Standards and interoperability towards 2014 and the New Zealand national e-health vision - the not so unexpected journey towards core personal health information being available at all points of care
2. HINZ Nov 2012
Privacy breaches
Disruptive innovation
Fabula, syuzhet, syzygy
2014
trees
data as an actor
personalised medicine
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3. In the news
Novopay a $30m horror show
‘… such rush-jobs are all too common … [the
government] may be setting the stage for future
horrors with its stated policy of getting a national
patient-record system in place by 2014’
Sunday Star Times, 25/11/12
4. The destination is …
Person-centred, integrated health care
Clinicians, consumers and IT people working in co-production
Providers having the confidence to invest in new solutions
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6. National priorities to 2014
eMedicines programme Regional information platforms
Pharmacy clinical integration eReferral and eDS
eMR, ePA CDRs, CWS, ED solution
NZULM, NZ Formulary PACS
LIS, pharmacy
PAS
National solutions Clinical integration
Cancer information LTC shared care
Cardiac health Maternity and well child
Comprehensive clinical assessment Patient portal
Health identity platform View of primary health info
FMIS, procurement, supply chain Urgent and unplanned care
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7. Top priorities for the next twelve months
Offered by IFHCs CWS
Common regional
Patients with LTCs and
Personal health info
and CDR
high needs
Appointments hospital
Accessible both
Multidisciplinary input
Repeat prescriptions
and community
Email consultations
Inter-regional view
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8. GP2GP
50% of GPs are users
5500 transfers alongside 36,000 e-referrals per month
Files over 5 MB have to be sent the old fashioned way
5500 (Nov)
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12. Emergency care
Ambulance accesses primary
care info and any discharge
summary
Ambulance shares ePRF (as an
event summary, but also a kind
of referral) with hospital ED
Common ED solution based
on hospital PAS and CWS eDS shared
via R-CDR
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13. Discharge summary
SNOMED coded presenting complaint,
diagnoses, procedures
Continually updated during hospital stay
Discharge Rx via NZePS
eDS shared
via R-CDR
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16. eMR and ePA in all wards
Going for Gold programme Shared medications lists
Transition to eMR and ePA
Standardised paper based eMR
and medications charts
CHALLENGES eMR system separate to ePA
Outdated pharmacy systems
Shelves versus drawers versus robots
Medical oncology ePA
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24. Clinical integration
eSCRV sources information from GPs,
pharmacy, community nursing and
hospitals
ERMS is the regional electronic request
management system (8,000 referrals
per month)
Health Pathways has 400+ treatment
plans and pathways (74,000 page views
per month)
Shared Care Systems for patients
with long term conditions
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25. SPaCE programme
Supporting Patients and Integrate primary care and
Clinicians Electronically hospital workflow
Incrementally replace eight Streamline the patient
systems across five DHBs journey
Go well beyond replacing
the incumbent systems
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26. Orders and results
Community lab and radiology test ordering solutions are appearing
(with decision support and order tracking functions)
Laboratory information standards review –
NZPOCS overhaul
HL7 v2.4 messaging implementation
Judicious coding
Message integrity between sender and receiver
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30. From: Bob Dolin
Sent: Tuesday, November 29, 2011 12:55 PM
To: Rishel,Wes; Pratt, Douglas (H USA); robert worden;
Structured Documents WG
Subject: RE: CDA or greenCDA
Hi Wes,
What is CCDA?
