Electronic Records Current and Future Trends and Some Important Ingredients for Success

1. Electronic RecordsCurrent and Future Trends andSome Important Ingredients for Success

2. Agenda: Main Points • Paradigm Shift: I vs. IT • Success Story: Electronic Banking • Electronic Records (ER) Are… • ER Advantages Over Manual/ Paper Records • Electronic Staff Records • Security, Confidentiality, e-Trust and PETS • Point of Care Connectivity/ Decentralised Diagnostics • The Tower of Babel and HL7 • Parlez-Vous Français? New York–Paris and SNOMED CT • Web Services: Plug-and-Play ER Services • NICE Guidelines Not So Nice—Computer-interpretable/-executable Guidelines • Enterprise Master Person Index and Data Integrity • Conclusion

3. Paradigm Shift: I vs. IT (1) • “The NHII includes not just technologies but, more importantly, values, practices, relationships, laws, standards, and applications that support all facets of individual health, healthcare, and public health. It encompasses tools such as clinical practice guidelines, educational resources for the public and health professionals, geographic information systems (GIS), health statistics at all levels of government, and many forms of communication among users.”Source: US National Health Information Infrastructure Strategy <http://ncvhs.hhs.gov/nhiilayo.pdf>

4. Paradigm Shift: I vs. IT (2) • We are in the I (information) era and past the IT era. • We should think and talk about “services” and “programmes” (main focus on people, information and tasks) not “systems” and “projects” (main focus on technology). • Services should be information-driven not information technology-driven. We should observe practice and check the needs of users before starting to develop a new service.

5. Paradigm Shift: I vs. IT (3) • NASA spent millions developing a pen that would work in space (newtechnology), while Russian cosmonauts simply used cheap ordinary pencils, which would work at any angle, with or without gravity (to achieve nearly the sametask)!

6. Success Story: Electronic Banking (1) • A bank keeps one “container” record per client (cf. EHR in the current UK I4H strategy) and records all transactions in it (irrespective of their type, and the branch, place or country they took place in—cf. EPR episodes in the current UK I4H strategy).

7. Success Story: Electronic Banking (2) • The record is always available everywhere (e.g., if you go to Scotland, or even outside the UK, they/you can still access your Barclays bank account that you opened in London) and on the Web (online banking and shopping) on a “need to know basis” that observes a set of clear security and confidentiality requirements.

8. Point of Use Access Shop everywhere!

9. Success Story: Electronic Banking (3) • When it comes to security, privacy and confidentiality, it’s not a matter of ensuring 100% absolute security and confidentiality (this is impossible and can be handicapping, even in the banking sector), but of maintaining good balance between actual (realistic) needs, risks, costs, potential losses (including impact on reputation), etc.

10. Success Story: Electronic Banking (4) • The precise coding is language independent so that the same information is retrievable and “writable” in any language, e.g., different VISA ATM interfaces and printouts for different languages and transparent currency conversion between countries, all using the same VISA card.

11. Success Story: Electronic Banking (5) • Data from aggregated customer accounts are analysed and used to inform various bank management and planning decisions. • Best of all, no confusing EPR/EHR definitions and separation; it’s just one account! • Banks were successful because they have focused on information and tasks to be achieved with it, employing technology to serve information and realise tasks.

12. Electronic Records Are (1)^ Medical/Health • A historical record of/for patient care (for example, a patient’s current problem say “infertility caused by adhesions” might be diagnosed/ interpreted/ approached in light of a past history event like prior surgery, e.g., complicated appendicectomy, many years ago) • A communication tool among care providers • A research and knowledge-gaining tool • A teaching tool

13. Electronic Records Are (2)^ Medical/Health • An operational tool (e.g., imaging/lab order entry and electronic prescription entry) • A business tool (e.g. to support billing and budgeting) • An administration record (e.g., to manage resources and for auditing and quality assurance via detailed audit trails and analysis of aggregated outcomes) • A medicolegal record (it should be possible to accurately trace all changes/transactions, who did them, and when)

14. Electronic Records Are (3)Source: US National Health Information Infrastructure Strategy <http://ncvhs.hhs.gov/nhiilayo.pdf> GIS >

15. Electronic Records Advantages Over Manual/ Paper Records (1) • Can be used by multiple personnel at the same time • Accessible from anywhere(even from home using mobile devices) • Clarity, better organisation and legibility • Different types of data can be integrated from multiple disparate sources transparently • Automated research and decision-support (DS) functions(outcomes analysis and data mining, computer-aided diagnosis, alerts, reminders, guideline-based care—all relevant patient data can be accessible to DS and do not require separate entry)

