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Standards and HIT:From the past to the future

W. Ed Hammond, Ph.D.

Professor Emeritus

Department of Community and Family Medicine

Department of Biomedical Engineering

Adjunct Professor, Fuqua School of Business

Duke University

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The past differs from the present …

• Technology was the major barrier.• High-speed and ubiquitous connectivity was

not available and actually was not a focus.• The need for standards was not a priority.• Applications focused on single domains.• Administrative and accounting needs

dominated.• Hospitals got all the attention.• In the clinical world, home-grown systems were

the preferred choice.• Little government interest and support for IT.• Little institutional support for IT.

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The present …• Technology is no longer an issue.• Providers still need convincing; vendors are

still very much legacy-oriented. Home-grown is still around.

• Still confusion on what we need, who should do it, who should pay for it, and the path we need to take.

• Standards are recognized as critical components but still looking for adoption.

• Hospitals have good service support; outpatients have little clinical IT.

• Sharing is still a dream. There are still business fears about sharing.

• Difficult decisions are still difficult.

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What kind of sharing are we talking about?

– When a person moves to another location, their EHR should go with them and be immediately useable.• Transfer EHR between independent sites

– To support the multiple sites of care a typical patient uses• Virtual or real summary record with links to sites; likely

real time access; RHIOS and NHIN– For patient referrals

• Likely to be query-based and/or algorithm driven

• Transfers will rarely be everything but a highly focused and purposeful transfer of data.

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Interoperability is the future

• Interoperability based on common data standards is a pre-requisite for the aggregation and sharing of data.

• In health care, widespread interoperability opens the door to extraordinary change in areas ranging from high quality care, individual patient safety during treatment, to population safety from epidemics, to the everyday chronic and acute care of millions of citizens, wherever they may be.

• But, today, vendor systems are not interoperable, institutional systems are not interoperable, and enterprises are not interoperable

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Interoperability

• Interoperability [IEEE and HL7]– Ability of two or more systems or components to exchange

information [functional interoperability] and to use the information that has been exchanged [semantic interoperability]

• Interoperability is like the word unique or being pregnant – no adjectives allowed.

• Sharing can occur at multiple levels– Human readable (?) form

– Document level sharing

– Messages

– Content

• Document images

• Free form

• Structured

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DATA

KNOWLEDGE

PROCESS

STA

ND

AR

DS

Low cost

Accessible

Patient Safety

Quality

Analysis

Statistics

Research

Clinical Trials

EBM

Analysis

Statistics

Research

Clinical Trials

EBM

Analysis

Statistics

Research

Clinical Trials

EBM

Analysis

Statistics

Research

Clinical Trials

Surveillance

Analysis

Privacy, Security, Trust, Integrity

Public/PrivatePartnership

Vendor/ProviderPartnership

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PreventiveCare

Acute Care ChronicCare

Data Data Data

DecisionSupport

Decision Support Decision Support

Norm

al

Concern

Abnorm

al

Outpatient

Specialty

Em

ergency

Hospital

Intensive

Control

Treatm

ent

Perform

ance

A view of the healthcare world

Sym

ptoms

Diagnoses

Treatm

ent

Outcom

es

Genom

ic Medicine

Nursing Homes, etc. Home Care

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Where do standards start?

• With the smallest element – the data element• If we define a structured set of any and all data

elements that might be contained within an electronic health record, and if

• we include precise and unambiguous definitions, data types, units, roles and use, and many other attributes, and if

• we define unique value sets for these data elements (single, integrated terminology)

• then we can achieve interoperability independently of how these data elements might be packaged for interchange.

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GROUPS OF STANDARDS

IDENTIFIERS, RESOURCE REGISTRIES, TOOL SETS, CONFORMANCE AND IMPLEMENTATION MANUALS

HIPAA, HL7, ASTM, ISO, CEN

APPLICATION LEVEL SUPPORT

FUNCTIONAL REQUIREMENTS, CONTENT DATA SETS, EHR MODEL, CCR, TRANSFER EHR, other EHR

HL7, ASTM, CEN, openEHR

ELECTRONIC HEALTH RECORD

Guidelines and Protocols, ARDEN SYNTAX, GLIF, GEM, PRODIOGY, PROTIGÉ, vMR, GELLO, othersHL7, ASTM, UK, others

KNOWLEDGE REPRESENTATION

Structured&free form documents, images

HL7 V2.N AND V3, DICOM, IEEE X73, ASTM, NCPDP, X12n and others

DATA INTERCHANGE

RIM, DATA ELEMENTS, DATA TYPES, TERMINOLOGY, TEMPLATES, CDAHL7, CEN, ISO, NCPDP, X12N, IEEE, SNOMED. LOINC, RXNORM, SPL

DATA ELEMENTS

XML, TCP/IP, Web services, OCL, CCOW, SECURITY, GIS, etc.

W3C, IETF, OMG, HL7 others.

GENERIC, BROAD USE

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EHR Interoperability Diagram

PatientEncounter

Provider EHR

Database

PersonalEHR

PopulationEHR

Profile

Profile

ProfileResearchDatabase

EnterpriseData

WarehousePersonal

EHR

Profile

Disease Registry

Profile Billing/Claims

Institution EHR

Database

ResearchDatabaseResearch

Database

Disease RegistryDisease

Registry

Derived from master data element registry

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Step out of the box• Fix terminologies!! We are so close!• Eliminate local vocabularies and data elements.

Mapping is not a solution!• Create a deadline by which all should be using

common, structured data.• Adopt modular, growable structures so we can

build functionality over time.• Create and use more tools.• Make stakeholder stew.• Don’t compete, at least at the bottom levels.

Build the playing field, then compete.• Don’t worry about credit. It’s not NIH, it’s UI.• Create new approaches to research – use

interested, geographically-distributed researchers creatively developing tools.