architecting a national ehealth infrastructure. positioning of openhie 2 who-itu toolkit, part i...
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Architecting a National eHealth Infrastructure
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Positioning of OpenHIE
WHO-ITU Toolkit, Part I page 8OpenHIE’s “Scope”
The Role of an HIS
HIS infrastructure, at scale: Supports care continuity over time and across
different sites Operationalizes guideline-based care
Health “transactions”: Provide management metrics regarding care
delivery May be aggregated to generate population
indicators
Strategic Elements
Patient-Centric Systems
M&E Systems
Integrated Health
Information Systems
PopulationHealth
Health Interventions
Operationalizes
Yield
Person-centric transactional data
Population-level health metrics
eHealth Infrastructure
Generate
Inform
Health Information
System
Modify SOP
eHealth Transactional
Data Financial, Management & Population Health
Indicators
Standard Operating Procedures
SOP-based Interventions
National Health Information
Exchange (NHIE)
Modify SOP
SOP-based Interventions
eHealth Transactional
Data Financial, Management & Population Health
Indicators
Standard Operating Procedures
Operationalize guideline-based care
National Health Information
Exchange (NHIE)
Modify SOP
SOP-based Interventions
eHealth Transactional
Data Financial, Management & Population Health
Indicators
Standard Operating Procedures
Support care continuity
National Health Information
Exchange (NHIE)
Modify SOP
SOP-based Interventions
eHealth Transactional
Data Financial, Management & Population Health
Indicators
Standard Operating Procedures
Provide management metrics
National Health Information
Exchange (NHIE)
Modify SOP
SOP-based Interventions
eHealth Transactional
Data Financial, Management & Population Health
Indicators
Standard Operating Procedures
Provide population indicators
National Health Information
Exchange (NHIE)
Modify SOP
SOP-based Interventions
eHealth Transactional
Data Financial, Management & Population Health
Indicators
Standard Operating Procedures
Support continuous improvement
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The “system context” for eHealth standards…
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HIS
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HIS
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The Enterprise Viewpoint describes healthcare workflows and functions. IT is expressed through a set of characteristic stories and/or use cases.
The Information Viewpoint answers the question: what
information is needed to support
the use cases?
The Computational Viewpoint describes the pattern of care; it answers the question: what actors exchange information and how is the conversation conducted?
The engineering viewpoint focuses on the specific design that realizes the enterprise, information and computational viewpoints. The technology viewpoint focuses on the specific choices of implementation technology.
HIS
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HIS
What is my service?Describe it using a storytelling
approach.
What information feeds this service? What information
arises from it?
How do I deliver this service? What is the pattern; what is the underlying logic?
What infrastructure (paper + IT) is needed to operationalize the service
delivery?
eHealth Standards…
The standards…
The engineering viewpoint includes a specification of the national eHealth norms and standards
These standards will cover the “5 C’s”: Care Guidelines Content Coding Communication Confidentiality
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The 5 C’s
Care Guidelines Care guidelines such as the country’s recommended immunization
schedule (EPI), HIV care management protocols, IMCI, etc.
Content Think of these as the total list of “fields on a paper form” (e.g. HL7
CDA, IHE PCC Immunization Content specification)
Coding Think of these as the code set standards that would apply to a specific
form field. e.g. ISO 5218 specification for Sex: 0=unknown, 1=male, 2=female, 9=not applicable
Communication Messaging standards such as HL7 or XDS
Confidentiality Specifications for managing privacy, security and patient consent. e.g.
IHE BPPC profile, Oauth, etc.
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Care Guidelines
There are care guidelines that describe evidence-based clinical practices
Integrated care pathways (ICPs) can be defined that give operational effect to these guidelines
Content and Coding
Content Standard
e.g. HL7 CDA Antenatal Care
Summary
Content and Coding
Coding Standarde.g. LOINC code for Blood Pressure
Content and Coding
Enveloping (e.g. IHE XDS)
Transporte.g. SOAP
Communications Standards
Confidentiality & Security Standards
Authentication (e.g. PKI) Who am I?
Authorization (e.g. OAuth) What am I allowed to see/do?