16. Electronic Records Advantages Over Manual/ Paper Records (2) • Context-sensitive best evidence knowledge links for physicians and patients • Data can be validated automatically: • Range checks (e.g., of lab test results) • Pattern checks (e.g., a telephone number pattern) • Numeric and other inter-data constraint checks (e.g., total of differential WBC is 100%) • Consistency checks (e.g., no pregnant male) • Temporal-abstraction checks (e.g., weight cannot change by 30 Kg in just 1 day) • Spelling checks for free text portions

17. Electronic Records Advantages Over Manual/ Paper Records (3) • The “somewhat difficult” ER data entry relative to handwriting can be improved (or even made superior) by using specialised speech recognition interfaces for data entry and on-screen drawing over/ marking of clinical diagrams.

18. Electronic Staff Records (1)(Not Just Electronic [Medical/Health] Records) • Research evidence shows that proper Electronic Staff Records (ESR) and Human Resource (HR) management can reduce length of patient stay in hospital and complications like bed sores, and ultimately improve clinical outcomes. • Good HR management can also attract new employees and motivate/keep existing ones.

19. Electronic Staff Records (2)(Not Just Electronic [Medical/Health] Records) • The ultimate ESR should include besides the standard payroll, employment record, and cost and budget centres modules, additional modules dealing with recruitment, training records, delivery of e-learning, knowledge and skills frameworks, time attendance and staff rostering, management of staff credentials and authentication for ER access, employee performance indicators (informed by employee-specific ER audit trails), and more...

20. Authorisation,Authentication and Encryption • Authorisation: Is the patient’s dentist allowed to see her gynaecological record? Which fields of my record can my GP view? Can another GP (same role, but different person) view the same fields? When? • Authentication: Is this user really my GP, Dr. Geoff Baker? • Encryption: Can an eavesdropper understand the message sent to my doctor or the communication between my GP and the consultant he referred me to? • Security depends largely on people not technology.

21. e-Trust and PETS • e-Trust can be defined as an ongoing interaction that establishes and maintains confidence between and amongst members of a widely dispersed community who may not personally know one another. • Digital credentials play a very important role in establishing e-trust. • The Electronic Staff Record can be used to manage staff credentials. • PETS (Privacy Enhancing Technologies), include traditional access controls, encryption, digital credentials/certificates, biometrics, and more... • Problems with PETS include standards, infrastructure, cost, management, monitoring, acceptability, and testing.

22. A Good Balance Is Needed • Absolute blind ER security can be handicapping with negative effects on the individual patient, e.g., in emergency situations, and on public interests, e.g., in case of bioterrorism and highly infectious diseases, and it will still be prone to hackers! • A good balance (like in electronic banking) is needed.

23. Point of Care Connectivity/ Decentralised Diagnostics (1) • Point of care connectivity to electronic records (mobile records) is rapidly becoming a reality. For example, a nurse, while on ward rounds, could immediately enter patient information into a PDA, rather than returning to the nurses’ station. • And with the rapid advances in miniaturisation, a full range of decentralised diagnostics and point of care testing devices has become available.

24. Point of Care Connectivity/ Decentralised Diagnostics (2) • A proactive real-time wrist monitor worn by the elderly person for example can send information on their current state of health and notify family or emergency services if required, creating an environment where care is reliable and dependable, thanks to the right people having access to the right information at the right time. • Other examples include digital glucometers and prothrombin time meters. • Many of these devices can be connected to computers to upload their data to an ER for storage and analysis. But the problem is that at least 2/3 of captured data from these devices never make it to the patient record, and that’s where HL7 (a communication interface standard) comes to help.

25. Why Multiple ER Services and Interoperability? • It is obvious from the previous slides that there is no single comprehensive information service that can completely cover all the needs of hospitals and other areas of healthcare services. • It is always necessary to deploy information services from various suppliers. • Hence the need for service interoperability!

