUCTION.care_plan.v1
CEN-EN13606-COMPOSITION.PlanAsistencial.v1
Health concern
Health Concern
CEN-EN13606-ENTRY.ValoracionActiva.v1
Health condition
Diagnosis
openEHR-EHR-EVALUATION-problem_diagnosis.v1
CEN-EN13606-ENTRY.ProblemaDiagnostico.v1
Health goal
Health Goal
openEHR-EHR-EVALUATION-goal.v1
CEN-EN13606-ENTRY.Resultado.v1
Healthcare activity
Interventions
openEHR-EHR-ACTIONS.procedure.v1
CEN-EN13606-ENTRY.Procedimiento.v1
ISO 13940
ISO 13606
There are an example of models for de chapter healthcare planning, whit the ISO concept and his respective models in each standard formalism.

16. Implementation strategy
Information sources
Pharmacy
AP Madrid
HCIS …
Data Format
is represented by
LinkEHR
Integration engine
The implementation strategy are base in tools to edit archetypes multimodel (ISO openEHR- HL7 CDA), mapper these whit data sources and produce transformation programs than the current integration engine execute XQUERY to generate communication artefact, in our case, both ISO extracts or HL7 CDA.
We communicate the extract to the a repository in the Health Institute Carlos III, than process and store in a data base conformant the dual model.
Rules
generate
Uses
Mediator
Extract 13606
HL7 CDA
Archetypes
viewer
Repository
Repository
Desing
Execution

17. Learned lessons
Usefulness of normalization of organizational concepts of the systems with ISO Recognized good practices in modeling with ISO to fully capture the existing meaning for a shared repository Extensive use of LINK class to represent temporal sequences, flows and clinical logic connections Reflect clinical record sessions instead of secondary composite document
We have show the usefulness of normalization of organizational heterogeneous concepts of the existing systems through correspondence with the concepts of ISO
We have recognized good practices in the modeling with to fully capture the existing meaning for a shared repository of clinical information. Especially relevant, the extensive use of LINK class to represent temporal sequences, flows and clinical logic connections. The COMPOSITIONS have to reflect clinical record sessions instead of secondary composite document.

18. Acknowledgments Project team Funding SERMAS
D.G. Health information systems
D. G. Primary Care
SD.G. Pharmacy
Advisor
Thank you for your attention
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