1. Integration projects and HL7 implementation at Wrightington, Wigan & Leigh NHS Trust Philip Firth IM&T Strategy Implementation Manager Wrightington, Wigan & Leigh NHS Trust Philip.Firth@wwl.nhs.uk

2. Introduction Background to projects in Wigan Acute Look at some of the integration issues that Acute Hospital NHS Trusts typically need to address Look at an example project with complex integration needs – Accident & Emergency Look at requirements for linking Acute Hospital NHS Trust systems to LSP solutions and the Spine

3. Existing Systems Integration - Maximizing local IT investment - Delivering functionality which meets local requirements - Delivering functionality which maybe out of scope for NPfIT

4. Current integration architecture at WWL

5. Acute Systems Integration Typical Issues

6. Standards - what standards??? Interface standards/output formats in Wigan –HL7 v2 (various implementations of) –EDIFACT –ASTM –System specific output – eg. Torex PAS openlink Acute Trusts need to learn to work with what’s available !!!

7. Implementation issues - PAS PAS ‘real-time’ interface No guarantee that messages would be delivered in the right order –Could get an Admission message prior to a Patient Registration Had to introduce a 15 minute time delay Result: bed-status in EPR system slightly out of sink

8. Implementation issues - Pathology Handling previous results – append or overwrite? –Microbiology – overwrite –Haematology, Chemistry – currently append Collection date and time not always supplied Reference ranges can change –Implication for graphing Sensitive tests –What is the best way to deal with HIV, GUM, pregnancy tests etc?

9. Implementation issues - Pathology Multiple patient IDs (NHS number, Hospital number) Multiple casenote numbers (Trust mergers) –Need to establish systems for cross referencing patient IDs Missing patient ID Pathology system sending internal patient ID Missing key patient data – DOB, Gender –Unable to guarantee a match – need to Dump message

10. Data Quality Biggest issue by far is unique person referencing Major education / change mgmt task to –Get patient administration staff to register patient details accurately and avoid duplicates –Get clinicians to use the Hospital / NHS Number Problem especially big in emergency care Issue has a huge knock on effect for the remainder of each episode care

11. Example: A consultant asked me to investigate why a particular chemistry result did not appear in the patient’s EPR record In this instance the patient ID recorded in the Hospital Number field turned out to be the patient’s telephone number MSH|^~\&|MLAB||||20040519113446||ORU^R01|X99156|P|2.3 PID|1||217779^^^^PAS~773702^^^^DEP||SURNAME^FORENAME^^^||19371113|M|||999 ACACIA AVENUE^ORRELL^WIGAN^^WN9 9XX||||| ZMP|G3417810^^NAT^SS^^L|^^L ZPV|AE|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|ACC|CC|CH|20177803|2004 0519|200405191026||FITS.|U||P OBR|1||20177803^CCMLAB|CC_RUEGK^Urea, Elects. Gluc (urgent)^L^^^L|||20040519||||||FITS.|200405191026||&AP^PINTO^A.^^^Mr.||||||||CH|F||^^^20040519^S| OBX|1|ST|CC_TONA^Sodium^L^44I5.^^RC||140|mmol/L|135-145|N|||F Data Quality Lesson: CANNOT use patient ID as the sole identifier – also need to cross reference with patient’s DOB, Gender, Surname …

12. Addressing data quality issues in Casualty Solution Integrated emergency floor system New emergency floor system is integrated with PAS to enable staff to retrieve up-to-date patient demograhics, including NHS Number New emergency floor Pathology / X-ray requests automatically include patient ID - improvement departmental system data quality New emergency floor system will be able to automatically register new patients on PAS - improvement 24 hour bed status

13. Integrated emergency system live Addressing data quality issues in Casualty

14. Issues that are not so easy to address … Real-time data capture –Not easy when an A&E receptionist is face to face with a patient who is either Confused Uncooperative Abusive Unconscious –Addressing these issues is proving to be a much more challenging task!!! Addressing data quality issues in Casualty

15. Rapid application development approach : (1) Present the HL7 results in the EPR test system environment via a stylesheet, and ask the domain experts for comments (2) Amend stylesheet, and repeat (1) until domain experts are happy to sign off stylesheet design (3) Implement stylesheet in live EPR system Addressing presentation issues using XSL Stylesheets

16. Microbiology example - Legacy Pathology System view Sensitivities in a fairly non user- friendly cross tabulation format

17. HL7v2 messages A Culture and Sensitivity result is reported using multiple OBX segments. A single organism result comprises an Organism OBX segment with subID N followed by an Organism Growth OBX segment with subID N followed by zero, one or more Organism Sensitivity OBX segments also with a subID value of N.

