1. Challenges of Interoperability Using HL7 v3 in Czech Healthcare Miroslav NAGY, Petra PRECKOVA, Libor SEIDL and Jana ZVAROVA Center of Biomedical Informatics Department of Medical Informatics Institute of Computer Science AS CR, v.v.i. Prague, Czech Republic

2. Outline Motivation Motivation Processing medical reports – “synonyms” cause ambiguities Processing medical reports – “synonyms” cause ambiguities Interoperability initiatives in Czech healthcare Interoperability initiatives in Czech healthcare Materials and Methods Materials and Methods Standardization of clinical terms Standardization of clinical terms International communication standard International communication standard Two EHR systems were used (commercial and academic) Two EHR systems were used (commercial and academic) Results Results Mapping of data model to classification systems Mapping of data model to classification systems Enabling semantic interoperability among EHR systems via SIP (Semantic Interoperability Platform) Enabling semantic interoperability among EHR systems via SIP (Semantic Interoperability Platform) Conclusion Conclusion

3. Motivation

4. Data exchange via free-text reports Narrative free-text reports – prevailing form of data used for communication Narrative free-text reports – prevailing form of data used for communication Reports comprise of many specific abbreviations and synonyms, which are not consistent even in one hospital Reports comprise of many specific abbreviations and synonyms, which are not consistent even in one hospital Free-text reports are always typed again and again – many typos Free-text reports are always typed again and again – many typos Different understanding of terms can cause wrong decision and thus threaten the patient Different understanding of terms can cause wrong decision and thus threaten the patient This practice should be stopped. This practice should be stopped.

5. Activities in Czech healthcare One of early interoperability initiatives was IZIP One of early interoperability initiatives was IZIP Main idea: Main idea: Citizens should have a centralized copy of their healthcare documentation – the “Internet Health Book” Citizens should have a centralized copy of their healthcare documentation – the “Internet Health Book” Main problem: Main problem: Data were stored in free text form, which hindered their usage for processing by computers (various analyses, decision support, etc.) Data were stored in free text form, which hindered their usage for processing by computers (various analyses, decision support, etc.) National communication standard National communication standard DASTA bound to national nomenclature “National Code-list of Laboratory Items” DASTA bound to national nomenclature “National Code-list of Laboratory Items” Development supported mainly by the Ministry of Health of CR Development supported mainly by the Ministry of Health of CR

6. Standardizing clinical content We have to agree on what we are talking about. We have to agree on what we are talking about. Stating minimal data models Stating minimal data models At our department a Minimal Data Model of Cardiology was prepared - MDMC At our department a Minimal Data Model of Cardiology was prepared - MDMC Creating a mapping to coding systems Creating a mapping to coding systems Make the model multi-lingual – just translate the coding system Make the model multi-lingual – just translate the coding system Fix the meaning of the concepts in the model Fix the meaning of the concepts in the model Despite of the amount of incompatible coding systems (circa 100) there is a tool (UMLS Knowledge Source Server) that enables to search a term in all coding systems at once. Despite of the amount of incompatible coding systems (circa 100) there is a tool (UMLS Knowledge Source Server) that enables to search a term in all coding systems at once.

7. Supporting interoperability Standardized clinical content Standardized clinical content Communication standard Communication standard Electronic health record (EHR) Electronic health record (EHR) What have we done? What have we done? We proposed a Semantic Interoperability Platform (SIP) based on HL7 v3 messaging. We proposed a Semantic Interoperability Platform (SIP) based on HL7 v3 messaging. We conducted an experiment were we exchanged data among different Czech EHR systems using HL7 v3 messages. This experiment was a pilot implementation of the SIP. We conducted an experiment were we exchanged data among different Czech EHR systems using HL7 v3 messages. This experiment was a pilot implementation of the SIP.

8. Materials and Methods

9. EHR systems WinMedicalc 2000 WinMedicalc 2000 Medium sized commercial modular Hospital Information System (HIS) used among others in municipal hospital in Caslav, which participated in our project Medium sized commercial modular Hospital Information System (HIS) used among others in municipal hospital in Caslav, which participated in our project We have chosen this HIS because it emphasizes the advantage of structured EHR over the documentation based on free-texts. We have chosen this HIS because it emphasizes the advantage of structured EHR over the documentation based on free-texts. ADAMEKj ADAMEKj Developed at our department (EuroMISE Center) Developed at our department (EuroMISE Center) Fully structured EHR system with the aim to collect outpatient genetic and clinical data in cardiology Fully structured EHR system with the aim to collect outpatient genetic and clinical data in cardiology Clinical parts of domain models of both EHR systems are based on MDMC Clinical parts of domain models of both EHR systems are based on MDMC

10. Coding systems In our solution we used various coding systems In our solution we used various coding systems ICD-10 – for terms concerning diagnosis ICD-10 – for terms concerning diagnosis LOINC – laboratory results LOINC – laboratory results SNOMED CT – all other terms SNOMED CT – all other terms For terms searching we used the UMLS Knowledge Source Server (http://umlsks.nlm.nih.gov/) For terms searching we used the UMLS Knowledge Source Server (http://umlsks.nlm.nih.gov/)

