NAGOYA-RHIE

Transcription

NAGOYA-RHIE

A REGIONAL HEALTH
INFORMATION EXCHANGE
SYSTEM
FOR STROKE CARE
(NAGOYA-RHIE)
9th International HL7 Interoperability conference 2008
IHIC 2008 Oct. 8-11, 2008
Crete, Greece
Masaharu OBAYASHI
Masayuki KAGAWA
Masaaki MIZUNO
Kanrikogaku, Ltd
FUJITSU LIMITED
Nagoya University Graduate School of Medicine
(Director of Tokai Medinet Forum -NPO)
Jun YOSHIDA
National Hospital Organization Higashi-nagoya Hospital
(Head Director of Tokai Medinet Forum -NPO)
Copyright
©2008 Tokai Medinet Forum -NPO
Nagoya-RHIE
The Nagoya-RHIE project is an initiative to develop regional
health information exchange (RHIE) system based on the global
standard, in Japan.
The NPO, named Tokai Medinet Forum, is an organization for
promoting the project sponsored by METI (Ministry of Economy,
Trade and Industry) to implement a RHIE system for stroke care in
the Nagoya area using global standards including HL7and IHE ,
and to evaluate their efficacy through trial experiment.
• Progress Status
In August, 2006, the project was initiated, and the system was
developed through out 2006 and 2007.
Trial use began from 4Q of 2007.
Now in 2008, the evaluation works is in progress.
Copyright
Introduction – Business Case
• national/regional context
National context supported by following organizations, but
current phase is regional trial in Nagoya.
- METI (Ministry of Economy, Trade and Industry),
-Japan Stroke Society,
-Japan Society of Neurosurgery,
-Japan Association of Rehabilitation Hospital and Institution,
-Japanese Association of Emergency Medicine,
-Medical Information System Development Center (MEDIS-DC),
- Japanese Association of Healthcare Information Systems
Industry (JAHIS)
.etc.
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Collaborative Pathway with XDS/CDA





