2. Architect EHR UMC St Radboud Nijmegen
Introduction
My name: Ernst de Bel
Architect EHR UMC St Radboud Nijmegen
Internist / intensivist/ econometrician
2001 : Clinical Data integration portal for the ICU using Web technology and AJAX
2004 : full time ICT
2003 : User of HL7 v3 as for application architecture sinds 2003
HL7 NL: Pharmacy, Patient Care
Project Radboud EPD

3. Project Radboud EPD

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5. Project Radboud EPD

6. Implementation HL7 v3 in the UMC St Radboud Nijmegen
Why use HL7 v3 for application design
Using HL7 v3 at various levels
Examples and demonstration
Project Radboud EPD

7. Intensive Care admissions
How it all started
IC Database
Intensive Care admissions
Census
Diagnosis, complications, outcome
Registration of minimal dataset for the evaluation of quality of care (NICE)
Project Radboud EPD

8. XML HL7 v2 XSLT HTML LRD HIS Rad. DB configuration Navigation
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10. EHR
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11. 2002-12 POC DBC (~ DRG) , Laboratory Result Reporting
Lab-Rad-Or (XpertMed web application)
IcWeb (NICE)
Building Order communication for the ICU
RvB: use XpertMed  EPD (tot 2008)
electronic order management ICU live
Medication orders and administration registration
Device orders : mech. Ventilation, pacemaker settings, dialysis etc.
RIM database (HL7-v3) for the hospital
progress and transfer summary (CareProvision, CDA)
new user interface, AJAX, SOA
interdisciplinary cooperation (oncology working group)
Concern Tracking for phycisians, configurable forms for nursing reports
Medication and Pharmacy
CareProvision as the basis for data integration
Project Radboud EPD

12. Projects, plans…. Electronic prescriptions Nursing record
Paramedic record
Oncologic data information system
PDMS Neonatology
Endoscopy
OR planning (OKAPI)
Pathology imaging
PDMS Psychiatry
Foto base NSC
Obstetric EHR
Pat Docu. System KNF
Chemotherapy admin sys, CIS
Patient care letters
Day care center
Blood bank
Digital Fertendo
DNA data repository
EHR family doctors
PDMS Klinical Genetics
Cardio-PACS
Informatics ER (ECare)
Overdrachtsysteem CIS
Patiëntregistratie Neurologie
Onderzoeksregistraties Urologie
Zorgregistratie fysiotherapie CSS
ICWeb
Radiotherapy
PDMS Hematology
Registratiesysteem lung function lab
Digital “Kinderendo”
Geriatrics interdisciplinary cooperation
Ordering / planning?
Trial management
Educational services

13. Planning Subst. preparation Orders Observation planning
Device preparation
Device setting
Orders
Medication/ Food
Observations
Devices
DeviceParameters
Order Results
Subst.Administration
Observations
Device applied
DeviceParameters
Actors
Physicians
Nurses
Other staff
Patient
Project Radboud EPD

14. Id Employee Name Type Start Stop Status 1 Z047110 Ernst de Bel Doctor
1996/10/01
Active 2
Z046710
Arno
Nurse
1993/08/01
active
performerId
patientId
Parameter code
Type
Value
Start
Stop
Status 1
PEEP
Order
10cm H2O
09/12 12:00
Active 2
Result
10cm
H20
09/12 12:10
Paracetamol 500mg
09/12 16:00 q6h
09/12 22:00
Done
Project Radboud EPD

15. Discovery of Heaven : To Do
HL7 education  shift of paradigm
HL7 tools for application development
HL7 database to persist HL7 structures
Project
Story board
Process / workflow modelling
Use cases
Actors, minimal datasets
Coding (HL7,SNOMED,ICF,LOINC)
Adherence to standards (NICTIZ-HL7)
Configuration of items for the UI
Implementation

16.  focus on information management  services
Paradigm shift
Focus on applications
 focus on information management
 services
Database modelling  object modelling
Stable database design, with optional horizontal and vertical splitting and scaling
Models reflect domain specific infromation the database not
Project Radboud EPD

17. Story to model
Pineut (Patient ) comes (12 juni 2004) to the ER department of of the UMC because of shortness of breath. Dr Smart listens and hears weezing leading to the diagnosis of astma. She prescribes Salbutamol and refers the patient to Kliniek St. Elsewhere for lung function measurement
RIMdb

18. ManufacturedMaterial determinerCode <=KIND name<=St ElseWhere
Observation
classCode <= OBS
code <= ‘chief complaint’
value <= ‘dyspnoea’
Person
classCode <= PSN
id<= (UMCN)
name<=Pineut
typeCode <=SUBJ
contextControlCode <=AP
Role
classCode <= PAT
id <=
typeCode<=RSN contextControl <= AP
Role
classCode <= DSDLOC
code <= ER
typeCode <=LOC
contextControlCode <=AN
Ambulatory Encounter
classCode <= ENC
code <= EMER
moodCode <= EVN
effectiveTime <=
Place
classCode <= PLC
name<=SEH
typeCode <=COMP
contextControl <= AP
Role
classCode <= PHYS
id<= Z047110
typeCode <=AUTH
contextControlCode <=AP
Person
classCode <= PSN
id<= Z (HRM)
name<=Smart
Observation
code <= ‘ausc lungs’
value <= ‘weezing’
typeCode <=MFST
contextControl <= AP
ManufacturedMaterial
classCode <= MMAT
determinerCode <=KIND
name <= Salbutamol
SubstancAdministration
moodCode RQO
doseQuantity 200µg
routeCode <= inhalation
effectiveTime <= (period =360)
Observation
code <= ‘diagnosis’
value <= ‘astma’
typeCode <=RSN
Role
classCode <= THER
typeCode <=TPA
typeCode <=RSN
Procedure
moodCode: RQO
code <= ‘lung function’
Role
classCode <= PROV
typeCode <=RESP
contextControlCode <=AP
Organization
classCode <= ORG
code<=HOSP
name<=St ElseWhere
RIMdb