11. Communication Standard Data transfers among EHR systems in our solution is performed by the HL7 v3 standard Data transfers among EHR systems in our solution is performed by the HL7 v3 standard It is widely accepted for the electronic interchange of healthcare information It is widely accepted for the electronic interchange of healthcare information RIM, DMIM, RMIM, Storyboards, Implementation Technology Specification (XML ITS) RIM, DMIM, RMIM, Storyboards, Implementation Technology Specification (XML ITS) The national standard DASTA has several shortcomings The national standard DASTA has several shortcomings Fixed to Czech healthcare only Fixed to Czech healthcare only No tooling support No tooling support No support for other coding systems than NCLI No support for other coding systems than NCLI Developed in a bottom-up manner resulting in no development methodology Developed in a bottom-up manner resulting in no development methodology

12. Results

13. Mapping the MDMC… MDMC consists of approx. 150 attributes, their mutual relations, units and data integrity restrictions MDMC consists of approx. 150 attributes, their mutual relations, units and data integrity restrictions 85% of terms were found in at least one classification system 85% of terms were found in at least one classification system Was the mapping easy? The terms could be classified into four groups: Was the mapping easy? The terms could be classified into four groups: Trouble free terms Trouble free terms Several possibilities of mapping to different synonyms Several possibilities of mapping to different synonyms Terms with too small or to big granularity Terms with too small or to big granularity No matching term found in any of available classification systems No matching term found in any of available classification systems Now we have a domain model with well defined semantics. Now we have a domain model with well defined semantics.

14. Mapping the MDMC… Description of encoded MDMC concept Code Coding system Treatment for ischemic heart disease (situation) 308068007 SNOMED CT Left ventricular hypertrophy (disorder) 55827005 SNOMED CT Diabetes mellitus (disorder) 73211009 SNOMED CT Swelling or edema (finding) 248477007 SNOMED CT Syncope (disorder) 271594007 SNOMED CT Measurement of the breath frequency in one minute 9279-1LOINC Measurement of intravascular diastolic pressure 8462-4LOINC Amount of proteins in blood sample 2885-2LOINC Sequelae of cerebrovascular disease I61ICD-10 Angina Pectoris I20ICD-10

15. SIP Terms Local Information Model (LIM) Local Information Model (LIM) A model derived from HL7 RIM classes – similar to D-MIM A model derived from HL7 RIM classes – similar to D-MIM Describes the domain (MDMC) of given EHR system (WinMedicalc 2000, ADAMEKj) Describes the domain (MDMC) of given EHR system (WinMedicalc 2000, ADAMEKj) The MDMC mapping was used to fill in the “code” attribute of each LIM class The MDMC mapping was used to fill in the “code” attribute of each LIM class LIM template LIM template Describes integral part of EHR (physical examination, lab. results, etc.) – similar to HMD Describes integral part of EHR (physical examination, lab. results, etc.) – similar to HMD Consists of classes from LIM Consists of classes from LIM XML Schema representation XML Schema representation LIM Message LIM Message XML document containing actual data from EHR XML document containing actual data from EHR Valid document according to the given LIM template Valid document according to the given LIM template HL7 v3 message HL7 v3 message Instance of an HL7 v3 message type Instance of an HL7 v3 message type

16. How does it work? LIM filler module – each EHR system has its own. LIM filler module – each EHR system has its own. HL7 v3 broker – configurable for each EHR system. HL7 v3 broker – configurable for each EHR system. SIP Schema: SIP Schema:

17. Conclusion

18. Why did we do it that way? To lessen the stress and fear of developers interested in HL7 v3. To lessen the stress and fear of developers interested in HL7 v3. We divided the work between HL7 v3 experts and HIS experts. We divided the work between HL7 v3 experts and HIS experts. Consequently, our solution is not depending on HL7 v3, it can be changed via a new “Broker” transforming component. Consequently, our solution is not depending on HL7 v3, it can be changed via a new “Broker” transforming component.

19. Conclusion Incorporation of international classification systems is the first and essential step towards interoperability. Incorporation of international classification systems is the first and essential step towards interoperability. Standardized clinical content would result in more reliable information stored in EHR, which will lead to less error- prone and safer care for patients. Standardized clinical content would result in more reliable information stored in EHR, which will lead to less error- prone and safer care for patients. We made a proposal and a testing implementation of SIP and were able to exchange data between two heterogeneous EHR systems. We made a proposal and a testing implementation of SIP and were able to exchange data between two heterogeneous EHR systems. A real challenge would be a national-wide implementation of SIP. A real challenge would be a national-wide implementation of SIP. Enable/support medical tourism Enable/support medical tourism Open the market for HIS solutions from abroad Open the market for HIS solutions from abroad It is necessary to translate classification systems (SNOMED CT) to Czech language It is necessary to translate classification systems (SNOMED CT) to Czech language

20. Thank you for your attention. The work was supported by the project no. 1M06014 of the Ministry of Education, Youth and Sports CR. Mgr. Miroslav Nagy Center of Biomedical Informatics Pod Vodarenskou vezi 2 Prague 8 182 07 Email: nagy@euromise.cz nagy@euromise.cz Tel. +420 266 052 081