Thanks,
Bob
30
We look at the standards and interoperability agenda, towards reaching the New Zealand health sector’s objective of shared personal health information by 2014National Health IT Board prioritiesClinical integration and the interoperability frontlineThe standards agenda
Be regional‘electrified health records’
Current headlines in Nov 2012Novopay a $30m horror showJackson scrambling to finish The Hobbit – one day out from premiereHowever, the first headline wrongly susposes the 2014 vision to be predicated on a national rollout of some monolithic system
This is the e-health destination as described by NHITBWith a further theme of sustainability in the health system
Different branches of the tree represent the different kinds of solution that will exist in the environment – from shared care systems at the top, for people with high needs, through systems that lubricate the wheels of healthcare in the community and the hospital, test results, reports and other objective health information in CDRs, and – at the base of the tree – demographics, allergies and alerts, enrolments/registrations
These are the National Health IT Board priority programmes for 2012-14 – the windowpanes Underpinned by work on infrastructure,connectivity, ICT organisational capability, standards
IFHCs will be able to offer access to a patient portal that presents a core set of personal health information and has functions like booking an appointment, requesting a repeat prescription and having email interaction with practitioners. Examples of nascent IFHCs include Midland Health Network, Canterbury Initiative, Island Bay medical centre, and Wairarapa and MidCentral PHOs.For patients with high needs around long term conditions, shared care systems will be in place enabling the involvement of a multi-disciplinary team. The frontline is now the community pharmacy, where we can expect to see shared care plans created for patients with high needs.Hospitals will have a clinical workstation and clinical data repository – common within the region, accessible by the community workforce as well as in the hospital. The R-CDR needs to present an inter-regional view.
GP2GP has been a success storyGP2GP 2.0 is in planning
Interconnected care solutions are in development that will enable information flows between all of the following: community pharmacy, general practice, community nursing, residential care, ambulance, ED
Community pharmacy referrals and assessmentsNZePS developed but not rolled outCCMS introduced as shared care solution Pharmacy Services Agreement for long term conditions New processes to support –Referrals into pharmacies Eligibility assessments by pharmaciesEnrolments for LTCSCreation of medications plansCommunication of medications plansOngoing clinical management by the pharmacistShared information within the care teamNZePS v2 has been successfully tested by the NZePS broker, one pharmacy vendor and three GP vendors, and paves the way for version two to be implemented in all pharmacy and GP systems as a precursor to national rollout. Work is underway on preparation for the rollout.The essential LTC Services a pharmacy must provide include, dispensing of pharmaceuticals, medicine reconciliation, synchronisation of medicines, reminder services (e.g. email, phone call) for collection of pharmaceuticals, regular screening of adherence to medicine regime, and regular engagement with the patient’s multidisciplinary care team.
Community Pharmacy Services Agreement opens the door to the introduction of shared care services between GPs and pharmacists with patients with high needs
This is care without walls – the ambulance has access to the patient’s past event information, including recent discharge summaries, via the regional CDRAmbulance might send an ECG as an attachment to the ePRF – presently an ECG can be sent via email, with patient consentePRF includes details of interventions, making it both a referral and an event summaryAmbulance ePRF use case illustrates very well the difficulty of having multiple non-interoperable referral systemsePRF phased rollout from July 201320% of ambulance calls are for people discharged within the past week70% of ambulance calls are medical as opposed to injuriesAmbulance particularly interested in discharge diagnoses from ED and discharge dispositionePRF portal will be made available to Accident and Medical centres, possibly also ED as a first stepAmbulance officers record meds found in the patient’s home – could scan barcodesAmbulance arrival board in ED
Having a SNOMED CT coded eDS would be like Xmas to GPsGlobal general practice reference set has ~3500 concepts (July 2013)Locally, all clinical systems SNOMED enabled from x date – 2015? A structured discharge summary will be importable into the GP PMS and shared care systems (which are accessible in the pharmacy), as well as being communicated via the R-CDR as an entry in the longitudinal recordDischarge Rx entered via SMT –Directed to the hospital dispensing systemOr to community pharmacies via the NZePSDischarge summary is a living document, continually updated from admission to discharge, and visible to all parties hospital and community through the hospital stay (this cannot be achieved very easily with a messaging model)
The conceptis of a managed list following the patient, reviewed and updated by the care teamIncludes allergies and alertsSitsalongside prescribing and dispensing information
A shared, repository-based information resourcePresented natively via existing point-of-care applications, loosely coupled to the repositoryQuestions the South Island e-medications workshop set out to address: What datasets are involved? How does the repository work? What are the interfacing requirements client-side? What is the interface to the eDS? What is the interface to eSCVR?
