I gave this prezo to Auckland Regional Clinical IS Leadership Group on Feb 21, 2014. It shows how difficult it can be to deal with certain kinds of health information when developing systems by an impressive example (originally from Dr. Sam Heard). Therefore we need rigorous and scientific methods to tackle this - in this case using openEHR's multi-level modelling approach to create a single content model from which all health information exchange payload definitions will be derived. New Zealand's Interoperability Reference Architecture (HISO 10040) is underpinned by openEHR Archetypes to create this content model. The bottom line of the prezo is that almost every national programme starts health information standardisation from the wrong place; most of them are complex technical speficifications, like CDA, which are almost impossible for clinicians to comprehend and provide feedback. The process is flawed! Instead it should start from simple to understand representations, such as simple diagrams, mindmaps etc.and then handed over to techies once clinical validity and utility is agreed upon.That's the beauty of Archetype approach - great tooling and the Clinical Knowledge Manager (CKM) enable clinicians and other domain experts to collaborate and develop clinical models easily.

1. Getting Clinical Information
Right
Emerging Medication Standards
Koray Atalag, MD, PhD, FACHI
k.atalag@auckland.ac.nz
HISO Member
HL7 New Zealand Vice-Chair
openEHR Programme Lead
The National Institute
for Health Innovation

2. Agenda
• The problem
• What‟s out there?
• Medication Example
• Methods & Standards
• Recommendations & Discussion

3. What’s the problem?
• Healthcare is hard!
– Breadth, depth, complexity, variability etc.
• So is dealing with health information...
– What is a Heart Attack?
– Is there such a disease as hypertension?
– Is Diabetes a single disease?
• Burning issue: getting a core dataset ASAP
– Who will be responsible to govern definitions?
– How to coordinate and support dataset teams?
– How to get clinicians/experts on the same page?
• An obvious gap in current approach
• Start with Medication (+ Allergies & ADR)

4. So what’s actually out there?
• PMS: each vendor has own data model
• GP2GP: great start for structure
• NZePS: started with a propriety XML payload, now
waiting for standard CDA
– PMS vendors implementing Toolkit based Adapter
•
•
•
•
Shared Care / Maternity / St John?
Hospitals?
Labs & Pharmacies?
Others?
 Can you really trust incoming data?
(without human control)

5. Unified Medication Definition
• Essential to get it right – first in patient safety!
– Needs to be clinically valid, computable and support multiple use
• Reused in many places, including:
–
–
–
–
–
–
ePrescribing, eReferrals
My List of Medicines
Shared Care systems
Patient and clinician portals
Health (status & event) summary
Public Health / Research
• New HISO Connected Care suite of standards
– HISO 10043 CDA Common Templates
– 10041.1 CDA Templates for Medications, Allergies and Adverse
Reactions just passed public consultation – coming soon
• NZMT / NZULM & Formulary > great start!

7. Why bother?
(with a standard structured Medication model)
“If you think about the seemingly simple concept of
communicating the timing of a medication, it readily
becomes apparent that it is more complex than most
expect…”
“Most systems can cater for recording „1 tablet 3 times
a day after meals‟, but not many of the rest of the
following examples, ...yet these represent the way
clinicians need to prescribe for patients...”
Dr. Sam Heard

8. Example: Medication timing
Acknowledgement: Sam Heard

9. Medication timing – and more!!
Acknowledgement: Sam Heard

10. Medication timing cont.
Acknowledgement: Sam Heard

11. Medication timing – cont.
Acknowledgement: Sam Heard

12. Medication timing – even more!
Acknowledgement: Sam Heard

13. HISO 10040 Interoperability
Reference Architecture
10040.1
R-CDRs
XDS
10040.2
CCR
SNOMED
CT
openEHR
10040.3
CDA
Acknowledge Alastair Kenworthy

14. The Principles
1.
2.
3.
4.
5.
6.
7.
Align to national strategy: as per national and regional plans
Invest in information: use a technology agnostic common
content model, and use standard terminologies
Use single content model: information for exchange will be
defined and represented in a single consistent way
Align to business needs: prioritise the Reference Architecture
in line with regional and national programmes
Work with sector: respect the needs of all stakeholders
Use proven standards: adopt suitable and consistent national
and international standards wherever they exist (in preference to
inventing new specifications)
Use a services approach: move the sector from a messaging
style of interaction to one based on web services

15. It’s REFERENCE LIBRARY
(of reusable clinical information models)
Data & meta-data definitions (data dictionary)
Relationships & clinical terminology

16. Usage of the Content Model

17. Health Information Exchange & More
Single Content Model
Automated Transforms
PAYLOAD
CDA
System A
Map
To
Content
Model
FHIR
HL7 v2/3
EHR Extract
System B
Map
To
Content
Model
UML
XSD/XMI
PDF
Mindmap
Data Source A
Data Source B
No Mapping
Secondary Use
Native CDR / Datamart

18. Creating CDA Payload

19. Draft HISO Medication Standard

20. Peer review of models

21. Resulting Models (using CKM Tool)

22. Who else is doing it?

23. Other upcoming HISO standards
•
•
•
•
10041.4 CDA Templates for Referral Requests
10040.4 Clinical Document Metadata Standard
10050.1 Maternity Data Set Standard
10050.2 CDA Templates for Maternity Care
Summary
• 10052 Ambulance Data Set Standard
They all share common clinical concepts; certainly the
Medication Definition
– Who’s responsible for making sure they are aligned?
– What mechanism exist to assist dataset developers / clinical
domain experts?
– How do you keep them aligned over time / governance?

24. Options / Recommendations
 Who can be responsible for making sure
datasets are aligned and interoperable?
 MoH, NHITB, HISO, HIGEAG, NICLG, other?
 What mechanisms to assist dataset
developers / clinical domain experts?
 Policy, principles, guides, examples
 HISO 10040.2 Exchange Content Model
 Tools? CKM but also Word, Excel, mindmaps, UML
 How do you keep them aligned over time /
support governance?
 CKM – Not Data dictionary, meta-data registry, Excel

25. Bottom line
• Content is „clinician‟s stuff‟ – not techy;
– yet most standards are meaningless for clinicians
• We need to invest in information
– Whatever technology will be
• Method defined in HISO standard
– Worked well for Medications
• Let‟s build rest of it as we go!
– NIHI is keen to facilitate clinical
content development and governance
+ tooling support
– This will also fulfil MoH “Data Dictionary” need

26. Thank you 
Questions?
k.atalag@auckland.ac.nz
The National Institute
for Health Innovation