Security (e.g. TLS, ITIL) Encryption, availability
Privacy (e.g. BPPC) Consent to share, to view Patient specified; BTG (break the glass)
override
Implementable Profiles
Integrated Care Pathways (ICPs)
Implementable Profiles
BuildingBlocks
Integrated Care Pathways (ICPs)
HL7v3 ISO 13606:1-5OpenEHR
IHE
Interoperable “Stacks” of Standards
3 internationally balloted “stacks” of standards.HL7 & OpenEHR based on an underlying info model.
IHE profiles multiple underlying standards.
Together, the different types of eHealth
standards support semantic
interoperability.
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Where are eHealth standards specified?
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HIS
The national eHealth standards framework is an artefact of the
engineering viewpoint.
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What eHealth standards do I need?
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HIS
The national eHealth standards I need are the ones necessary to tell my health stories.
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HIS
enterpriseviewpoint
informationviewpoint
computationalviewpoint
engineeringviewpoint
technologyviewpoint
P1 P2 P3 P4 P5
B B B B B
P1
P2
P1
P4
P3
P5
P4Care Scenarios
InteroperabilityProfile
Base Standards
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Working through an example…
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What is your NID #?
The “Story”
Antenatal Care
Mosa is a 19 year old woman living in a village in sub-Saharan Africa; she has two young children and is pregnant with her third.
Grace is a community health worker (CHW) in Mosa’s village. Grace has had 2 weeks of basic clinical training.
Mosa has a client record established in a national registry.
Grace is able to execute rudimentary eHealth transactions using her mobile phone
Antenatal Care
Grace establishes a care context regarding Mosa’s shared health record
Grace records a health observation for Mosa: that Mosa is pregnant
Based on the national maternal care guidelines, Grace is stepped through a series of health questions (HIV/TB/Malaria) and clinical observation requests (weight, temperature, blood pressure, etc.) for Mosa which Grace records using her mobile phone
If Mosa’s condition warrants it, Grace creates a care referral; otherwise, she schedules the next ANC visit with Mosa
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The “Data”
Antenatal Care
Grace establishes a care context regarding Mosa’s shared health record
Grace records a health observation for Mosa: that Mosa is pregnant
Based on the national maternal care guidelines, Grace is stepped through a series of health questions (HIV/TB/Malaria) and clinical observation requests (weight, temperature, blood pressure, etc.) for Mosa which Grace records using her mobile phone
If Mosa’s condition warrants it, Grace creates a care referral; otherwise, she schedules the next ANC visit with Mosa
Antenatal Care
Grace establishes a care context regarding Mosa’s shared health record
Grace records a health observation for Mosa: that Mosa is pregnant
Based on the national maternal care guidelines, Grace is stepped through a series of health questions (HIV/TB/Malaria) and clinical observation requests (weight, temperature, blood pressure, etc.) for Mosa which Grace records using her mobile phone
If Mosa’s condition warrants it, Grace creates a care referral; otherwise, she schedules the next ANC visit with Mosa
Antenatal Care
Grace establishes a care context regarding Mosa’s shared health record
Grace records a health observation for Mosa: that Mosa is pregnant
Based on the national maternal care guidelines, Grace is stepped through a series of health questions (HIV/TB/Malaria) and clinical observation requests (weight, temperature, blood pressure, etc.) for Mosa which Grace records using her mobile phone
If Mosa’s condition warrants it, Grace creates a care referral; otherwise, she schedules the next ANC visit with Mosa
Grace’s ID Mosa’s IDTransactionTimestamp
Location
Diagnosis
Care Guideline
Clinical ObservationsHealth History
CDSReferral Plan of Care
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Client RegistryClient IDNameDate of BirthDate of Death
Care EncounterClient IDProvider IDFacility IDDocument IDTimestampDocument Type
ObservationsDocument IDObservation TypeCode SystemCoded ObservationValueUOMText
OrdersDocument ID
Provider RegistryProvider IDNameRole ID Results
Document ID
InterventionsDocument ID
DiagnosesDocument IDCode SystemCoded Diagnosis
Facility RegistryFacility ID
0..N
0..N
0..N
0..N
0..N
0..N
1
1
1
1Document TypeDocument TypeDocument Template
0..N1
Care GuidelineCoded DiagnosisPlan of Care…
Plan of CareClient IDCoded DiagnosisPlan of Care…
0..1
0..N
1
0..10..N
PrivelegesRole ID
ConsentsClient ID
1
0..N
0..N1
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The “Pattern”
Antenatal Care
Grace establishes a care context regarding Mosa’s shared health record
Grace records a health observation for Mosa: that Mosa is pregnant