The need in many DHBs to upgrade their pharmacy management systems, such as in Midland region where all DHB pharmacies will share a single application instanceHospitals will also adopt prioritisation standardsThere will be a national agreement on e-prescribing, which will provide DHBs with an off-the-shelf waiver under the Medicines Act to permit e-prescribingThis will all build on pilot work at Taranaki, Southern, Waitemata and Counties Manukau DHBsNational implementation will begin mid 2013, following a hardening exercise on the recommended solution‘Going for Platinum’DHBs implementing new/updated ePM systems for dispensing and pharmacy management – predominantly CSC ePharmacyCSC ePharmacy interfaces to MedChart for medication ordersAlso has interfaces to suppliers’ systems, FMIS, PyxisMidland has plans to create a single-instance regional solution:single instance of the back endlocal deployment of the client-side applicationmulti-tenanted, but with a common configurationintegration with district level PAS and FMIS
Hospital medications management is also topicalThis slide shows how My List of Meds relates to the hospital medications chart – used as an input to medicines reconciliation on admission, and updated out of the discharge summaryMedical oncology solutions will tend to be different to the ePA solution for the rest of the hospital, and will also cater to both inpatients and outpatientsA combined view will be presented somehow, in the portal if not the wider hospital ePA solution
EMR Adoption Model (EMRAM) for uptake of HIT within the hospital. There are 8 stages, with the topmost being a fully paperless environment. Below this, physician documentation / charting (structured templates), full CDSS and closed loop medication administration environment are fully implemented.Electronic Medical Record Adoption Model – a structured assessment developed by HIMSS Analytics to measure hospital progress towards full electronic system rollout.NHITB will coordinate EMRAM assessments that benchmark New Zealand hospitals against similarly sized hospitals globally. All hospitals in the US, along with most Canadian and European hospitals, have completed EMRAM assessments. DHBs are keen to participate, and results available to date indicate New Zealand hospitals compare well globally.To progress from one stage of adoption to the next, a hospital must have implemented everything at the preceding levelScores go to 4 decimal places, depending on achievements at higher levels (which makes big jumps possible)
The first of three examples of the emerging class of interoperable shared care solutionsComprehensive care assessments with the sector’s interRAI application, hosted nationallyAssessments are created and stored in one system, but used in others – for care planning, by the GP, on admission to hospitalDeveloping this capability is an incremental taskCurrently, the application can present PDF-formatted assessment reports within an application sessionBuilding on this, CDA level 1 can be used to attach metadata to the report and it can be conveyed via web services to portal usersFinally, when an XDS infrastructure is in place, and we have a suitable set of templates, we can move to CDA level 3 content shared out of an XDS-enabled repository
Porous regional boundaries and centres of excellenceCentral Region is Region Central
There is plenty of locked-up clinical data that DHBs would like to make available via the R-CDRXDS seems to offer a robust way of doing this – we hope cost effectiveHIE community policy?
We need the new standard to drive the repository-based information sharing described by the National Health IT Plan.Solution scope options for NHITB/healthAlliance pioneering work on R-CDRsAn important use case is shared care system access to repository-held records, such as test results, discharge summaries and My List of MedicinesThere is also the ‘after hours’ use caseThere is an interesting comparison with the implementation of Australia’s PCEHR, which has the following features:Single national XDS registry (XCA not required)Registry and repositories implement XDS and ATNAPatient privacy consents (non BPPC) based on Practitioner-Role-Organisation and Organisation-Patient-Document relationships (with opt-outs)Eight CDA document types in circulation – a mix of levels 1, 2 and 3Registry vendor supportive of PIXV3 (though not implemented)
SPaCE programme likely to have chosen a vendor by Xmas
What standards do we need to reach the 2014 goal?Of these, HISO 10040 is an interim standard (awaiting trial implementation)Transfer of Care Standard is scheduled to be released for public comment in the first half of 2013, ePharms (necessary for the NZePS) after thatThe Comprehensive Care Assessment Document will be a standardised interRAI extractWe will also have refreshed health identity standards
The diagram shows the CDA solar system, with the blue planets representing sets of templates and document types we use locally, deriving from international specifications (green)We are strongly internationally influenced, reusing wherever the fit to requirements is better than we could hope to achieve by ourselvesThe Continuity of Care Record (CCR) – although not itself CDA – is the origin of our conceptual data model for information exchangeThe other document types shown are: Consolidated CDA (CCDA) developed by the US’s ONC for Health IT; Continuity of Care Document (CCD); local GP2GP; local e-discharge summary (eDS); local e-prescription document; local transfer of care – generic referral/discharge document