Standards
 Collaborative clinical pathway
 Clinical Document for clinical pathway (HL7CDA)
 Framework for sharing clinical document (IHE XDS/PIX/PDQ)
Sharing Information
 Register clinical documents with appropriate classification of stage of clinical pathway
 Whenever necessary in the care of clinical pathway, the documents could be found and
retrieved
 Support of patient identification in regional collaboration
Security and Privacy
 Provide adequate security facilities such as VPN, HPKI, node authentication, user
authentication, encryption and audit trail.
 Access control to protect patient’s privacy
Support of collaborations
 Notification facilities by SMTP and Web Services
 Exchange clinical data between HIS database and CDA document through Excel, CSV and
flat simple XML format
Possibility and Extension
 Secondary use of clinical information, e.g. for variants analysis, clinical study and trial
 Applicable to other clinical pathways, e.g. repeated clinical pathway such as diabetes care
 Registry Federation among RHIEs
 Interoperability of different vender client systems for various clinical paths
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• health information exchange network
XDS was implemented to exchange 6 type CDA documents on
the RHIE system for collaborative stroke care
-first notification (referral) for pre-discharge
-discharge summary for transfer from acute hospital
-evaluation report after 3 months rehabilitation
-discharge summary for transfer from rehabilitation hospital
-report of post-discharge in home care
-current medication and allergy for emergency medicine
This system has been developed based on IHE IT
Infrastructure Technical Framework and OASIS ebXML
registry repository standards
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• interoperability problem
Standards are needed for interoperability
-common collaborative pathway for stroke care
-common clinical documents for the pathway
-common framework for sharing documents
-transformation between legacy HIS data and common
clinical documents
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• Challenge interoperability problem
The project participant companies in JAHIS have made an effort to
develop the Japan realm profile and implementation guide for HL7 standard
and IHE profile for such as
CDA R2, HL7 V2.5,
XDS (Cross-Enterprise Document Sharing) with
PIX (Patient Identifier Cross-Referencing),
PDQ (Patient Demographics Query) and
ATNA (Audit Trail and Node Authentication)
The joint venture organized under the NPO has been developing the
system.
In this project, some of IHE profile has been enhanced.
For example,
XUA (Cross-Enterprise User Authentication),
NAV (Notification of Document Availability) profiles have been extended
by coupling them with access control mechanism based on
XACML (eXtensible Access Control Markup Language)
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Authentication
User
Health Information Exchange Network
PWP
XUA
PIX/PDQ
Audit Trail
PID registry
PIX
Manager
ATNA
Center
Notification
NAV
Find PID
Register Global PID
HIS,PACS,
RIS
Patient
Identificati
on Source
XDS registry
Document
Registry
HIS,PACS,
RIS
Patient
Identification
Source
XDS
Document
Source
Register metadata
Register document
Query document
Document
Consumer
Retrieve document
XDS Repository
Document
Repository
Facility A
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Facility B
[ITI-14] Register Document Set,
[ITI-15] Provide and Register Document Set,
[ITI-16] Query Registry,
[ITI-17] Retrieve Document,
[ITI-18] Registry Stored Query,
Facility Gateway1
PID
Source
ADT
Source
Patient
Demographics
Query
Medical Center for Nagoya-RHIE
[ITI-8] [ITI-9]
[ITI-15]
[ITI-9] PIX Query,
[ITI-8] Patient Identity Feed,
[ITI-21] Patient Demographics Query,
[ITI-22] Patient Demographics and Visit Query.
ADT
[ITI-8] [ITI-9]
PDQ
PDQII
Patient
Demographics
and Visit
Query
XDS
adaptor
[ITI-17]
[ITI-16]
XDS
adaptor
[ITI-14]
XDS
adapter
PDQ
[ITI-15]
[ITI-14]
ebXML
(omar)
[ITI-16]
XDS
[ITI-18]
ATNA
Document
Consumer
[ITI-17]
Repository
Audit Trail
DB
Registry
Management
Tools
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PID
Source
[ITI-9]
[ITI-22]
Document
Source
Facility Gateway2
Patient
Visit Repository
PIX
[ITI-21]
Overview of
Nagoya-RHIE
system
Example: Process Model of First
Notification (Referral) for Pre-discharge
[ITI-15]
[ITI-9]
[ITI-8]
[ITI-17]
[ITI-9]
[ITI-14]
[ITI-16]
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Patient
Family
Paramedic
Emergency
Stroke
Care
Acute Hospital
Rehabilitation
Hospital
Folder based
Access Control
Specialist
Nurse, co-medical
Registry
Home doctor
Clinic / Care at
home
CDA documents
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Repository
Owner
Subscriber
• reasons for adopting CDA
Developing standard is generally very expensive and needs
to make much effort
-CDA is a global standard for clinical document based on
XML technology
-particular realm profile such as Implementation guide is
needed, however, it is easier to be defined using CDA R2
standard
-implementation is made easier with general XML tools
Copyright
• describe users
There are two kinds of users:
Clinical providers including doctors and nurses are primary
users of RHIE systems.
However, it is not necessary for them to know about CDA.
They could work through rendered form of CDA on the window.
The second type, implementers of a system are direct users to
create and read clinical documents written by CDA.
However, it is not so difficult for them to import/export legacy
data from/to CDA document if adopting our approach.
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Implementation, Methodology and Tools
• design methodology/paper documents
Design methodology is described in many documents of
JAHIS and NPO in Japanese.
• use of implementation guides
Japanese implementation guide for stroke care documents
has been developed
Copyright
• implementation of document types
1) First notification (referral) for pre-discharge
2) Discharge summary for transfer from acute hospital
3) Evaluation report after 3 months rehabilitation
4) Discharge summary for transfer from rehabilitation hospital
5) Report of post-discharge care at home
6) Current medication and allergy for emergency medicine
Attachments
Image.Report
Lab.Result
Path-stage
indicated by
EventCode
Document Type
specified by
ClassCode and
typeCode
Path-Stage