18. Microbiology The final stylesheet design was deemed an improvement to the legacy system text based screen More user-friendly cross tab for Organism vs Sensitivities

19. Critical issue - TIME Building interfaces is not a 5 minute job TasksTIME –Find funding to initiate project? (show-stopper?) –Design interface, agree end-to-end requirements1-3 months ? –Supplier set-up / configure interface 1-3 months ? –NHS Trust set-up / configure interface 1-3 months ? –End-to-end testing1-3 months ? –On-going Stylesheet development? In summary, even a bog-standard unidirectional HL7 interface could take anything from 3 to 15 months, from start to finish

20. Key benefit of basing your integration architecture around XML EXCHANGE OF BOTH DATA AND PRESENTATION

21. Data and Presentation Web technology is enabling the Trust to benefit from both Data exchange: development of interfaces which move XML patient data between an EPR (an XML clinical repository) and other departmental systems Presentation: development and sharing of stylesheets which present a common view of departmental system data across multiple applications

22. Example Bi-directional transfer of data and presentation between EPR and A&E EPR Electronic Patient Records Emergency Floor Electronic Patient Records Discharge Letters, Emergency Care summary Pathology results, Patient demographics Data and Presentation JOIN Shared XML data and stylesheets

23. Haematology result in the EPR system

24. Haematology result in the A&E system

25. Addressing data quality and change issues Planning ahead for NPfIT / LSP integration

26. The clinician's perspective on electronic health records and how they can affect patient care. BMJ 2004;328:1184-1187 (15 May) Many attempts to get clinicians to use electronic health records have failed, often because of difficulties with data entry. Kay and Purves maintain that narratives are at the heart of clinical decision making and refers to this concept as "narrative reasoning Van Ginneken states that many computerised medical record systems are rejected by clinicians because they are not based on a story metaphor Challenge: How to get clinicians to enter ‘coded’ information into a computer when they would prefer to hand write on paper or type essays into a free text box?

27. Emergency Floor system design Change management issues –A&E clinicians had never previously entered clinical data into a computer – all notes were recorded on a paper cascard –Solution had to be QUICK and USER-FRIENDLY !!! Single screen to record all discharge information Order comms – all requests for investigations recorded Treatment given – point and click Drugs administered – point and click Diagnosis – point and click Clinician notes – free text

28. Emergency Care System Emergency Floor system design Simple / Quick point and click data capture

29. Emergency floor system Discharge screen auto generates an XML discharge summary message Stylesheets to produce 2 documents on discharge: (a) Patient letter (b) GP letter

30. Emergency floor discharge summaries Discharge summaries are currently stored in XML format and presented on screen using an XSL stylesheet (A&E and EPR systems) Diagnosis values are coded ICD10, but can easily be coded in SNOMEDCT as well XML data could be transformed into valid HL7v3 Provision of care messages using XSLT prior to routing to the Spine

31. NPfIT Integration Challenges

32. Scope - NPfIT clinical messaging The scope of Phase 1 clinical messaging is very big and complex It is HL7 version 3 which is new to the majority of people in health informatics

33. Primary Care LSP / Existing EBS Slots (provide and fill)Referral OOHEncounter ** NHSD Encounter ** Phase 1 Clinical Messaging Flow Summary Any PSIS / NCRS Accredited System PSIS Query Secondary Care LSP / Existing PoC Discharge Report (Inpatients) or PoC Care Event Report (Out Patients) PoC Disch or Care Event Report ETP Pharmacy Prescribe Cancel Full / Partial Dispense PSIS Medication Updates SAP SAP Encounter (PoC Care Event Report) GP2GP Diagnostic Imaging DI Report DI Report DI Encounter DI Requestor Care Event Report (Primary Care) PoC Emergency Admission Notification ** A&EA&E Report ** Mental Health Adm Disch CPA Summary Adm / Disch / CPA Summary Notifications NOTE: Flows marked with ** are also sent to PSIS but not shown on this diagram for ease of reading

34. Existing Systems Integration Replacement of NHS IT systems will not happen overnight in Acute Hospital Trusts Key department systems may not be replaced before 2010 Existing systems integration is therefore a key issue for Acute Hospital Trusts

35. Existing specialist or departmental systems will interface to the LSP core solution NOT directly to the Spine Spine compliance LSP compliance

36. LSP Existing Systems Integration Single logical link between LSP data centre and the Authority Service Recipient via N3 Messages HL7 V2.4 and encrypted Integration engine required (Seebeyond license is free for CSC TIE use only) Inbound messages must be agreed with NPfIT (conforming to the rules referenced in CRS Interactions with Existing System (NPFIT-FNT-TO-TAR-0004) and Principles for CRS Clinical Data Access by Local NHS Systems (NPFIT-FNT-TO-TAR-0006.01))

37. WWL / CSC NPfIT integration approach