How standards for How standards for integration will enable integration will enable key business objectives.key business objectives.

Jagdip Grewal Jagdip Grewal

Chief Technical ArchitectChief Technical Architect

Agenda

• CFH Update and Why are we here?• Enterprise Architecture – Integration Domain• CFH and HL7 CDA• The Future

Our Objectives

To deliver a 21st century health service through efficient use of technology to:

• Enable and improve Access and

Choice

• Enable care pathways and

patient focus

• Improve accuracy in treatment

• Create opportunities for

improved efficiency

• Create opportunities for real

NHS reform

……and the NHS in England and the NHS in England is BIGis BIG

In a typical week:• 6 million6 million people will visit their GPs• More than 800,000800,000 outpatients will be treated• Over 10,00010,000 babies will be delivered by the NHS • NHS ambulances will make over 50,00050,000 emergency journeys • Pharmacists will dispense approximately 8.5 million8.5 million items• NHS surgeons will perform around 1,2001,200 hip operations, 3,0003,000

heart operations and 1,0501,050 kidney operations• Labs and associated services will provide results on

millionsmillions of tests

Or another way, 3 million3 million critical transactions a day

There is no way to do this on a small scaleThere is no way to do this on a small scale

SupplySupply --sidesideReformsReforms

DemandDemand --side side ReformsReforms

Transactional Transactional

Reforms

System Management

Reforms

Better careBetter patient

experienceBetter value for

money

System Management

Standards, Accreditation & Inspection

Values, Brands & Codes

Planning, Performance & Assessment

Financial Strategy

Wider Review of Regulation

Payment by Results

Information Strategy & Systems

Payment & Settlement

Plurality in Primary Care

Foundation Trusts

Plurality / Contestability

Independent Sector

NHS Treatment Centres

Out of Hospital

18 Weeks

Workforce

Patient Choice

Commissioning

PCT Development

Patient Info

Long Term Conditions

Demand Management

Motivation: Why ?

Progress to date

• NHS Connecting for Health deployment statistics (to 3 October 2006) 276,899 users registered for access to the Spine 5,654,360 prescription messages transmitted using

the Electronic Prescription Service (EPS) 1,348,277 Choose and Book bookings 70,907,782 images stored using Picture Archiving and

Communications Systems (PACS) 15,686 National Network (N3) connections

• Thousands of systems exchanging information Over 9000 Accredited Systems connected

Why are we here?

• Enable the best integrated healthcare by the time these children grow up!

Agenda

• CFH Update and Why are we here?• Enterprise Architecture – Integration Domain• CFH and HL7 CDA• The Future

Enterprise Architecture – Integration is a key domain

Sec

uri

ty

Inte

gra

tio

n

Infrastructure

Enterprise Services

Channels

Local Services

Views

Infrastructure

Enterprise Services

Local Services

Channels and Presentation IntegrationSecurity

Information, Knowledge and

Research Services

Diagram file: Conceptual IS IT services v10.vsd

Profiling & personalisation

Session & context management

Scanning[116.6]

Reporting [385.7.17, 720.6.4, 600.5.5,

360.14.9]Deployment

Scheduling Services

Enquiry Support

Network ServicesPrint

managementMonitoring [360.6.8,

et al] Fault management

[600]Help desk Support

[600]

Reporting including Statutory Reports

Electronic Booking Service [109]

Terminology Data Services

[380]

eMail

E Booking [109]

Financial Services [117]

Operational reports

Clinical audit Data Sets

Ad Hoc Reports

Configurable reports [124.3]

Analytical tools [124.4]

Search & Lookup

Virtual Visiting[123.2]

Home monitoring[107.5.2 & 123.1]

Bed mgmt [107.7]

Diagnostic & Investigative

Services [114]

Patient Record Presentation

Requesting services [110]

Results Mgmt [111]

Decision Support [112]

Alerting

Clinical Noting [106.5]

Clinical Performance Management Information

Reporting

Connectivity

Audit: Local Capture & management

Audit record Consolidation

(Cluster)