19. player
scoper II
RIMdb

20. RDBMS MS SQL Server Databases XML + xsltxml or html Implementation
TerminologyServices
Templates (constraints)
RIM
Domain applications for business logic (AdministrativeManagement, CareProvision, Observations, Medication, Pharmacy)
XML + xsltxml or html

21. Basic abstract class instances table Extension classes : side table
Entity – LivingSubject – Person
Entity – Material – ManufacturedMaterial – Device
Role – Patient , Employee, Access
Act – SubstanceAdministrationAct, SupplyAct, EncounterAct, ObservationAct
Relations defined using internal parameters: entityId, roleId, actId
Relation tables : Participation, ActRelationship, RoleLink
Tables for messaging domein : Interaction, Message, QueryParameter

22. Simple mapping Datatypes Variabele mapping ANY  SQLvariant
BL,BN  xs:boolean  bit
ST xs:string  varchar
ED (text/plain of text/html) text + attributes in supplementary table
INT xs:integer integer,bigint
FLOATxs:numeric float
TS  datetimestring
Variabele mapping
ANY  SQLvariant

23. CS :HL7 structural attributes
classCode (ActClass,RoleClass,EntityClas)
determinerCode (EntityDeterminer)
moodCode (ActMood)
statusCode (ActStatus,RoleStatus, EntityStatus,ParticipationStatus)

24. Codes
Alle codes (except CS) mapped to internalId TerminologyServices CodeSystem : OID, CodeSystemName ConceptCode : internalId, code, codeSystem ConceptDesignation (displayName, languge) ConceptDescription (originalText, language)

25. RIMdb

26. Complex datatypes Cardinality = 1  fields
Role.effectivetime (IVL_TS)  effectiveTimeStart, effectiveTimeEnd
Role.quantiy  numeratorValue, numeratorUnit, denominatorValue, denominatorUnit
Cardinality > 1  table
EntityName, Telecom, Address
ActAttribute for priorityCode, confidentialityCode enz. methodeCode, reasonCode etc.
II (ActII,RoleII,EntityII) : internalId, root , extension
IVL_TS : effectiveTimeStart/effectiveTimeEnd timeStart/timeEnd
GTS : effectiveTimeLiteral + PIVL_TS (phase, width, period, operator)

28. Entity Field Name Implementation roleId Int Primaire sleutel playerId
FK (Entity)
classCode (CS)
Varchar
RoleClass
codeId (CS)
int
RoleCodeNL
statusCode
RoleStatus
effectiveTimeStart
Datetime
effectiveTimeEnd
quantityId
RTO
scoperId

29. Role Veldnaam Implementatie entityId Int Primary key classCode (CS)
Varchar
ActClass
determinerCode (CS)
ActDeterminer
(id [II])
Tabel EntityII
entityId,rootId, extension
codeId (CD)
VIEW ConceptCode
(quantity [SET(PQ)])
Tabel EntityQuantity
(name)
Tabel EntityName
desc (ED)
Text
statusCode (CS)
varchar
existenceTimeStart
Datetime
existenceTimeEnd
(telecom)
Tabel Telecom

30. RIMdb

31. Project Radboud EPD

32. Writing DetectedIssueEvent (if any)
Query strategy
Decomposing Message
Message
ControlAct
Participations : AUT,ENT,VRF
ParameterItem
Writing DetectedIssueEvent (if any)
Filling “Act tree” in memory: set of ActRelationships
Pull out ActRelationship – Act – Participation – Role – Entity based on primary keys
Assemble Message with XSLT

33. Writing from Message: Stored Procedures
createRole
createPatient
createAct
createObservation
createSupply
createEncounter
obsoleteAct, nullifyAct, holdAct, activateAct, suspendAct….

34. Building new instances from Templates
Configuration tool to define standard acts and actrelationship New instances are created from these definitions createActFromTemplate createActRelationshipFromTemplate Participations are added by the application

36. Implementation Entities + Roles
PersonnellManagement : HRM  Active Directory Services  RIM (Roles + Role Based Authorizations)
PatientAdministration : HIS  RIM (HL7 v2)
Places: reference database  RIM
OrganizationManagement: ADS  RIM (specialties, working groups etc.)
Materials : Pharmacy + Food Care + Matrix  RIM
Project Radboud EPD

37. Acts : domain specific applications
Encounter overview from 4 separate systems
Ordering substances to administer + administration registration
Ordering device settings and observations (ICU)
Care Transfer Request
Clinical summaries
Concern and diagnosis tracking
Multidisciplinary cooperation
Care Tracking and generation of billable Care Provision episodes
Document management
Project Radboud EPD

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44. Work flow in the application : sticking objects together
PrescriptionRXPredeterminstionRequest
Selecting patient
Create new prescription
Connect patient to prescription
Sticking product as directTarget to prescription
Adding author, dataEnterer
Sticking DetectedIssues interactions, double medications
ActivatePrescriptionRequest
Adding SubstanceAdministrationRequest
Add DetectedIssues for dosage
Add Verifier
Activate
Project Radboud EPD

45. Voorschrijven van medicatie
Project Radboud EPD

46. Registratie bij toediening
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47. Much overhead compared to amount of information
Problems with HL7 v3
Steep learning curve
Much overhead compared to amount of information
Model sometimes ‘clumsy’
Too tight, too open?
Project Radboud EPD