Based on the national maternal care guidelines, Grace is stepped through a series of health questions (HIV/TB/Malaria) and clinical observation requests (weight, temperature, blood pressure, etc.) for Mosa which Grace records using her mobile phone
If Mosa’s condition warrants it, Grace creates a care referral; otherwise, she schedules the next ANC visit with Mosa
Antenatal Care
Grace establishes a care context regarding Mosa’s shared health record
Grace records a health observation for Mosa: that Mosa is pregnant
Based on the national maternal care guidelines, Grace is stepped through a series of health questions (HIV/TB/Malaria) and clinical observation requests (weight, temperature, blood pressure, etc.) for Mosa which Grace records using her mobile phone
If Mosa’s condition warrants it, Grace creates a care referral; otherwise, she schedules the next ANC visit with Mosa
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4
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7
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1
23
4
5
6
7
Authenticate & authorize
Enrol in care programme
Guideline-basedcare delivery
Establish follow-up
Escalatecare
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SMS
SMS
SMS
SMS
SMS
SMS
SMS
SMS
SMS
SMS
Authenticate & authorize
Enrol in care programme
Guideline-basedcare delivery
Establish follow-up
Escalatecare
XDS
PIX
XDS
XDS
XDS
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Authenticate & authorize
Enrol in care programme
Guideline-basedcare delivery
Establish follow-up
Escalatecare
XDS
PIX
XDS
XDS
XDS
Grace’s ID
Diagnosis
OBS & Care Plan
Referral
Referral
Care Guideline
Mosa’s ID
Location ID
SMS
SMS
SMS
SMS
SMS
SMS
SMS
SMS
SMS
SMS
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Base ID standards
Messaging Standards
Standards of Care (EBM)
Content & Coding StandardsThe standards are used to
tell the “health story”.
The Requirements…
An analysis was made of WHO’s current published care guidelines for: 1. HIV 2. Malaria 3. TB4. Antenatal care5. Emergency care6. Public health emergency response
There are common tasks/processes which appear in multiple care workflows
Common Processes
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Integrated Care Pathways
The guideline-based workflow patterns arising from the analysis may be described using Integrated Care Pathway (ICP) diagrams
ICPs describe high level, person-centric care workflows that may be long-running and cross institutional boundaries
An ICP may be documented using rudimentary graphical primitives from the Business Process Modeling Notation (BPMN)
Start End Decision / Branch
“Building Blocks”
The analysis across multiple programmes yielded a set of common processes and an “archetypal ” pattern
This re-usable pattern may be employed as the basis for each unique care guideline
The “path” thru the ICP is different, depending on the guideline (if-then decision braches)
Operationalizing Guideline-based Care
Every guideline-based care workflow may be described as a unique ICP route through the common processes
To operationalize guideline-based care, eHealth infrastructure would need to:
Support the common processes Support the unique decision logic for each guideline
In this way, the archetypal ICP may be used to describe the base requirements for a national normative eHealth standards framework
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Letterman “Top 10”
1. “On-board” a client2. Capture health information about a client3. Fetch the client’s health information4. Order lab tests5. Get lab results6. Order meds7. Dispense meds8. Refer (escalate care)9. Discharge10. Send reminders / information
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Create demographic record
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Find a client
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Find client… and maybe others
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Housekeeping…
Local code sets must be resolved to the enterprise code sets
Local patient, provider and location/facility IDs have to be resolved to enterprise IDs; all SHR records are indexed by the ECID, EPID, ELID
Federated provider, facility, service and organization registries are aggregated and cross-indexed by the Care Services Discover (CSD) InfoManager; each registry is subject to its own governance
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Resolve local IDs to enterprise IDs
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Cross-reference federated registries
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Save and store PHI
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Retrieve PHI
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POS: the “Fantastic FOUR”
Set up a client in the CR (PAM) Find a client in the CR (PIX… PDQ as a last resort) Save information about a client (XDS, put CDA):
XDS-MS Medical Summaries (referral, discharge summary)
CCD – antenatal summary, immunizations, summary health record
XD-LAB (lab orders, lab results) PRE (prescriptions), DIS (dispense)
Retrieve information about a client (XDS, get CDA): All of the above (as documents) Ad hoc CDA “built” from discrete data