Audit: View, Analyse, Search

SSOAuthentication

114.10.15

RBAC 730.12

Consent management [730.1]

Patient Record Access Control

[730.17]

Sealed envelopes [730.48]

Digital Signature[730.67]

Encryption [730.87.2, 975.6.3]

User Registration

User Directory

Central Audit

Audit record Consolidation

(National)

Local Application Integration

Social Care Integration

Legacy Departmental integration

Legacy Reporting integration

Data MigrationVideo Conferencing [123.3]

Order Management [110.11]

Dispensing[113.12]

Prescribing [113.6 – 11]

Medicines Administration

[113.13-15]

Enterprise Directory Services [350]

Service directory

Service registration maintenance

Workflow and Business Rules Services [370]

Validation

Transformation

Coordination, Reminder, Alert

Workflow management

Clinical Summary Access [311]

View Spine data

Update Spine data

Prescribing Alerts

Print prescription

Management Reports 311.19

Secondary Data Uses [385]

Pseudonymisation

Data storage

Data extract

Data transfer

Analysis

Demographics [211]

NHS No. Services

Patient trace & info

Registration & Maintenance

Reporting

External Interfaces

Screening

Service Hosting

Clinical Summary Records [200]

Update stored data types

Store, maintain, retrieve summary etc data

Duplicate Record mgmt

Create event, workflow or alert

Medications Management (EPS) [769]

Prescribing [113.6-11]

Dispensing 113.12

Medication mgmt recording

Update patient record

User interface services

Device and media repurposing

Disaster Recovery [720]

Data backup

Replacement IS and IT resources

Restore services

Devices

Peripherals

NHS Direct122

Patient Personal Health Information

(MyHealthSpace 311)

Document Management

[116]

Data Quality Services [736]

Workflow [101.7]

Workflow 101.7

Manage access

Create & manage Kbase

Patient & Identification Services

Patient Identification

[102]

In patient Tracking

Registration [102]

Duplicate Record mgmt

Address lookup & validation

Care management

Caseload mgmt

Waiting list mgmt

Referral mgmt

Major incident mgmt

Scheduling mgmt

[108, 114]

Assessment services [104]

Medicines Administration

[113.13-15]

Encounter mgmt

Resource mgmt

health issue mgmt

patient tracking

risk & warnings mgmt

professional care relationship

mgmt

Admission Transfer

Discharge

Patient incident and complaint

mgmt

Interventions mgmt

Mental health Act admin mgmt

Prevention, Screening,

Surveillance [103]

Demand & Access mgmt

[107.8]

Care management

Model Care pathways & plans 105.5

Care pathways 105.6

Care Planning 105.10 - 11

Correspondence mgmt [106.6]

NSF Support

Diabetes NSF 162

Cancer NSF [163]

Older People’s NSF [165]

Children’s NSF [166]

Coronary NSF [164]

Renal NSF [167]

Long Term Care NSF [168]

NSF Information Services [160]

Setting Specific Services

Ambulance [154]

Mental health [161]

Ambulatory Care Mgt

[107.6]

Emergency Services [122]

Maternity Services [118]

Domiciliary Care Mgt

[107.5]

Screening Mgmt

Dental[120]

Theatre management [125]

Digital Imaging [115]

Image Acquisition 115.5

Image Archive 115.6

Image Retrieval 115.7

Image Viewing 115.8

Hardcopy production 115.8.89

Enterprise Application Integration [360]

Data Transformation 360.4

Interface Mechanisms 360.3

Message validation 360.6

Message structure transformation & mapping

360.6

Business Rules and workflow 360.6

Routing 360.6

Error handling 360.6

Message Queue360.1

Translation (coding) 360.5, 380.3

EDI360.16.7

Certificate management

Demographic mgmt [102]

Integration Architecture Domain - Standards• CFH is committed to HL7

Use of V3 decision in 2003! Still needs development work and we will continue to

work within HL7 - e.g. HL7 Tooling Collaborative (

http://www.hl7toolingcollaborative.org/)

• Strategic alliance between HL7, ISO and Cen Agreed at joint meeting in Geneva, October 2006 Aim to co-ordinate work programme and joint

standards Plan to pull in others SDOs to join (e.g. SNOMED)

Allow Incremental Rollout

• All care settings will be upgrading systems for several years to come. A release from a supplier could take 1-2 years to rollout across a cluster.

