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EHR Systems: an Introduction
Bernd Blobel1 & Dipak Kalra2
1eHealth Competence Center
University of Regensburg Medical Center
Regensburg, Germany
2Centre for Health Informatics and Multiprofessional Education
(CHIME)
University College London
eHCC
eHealth Week 2007 – EuroRec Institute / ProRec Germany Workshop“Electronic Health Records and eHealth – State of the Art”Wednesday, 18 April 2007, Berlin Germany
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Definitions (according to ISO/DTR 20514 Health informatics - Electronic
health record – Definition, scope and context ) (1/2)
EHRa 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 systemthe 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.
EHR nodea physical location where EHRs are stored and maintained.
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Definitions (according to ISO/DTR 20514 Health informatics - Electronic
health record – Definition, scope and context ) (2/2)
EHR architecturea model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, auseful 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.
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Clinical trials,functional genomics,
public health databasesEHR repositories
Clinical devices,instruments
Clinical
applications
Decision support,
knowledge management
and analysis components
Mobile devices
Personnel registers,
security services
Systems feeding or accessing the EHR
Date: 1.7.94
WhittingtonHospital
Healthcare Record
John SmithDoB: 12.5.46
virtual virtual
EHREHR
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Observation
Interpretation Action
Data
Information
Observation
Diagnosis Therapy
Knowledge
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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• ...
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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
applicationssemantic I.
•Service-oriented Interoperability- Direct invocation of application services,
co-operativity of applications
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EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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- Ethical/cultural Member States, EC and Stakeholders
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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
services
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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)
• Advanced security, safety and privacy services
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Ente
rprise V
iew
Info
rmation V
iew
Com
puta
tional V
iew
Engin
eering V
iew
Technolo
gy V
iew
Business Concepts
Relations Network
Basic Services/Functions
Basic Concepts
Domain n
Domain 2
Domain 1
Component View
Com
po
nen
tD
ecom
positio
n
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Knowledge Representation through a Metathesaurus
(after Bodenreider)
• Conceptso Synonymous terms are clustered into a concept
o Properties are attached to concepts, e.g.,� Unique identifier
� Definition
• Relationso Concepts are related to other concepts
o Properties are attached to relations, e.g.,� Type of relationship
� Source
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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• Capable of interoperability
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
In a medical summary
Procedure Appendicectomy
Problem List
1993
Diagnosis Acute psychosis2003
Diagnosis Meningococcal meningitis1996
Procedure Termination of pregnancy1997
Diagnosis Schizophrenia2006
Can we safely interpret a diagnosis out of its context?
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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
Management plan Admission etc.....
Diagnosis Schizophrenia
Working hypothesisCertainty
Seen by junior doctor
Junior doctor,
emergency situation,
a working hypothesis
soschizophrenia is not a
reliable diagnosis
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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- justification, clinical reasoning, guideline references
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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• Access rights
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
Potential interpretation contexts
Data archive
management
EHR
repository
management
Professional
accountability
Medical knowledge
and health culture
Life-long
EHR
Clinical
encounter
Clinical contextsMedico-legal contexts
schizophreniaschizophrenia
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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 healthcare professionals
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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- making semantic equivalence harder to determine
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany
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
- aids future interpretation, analysis, computation
EHR Systems: an Introduction
Bernd Blobel & Dipak Kalra“Electronic Health Records and eHealth –
State of the Art”
Wednesday, 18 April 2007, Berlin Germany