Acute care
Term
Rehabilitation Long
Term
Term
Referral
Clinical-Path-Document（
CDA R2）
Folders for
a Patient
Common
Folder0
Series１
Path Folder1
Series2
Path Folder2
…..
Others
Own Folder
Folder Specified by
CodeList
-ADT（HL7V2.5）
-Document for Emergency Medicine (CDA R2)
Specified by classCode and typeCode
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• correspondence with paper documents/forms
There are some Excel forms, correspondence with Discharge
summary, Evaluation report and Report of post-discharge care at
home
• use of terminology and terminology
infrastructure
J-MIX; Japanese Vocabulary Set for medical data items (instead
of LOINC or SNOMED-CT)
• management of identifiers
OID is defined in header-codetable and body-codetable
J-MIX is used and extended J-MIX code is defined in bodytemplate
Patient identifier is managed with IHE PIX function
Copyright
•information reuse
header-instance can be defined by selecting elements of
header-template
body-instance can be defined by selecting elements of bodytemplate
•complementary standards
IHE IT Infrastructure Technical Framework profile
OASIS ebXML registry repository standards
Copyright
•security and confidentiality issues
The system has been enhanced by the following functions and
tools including open source programs.
-Master data of User, Facility, Group, and Node (ebXML)
-Access Control and Notification using Folder (ebXML)
-Single Sign On (using openSSO)
-Life Cycle Management for XDS metadata
-Digital Signature (HPKI)
-Import/Export HIS data into/from CDA document
•software tools
Excel, XML editor and XSLT engine
•conformance testing
Not yet available
Copyright
CDA in Use (Content Management)
Project type:
•exploratory, pilot, large scale deployment
advanced pilot project
CDA workflow:
•sites where CDA is in use
involve about 30-40 hospitals and clinics in Nagoya area
•number of users
currently about 200 medical staffs are involved
Copyright
•Map/template specification
Specification can be provided using Excel sheets as follows:
1) header-codetable: define code system and value set
2) header-template: define element type of header
3) header-instance: define element value and mapping
4) body-codetable: define code system and value set
5) body-template: define element type of body
6) body-instance: define element value and mapping
•Instance Values
Instance values can be provided as simple XML format from HIS
DB or Path Editor.
•Automatic generation of CDA document
XSLT Transformation from Map/Template specification and
Instance values into CDA document can be performed.
Copyright
•volume of documents exchanged
The table shows the volume of the specification for
collaborative stroke care document.
sheet name
sheets
number of elements
1
header-codetable
1
10
2
header-template
1
11
3
header-instance
6
11,11,16,16,16,16
4
body-codetable
1
96
5
body-template
1
331
6
body-instance
6
4,28,239,34,331,241
•training and education for users, implementers
End user can use the system without knowing XDS/CDA
Implementer of client applications should only understand the
flat XML formats to exchange medical information.
Copyright
•CDA import/export in the electronic health record
Copyright
For stroke care, 6 types of CDA documents can be generated
based on Map/Template specification and Instance Value set
body-codetable
header-codetable
body-template
header-template
body-instance
header-instance
XML
format
Figure 5. Example of Automatic Generation of CDA Document
Copyright
Evaluation/Assessment
Technical view point is to resolve the interoperability problem as
follows;
-common collaborative pathway for stroke care
-common clinical documents for the pathway
-common framework for sharing documents
-transformation between legacy HIS data and common clinical
documents
Clinical view point is to improve the pathway process comparing
the case of without IT system.
-improve the score of care outcome according to evaluation
criteria
-establish the pathway process including human network and
communication
-able to obtain demographical data on collaborative stroke care
Copyright
• method of evaluation
deploy the system to participant facilities and apply patient
care in the real filed
• results
Technical view point is to resolve the interoperability
problem as follows;
-common collaborative pathway for stroke care: success
-common clinical documents for the pathway: success
-common framework for sharing documents: success
-transformation between legacy HIS data and common
clinical document: success
Copyright
Clinical view point is to improve the pathway process
comparing the case of without IT system.
-improve the score of care outcome according to evaluation
criteria: under evaluation
-establish the pathway process including human network and
communication: under evaluation
-able to obtain demographical data about collaborative stroke
care: under evaluation
• feedback to next CDA release 3
analysis of result and consideration will be needed
Copyright
Future Plans
•changes/extensions to CDA design
extend our approach to the other CDA document
•planned changes/extensions to overall exchange
architecture
In the current implementation, pathway editor needs high cost
to maintain program according to change of specification.
More flexible tool is expected as a pathway editor.
Development of architecture and tool for specification driven
pathway editor will be planned.
Copyright
•next steps
archetypes of openEHR (CEN13606) is similar to the
specification
then to be able to handle the archetype and template of
openEHR within our approach
As a next step, the Nagoya-RHIE project will begin to apply the
system to other collaborative pathways such as orthopedic
surgery, especially femoral [femur] neck fracture.
Copyright
Conclusions and Lessons Learned
•conclusions
The new approach and tool for creating CDA document from
specification and instance value set is useful to reduce the cost
of developing RHIE system
•lessons learned
For now, our aimed collaborative care system could be
achieved by XDS and CDA.
Specifying the standard for Japan realm could be done
smoothly in JAHIS (effort and cost reduced).
•summary of primary business drivers,
challenges ahead
XDS with HL7CDA may be a good framework for EHR.
design and realize PHR-EHR system based on XDS and CDA
Copyright
Thank You!
Question?
Copyright

NAGOYA-RHIE

Transcription

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