• Need to enable a way of transferring information between systems which allows For different levels of SNOMED compliance of

systems And for those which are not compliant, to allow

the clinician to view the information

How do clinicians work?

• Need to be aware of information overload The right information is key

• Clinical coding teams Will be here for a while yet

• Business change in NHS will take a while

Need to enable increasing coding of clinical flows

Post-coordination

Full Pre-coord

Partial Pre-coord

Text

Provider of Care’sSystem

Primary Physician’sSystem

Post-coordination

Full Pre-coord

Partial Pre-coord

Text

SnomedCompliance

Benefits

Agenda

• CFH Update and Why are we here?• Enterprise Architecture – Integration Domain• CFH and HL7 CDA• The Future

CFH and HL7 CDA

• In Q2 06 a decision was made to adopt HL7 Clinical Document Architecture as the basis for all clinical messages.

• This supports the vision of allowing messages to flow between organisations and be processed at the capability of the receiving system. The minimum would be to view the message as a

document. GP summary message v1 (MIM 4.2) is not HL7 CDA. Other MIM domains (Emergency, Discharge etc) are

being amended to be HL7 CDA compliant to be published shortly.

About CDA – a reminder

• CDA documents carry a number of different pieces of information:

Metadata – information for document management e.g. type of document

Text – a textual representation of the clinical content which is rendered for human readability

Coded – a fully structured representation of the clinical content which is used for decision support

Components of CDA

• The clinical content in a CDA Release 2 document is stored in: Sections

- Allowing for classification and storage of narrative text- NHS CfH will define business headings and CRE Type

sections

Entries- The coded elements of the document- These will be constrained from the CDA CSP using templates

ED Care Provision Event

Templates

• Templates will allow constraints to be applied to the section, entries and roles of the CDA document

• The mechanism for templating is currently being developed by Comms and Messaging

• It will allow for greater extensibility of the messages using a modular approach as seen in MIM 4.1.04

• A library of templates will be maintained to meet changing requirements

• The following classes will have templates applied: Sections

- e.g. Business Headings, CRE Types etc Entries

- e.g. Clinical Statements Roles

- e.g. author

Template List Identifier

• The template list identifier lists the allowable templates in the same way a vocabulary lists the allowable codes

• It allows for greater extensibility of the messages as new templates can be added to the list removing the necessity to update the base model

• The format of the identifier will be:NPFIT-nnnnnn#<type>

• Examples:NPFIT-000001#RoleNPFIT-000002#ClinicalStatement

Section Template Example

The Template in ClinicalStatement is an abstract choice.

The template which will actually appear in it’s place in an instance is one from the template list identifier NPFiT-000005#Section

Abstract Choice

Clinical Statement Template Example

The Template in AuthorChoice is an abstract choice.

The template which will actually appear in it’s place in an instance is one from the template list identifier NPFiT-000001#Role

Validation

• The instances will carry the generic CDA class names and will be validated against the CDA schema

• The instances will be validated against the templates using a validation tool set which could include schema, schematron etc

CDA TemplatesInstance

validation validation

What will this achieve?

• Flows to and from different care settings e.g. Acute to GP Without all systems being

- HL7 v3 compliant- Fully SNOMED compliant

• Earlier benefits from information flows through CFH infrastructure (i.e. Spine)

Agenda

• CFH Update and Why are we here?• Enterprise Architecture – Integration Domain• CFH and HL7 CDA• The Future

The Future

• Devices (MRI etc.) Will collect more and more data

• Life sciences industry and genomics

• Personalised health care?

Standards - Long and interesting journey ahead….

Summary

• CFH committed to HL7 Key standard in its Enterprise Architecture

• CFH has decided to use HL7 CDA Release 2 for clinical information flows Using templates to constrain part of the

document