26. With each application of a new ER component, the “Tower of Babel” becomes even higher and the language diversity is expanded by yet another dialect. Each new component must be adjusted to the existing dialects of an individual institution. This leads to high prohibitive costs for both the supplier and the user. When components are not able to exchange data with each other, an interruption in the electronic flow of information follows that has to be manually compensated (partially) by hospital personnel preparing, printing and re-entering written records, thus loosing many of the ER gains. The ER Tower of Babel The Tower of Babel - Pieter Bruegel (about 1525-1569), usually known as Pieter Bruegel the Elder 1563; Oil on oak panel, 114 x 155 cm; Kunsthistorisches Museum Wien, Vienna Based on Genesis 11:1-9

27. The ER Tower of Babel: Interconnecting vs. Understanding • One of the simplest ways to connect two ER components would be to send an e-mail. The only requirement would be that both computer systems are connected with each other by a network. The technical management of the transmission of e-mail is specified in a network protocol, the so-called Simple Mail Transfer Protocol (SMTP), a part of the Internet (TCP/IP) protocol suite. • This allows for text messages to be exchanged using simple programs, however it does not guarantee that the component receiving the data will be able to parse or “understand” them and react appropriately, e.g., to reuse the data in another context, enabling true interoperability. • An interface is needed between each pair of components which exchange data to ensure proper interoperability. • Examples: • How the date is written/ exchanged? (syntax, grammar) • Is the first item the forename or surname? (semantics)

28. The ER Tower of Babel:Interfaces for Understanding • n.(n-1) is the formula to calculate the theoretical number of interfaces between n components, e.g., for 5 components, up to 20 different interfaces are at times necessary. When replacing a components, multiple interfaces must be redefined. • With many individual interfaces communication chaos can arise.

29. Solving the ER Tower of Babel:HL7 for Understanding/ Interfacing (1) • HL7 name refers to (health) layer 7 of Open Systems Interconnection (OSI) 7-layer communication model of the International Standards Organisation (ISO). • HL7 is an international standard for exchange of data among different hospital computer applications and represents a valuable implementation aid for integrating heterogeneous components (ANSI-accredited and member of ISO TC215). HL7 RIM

30. Solving the ER Tower of Babel:HL7 for Understanding/ Interfacing (2) • HL7 CCOW (Clinical Context Object Workgroup) specification for example enables users to log-in once and access different components, and components to be synchronised (e.g., if the currently selected patient is changed in one component, the change is automatically propagated to the other components to show that patient’s data).

31. SNOMED CT: A Standard Language of Health (1) • Modern clinical terminologies like SNOMED CT (Systematised Nomenclature of Medicine - Clinical Terms; released Feb 2002 — http://www.snomed.org) organise concepts into multi-hierarchy structures that are defined by logic-based expressions.

32. SNOMED CT: A Standard Language of Health (2) • SNOMED CT is a knowledge- and concept-based compositional (post-coordinated) terminology that contains over 325,000 concepts, 800,000 synonyms/ descriptions, and more than 950,000 semantic relations between concepts. • SNOMED CT is HL7-compatible and extremely important in implementing HL7-compliant systems.

33. Parlez-Vous Français? New York–Paris SNOMED CT: A Standard Language of Health (3) • A clinical terminology may be used to represent a standard language of health, which contributes to consistency in communication of patients’ clinical records (natural-language neutral/ multilingual communication). • For example, an internist in New York can communicate SNOMED CT-encoded patient data to a radiologist in France, and the radiologist can immediately understand and apply the information - even if using a completely different natural language and software system.

34. SNOMED CT: A Standard Language of Health (4) • Clinical information stored in a structured coded form (rather than free text) ensures that the information in the electronic record is also analysable for decision support, research, audit or managerial purposes. • For instance, a patient’s record could be automatically checked for conditions which contraindicate the use of a particular drug; or a population of patients could be audited to compare the efficacy of different treatments for a particular condition.

35. SNOMED CT: A Standard Language of Health (5) • SNOMED CT-tagged and encoded reference databases, patient education material, and treatment guidelines can be easily and contextually linked to similarly encoded electronic records for easy access targeted to the particular needs of a client at the point of care.

36. What Is Web Services? • A Web Service is a unit of application logic providing data and services to other applications. • Applications access Web Services via ubiquitous Internet protocols and data formats with no need to worry about how each Web Service was implemented (i.e., its underlying technology, programming language, or platform). • Web Services combine the best aspects of component-based development and the Internet. • All major software vendors such as Microsoft, Sun, and IBM now support Web Services. • Distributed Services/ Resources • Shareable • Reusable • Customisable and flexible • Save duplicate efforts

37. Web Services in a Nutshell (1)Service/Provider Clients/Consumers • Microsoft has implemented Web Services in its .NET/Web Services framework and it is starting to evolve into an industry-wide standard (http://www.w3.org/2002/ws/). • A WSDL (Web Service Description Language) contract in XML (eXtensible Markup Language) is automatically published by the Internet Information Server (IIS, a Microsoft server) of Web Service provider and is used to prepare the necessary Proxy Class DLL on the remote client. • A Proxy Class allows us to code locally against a remote Web Service by proxy. • Distributed Services/ Resources • Shareable • Reusable • Customisable and flexible • Save duplicate efforts

38. Web Services in a Nutshell (2)Service/Provider Clients/Consumers • SOAP (Simple Object Access Protocol) allows information exchange between service and clients in XML via standard Web protocols like HTTP (HyperText Transfer Protocol). • A repository for Universal service Description, Discovery and Integration (UDDI—http://uddi.microsoft.com/) allows service providers to “advertise” their services, and service consumers to locate these services, much like telephone Yellow Pages. • Services can reuse/ repackage/ combine other services.

