EHR Systems: an Introduction

EHR Systems: an Introduction

Bernd Blobel

1

& Dipak Kalra

2

1_{eHealth Competence Center}

University of Regensburg Medical Center Regensburg, Germany

2_{Centre for Health Informatics and Multiprofessional Education}

Definitions

(according to ISO/DTR 20514 Health informatics - Electronic health record – Definition, scope and context )

(1/2)

EHR

a repository of information regarding the health status of a subject of care, in computer processable form.

An EHR provides the ability to share patient health information between authorised users of the EHR and the primary role of the EHR in supporting continuing, efficient and quality integrated health care.

EHR system

the set of components that form the mechanism by which electronic health records are created, used, stored, and retrieved. It includes people, data, rules and procedures, processing and storage devices, and communication and support facilities.

Definitions

(according to ISO/DTR 20514 Health informatics - Electronic health record – Definition, scope and context )

(2/2)

EHR architecture

a model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, a

useful and effective ethico-legal record of care, and may retain

integrity across systems, countries, and time. The Architecture does not prescribe or dictate what anyone stores in their healthcare

records. Nor does it prescribe or dictate how any electronic healthcare record system is implemented. ... [It] places no restrictions on the

types of data which can appear in the record, including those which have no counterpart in paper records. ... Details like “field sizes”,

coming from the world of physical databases, are not relevant to the electronic healthcare record Architecture.

Clinical drivers for the EHR

• Manage increasingly complex clinical care • Connect multiple locations of care delivery • Support team-based care

• Deliver evidence-based health care • Improve safety

- reduce errors and inequalities - reduce duplication and delay • Empower and involve citizens

• Underpin population health and research • Protect patient privacy

Clinical trials,

functional genomics, public health databases

EHR repositories Clinical Decision support, knowledge management and analysis components Mobile devices Personnel registers, security services

Systems feeding or accessing the EHR

Date: 1.7.94 Whittington Hospital Healthcare Record John Smith DoB: 12.5.46

virtual

virtual

EHR

EHR

Interoperability Levels

•Technical Interoperability

- Technical Plug&Play, signal compatibility, protocol compatibility •Simple Data Exchange Interoperability

- EDI, HL7 Version 2

•Meaningful Data Exchange Interoperability - agreed Vocabulary

•Functional Interoperability

- Harmonised behaviour of communicating applications

semantic I. •Service-oriented Interoperability

- Direct invocation of application services,

Interoperability Aspects from a European Perspective

Interoperability issues have to be managed from different viewpoints

- Legal Member States and EC

- Administrative Member States, EC and Stakeholders

- Technical Industry and SDOs

- Social Member States, EC and Stakeholders

Observation Interpretation Action Data Information Observation Diagnosis Therapy

Knowledge

EHR Projects and Standards

• ISO TC 215 TS 18308, DTR 20514 • CEN EN 12967 „Health Information System Architecture“ • CEN EN 13606 „EHR Communication“ • openEHR • GEHR • G-CPR • ASTM CCR

• HL7 RIM & CDA, EHR-S Functional Model, EHR-S Interoperability Model, CCD • HARP

• EuroRec, ProRec Centres

Requirements for achieving interoperability and

harmonisation (1/2)

• Openness, Scalability, Flexibility,

Portability

• Distribution at Internet level

• Standard conformance

• Service-oriented semantic

interoperability

• Consideration of timing aspects of

data and information exchanged

• Lawfulness

• Appropriate security and privacy

Requirements for achieving interoperability and

harmonisation (2/2)

• Distribution, Component-orientation (flexibility, scalability)

• Model-driven and service-oriented design

• Separation of platform-independent and platform-specific

modelling → separation of logical and technological views (portability)

• Specification of reference and domain models at meta-level

• Interoperability at service level (concepts, contexts,

knowledge)

• Unified Process

• Common terminology and ontology (semantic interoperability)

ri s e V ie w a ti o n V ie w o n a l V ie w ri n g V ie w lo g y V ie w Business Concepts Relations Network Basic Services/Functions Basic Concepts Domain 2 Domain 1

Component View

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Knowledge Representation through a Metathesaurus

(after Bodenreider)

• Concepts

o Synonymous terms are clustered into a concept

o Properties are attached to concepts, e.g.,

Unique identifier
Definition

• Relations

o Concepts are related to other concepts

o Properties are attached to relations, e.g.,

Type of relationship
Source

Key requirements for the logical or virtual EHR

• Comprehensive

• Faithful

• Life-long (and beyond)

• Medico-legally rigorous

• Appropriately available

• Supporting diverse cultures and professions

• Capable of evolution

• Educating

• Empowering and respecting

In a medical summary

Procedure

Appendicectomy

Problem List

1993

Diagnosis

Acute psychosis

2003

Diagnosis

Meningococcal meningitis

1996

Procedure

Termination of pregnancy

1997

Diagnosis

Schizophrenia

Clinical interpretation context

Emergency Department

“They are trying to kill me” Symptoms

Reason for encounter Brought to ED by family

Mental state exam Hallucinations

Delusions of persecution Disordered thoughts

Diagnosis Schizophrenia

Seen by junior doctor

Junior doctor, emergency situation, a working hypothesis so schizophrenia is not a reliable diagnosis

Examples of clinical interpretation context

•

within the overall clinical story

-

past, present

-

intended treatments, planned procedures

•

clinical circumstances of an observation

-

e.g. standing, fasting

•

presence / absence / certainty of the finding

•

hypotheses, concerns

•

a diagnosis for a relative

-

but not the patient!

•

confidence and evidence

-

seniority of the author

Examples of medico-legal context

•

Authorship and responsibilities

•

Dates and times

-

occurrence, clinical encounter, recording, schedules,

intentions

•

Information subjects

-

whose record is this? (who is the patient?)

-

about whom is this observation? (e.g. family history)

•

Version management

Data archive management EHR repository management Professional accountability Medical knowledge and health culture Life-long EHR Clinical encounter

Potential interpretation contexts

schizophrenia

Semantic interoperability challenges

•

the meaningful sharing and combining of health record data

between heterogeneous systems

•

the consistent use of modern terminology systems and medical

knowledge databases

•

the integration and safe use of computerised protocols, alerts

and care pathways by EHR systems

•

data quality and consistency to enable rigourous secondary uses

of longitudinal and heterogeneous data: public health, research, health service management

Reasons why this is hard:

it’s not just about agreeing terms

• A global and singular representation for each clinical expression is not realistic,

and may not be desirable

• Different levels of detail, different levels of granularity are needed for different clinical settings

- clinical practice is too diverse and evolving for fine grained standards

- different cultures, and natural languages need to represent clinical meaning differently

- patients and carers need a different level of jargon from health care professionals

Reasons why we make it harder

• The record structure influences how a term is to be interpreted - the heading it is under

- other surrounding context

• Record structures and terminology systems have been developed in relative isolation

- with no co-operation on their mutual requirements or scope - resulting in overlapping coverage or clumsy fit

• With co-ordinated terminology and sophisticated EHR architectures - there is a risk of introducing further inconsistency

Archetypes will help

• Empowerment of healthcare professionals

- enable consensus clinical data sets and structures to be shared • Offer a focused way of binding generic EHR models to

compositional terminology

• Provide target knowledge representations for use by guideline and care pathway systems

• EHR entries identify the Archetypes used when the data were created, and/or to which they map