39. Web Services: PhilosophyFocus on People and their Information • The philosophy behind Microsoft’s implementation and other similar implementations like IBM WebSphere is that systems should be able to talk to each other instantly and reliably without the “headache” of developing ad hoc information exchange protocols. • It’s about developing an information architecture that is oriented around people and their information, instead of around specific devices, applications, systems or locations. • Providers should advertise and provide their services in a reusable and flexible form to all disparate clients (service consumers) who might want to use these services and to integrate them in their interfaces in custom ways. • Distributed Services/ Resources • Shareable • Reusable • Customisable and flexible • Save duplicate efforts

40. Web Services: Google Example

41. Web Services: Examples of Plug-and-Play ER Services • Examples of possible Web Services to be consumed by ER clients include terminology servers/services, computer-interpretable guidelines servers/services, knowledge servers/services (clinical problem to knowledge linking services), a GIS surveillance server/service, and many more… • A May 2002 revision of HL7 CCOW standard is expected to provide technology mapping to SOAP. • Distributed Services/ Resources • Shareable • Reusable • Customisable and flexible • Save duplicate efforts

42. NICE Guidelines Not So Nice — Computer-interpretable Guidelines (1) An online 26 page summary guideline like the one pictured on the left from NICE (National Institute for Clinical Excellence) on “Induction of Labour” in PDF is not much better than its printed (paper) version.

43. Computer-interpretable/ -executable Guidelines (2) • Decision support is most effective when integrated with the electronic record. The most likely opportunity for providing decision support is when the physician is assessing the patient record or entering an order. • All or most relevant patient data can be accessible to the decision support component/service and do not require separate entry. • Computer-interpretable guidelines (CIG) are the latest in decision support services. They aim at delivering patient-specific, evidence-based recommendations that are integrated with electronic records at the point of care, i.e., integrated into workflow.

44. Computer-interpretable/ -executable Guidelines (3) • CIG are used to generate automated reminders/alerts; in decision support and task management; to perform retrospective analysis to test if patients were treated appropriately; to check order entry appropriateness, referral criteria; for background monitoring, execution of care plans and quality review. • Individual patient data from the ER are matched to guideline terms and flowchart; the recommendations in guidelines are matched to actions in order entry system or for prescription printing. • The ultimate goal is to fully apply guidelines to clinical practice, and continually evaluate their application and modify/refine guidelines accordingly (protocol-guided care).

45. Clinical Decision Support and Guidelines Within HL7 • Clinical Decision Support and Arden Syntax Technical Committee of HL7 • Arden Syntax and Clinical Guidelines Special Interest Groups of HL7

46. Enterprise Master Person Index and Data Integrity (1) • An Enterprise Master Person Index (EMPI) links all acute and ambulatory data of a given patient to provide at a glance a complete medical record with both demographic and encounter data from across the care continuum (i.e., from across an entire healthcare delivery network and multiple disparate information repositories). EMPI ensures proper and unambiguous person identification throughout the enterprise (enterprise-wide patient tracking) and beyond into the larger community.

47. Enterprise Master Person Index and Data Integrity (2) • A unique identifier is assigned to every person benefiting from healthcare services. These identifiers make it possible to bring together demographic and clinical information for individual patients from the organisation’s (e.g., NHS) many healthcare sites where patients have been treated or had any sort of clinical encounter. • EMPI should cross-reference any local patient identification systems in use to preserve investments in existing legacy systems.

48. Conclusion • If the banking industry is able to successfully realise their/our Electronic Wealth Records, there is no reason why it shouldn’t be possible to “similarly” build and deploy the robust next-generation Electronic Medical/Health Records we all dream of. • Certainly it’s not as simple as replacing the ‘W’ with an ‘M’ or an ‘H’, but the main ingredients for success remain largely the same across different industries. There are many useful things to learn from the banking industry including focusing on information (not technology) and services to be provided with it, and ensuring perfect interoperability and extensibility of information services and their components by fully adopting agreed-upon industry standards and languages of communication.