HL7 & Health Information Exchange in Thailand

HL7 & Health Information Exchange
in Thailand
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital
Mahidol University, Thailand
June 24, 2014
www.SlideShare.net/Nawanan

2
A Bit About Myself...
2003 M.D. (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics (U of MN)
2012 Certified HL7 CDA Specialist
• Lecturer, Department of Community Medicine
• Deputy Executive Director for Informatics
(CIO/CMIO), Chakri Naruebodindra Medical Institute
Faculty of Medicine Ramathibodi Hospital
nawanan.the@mahidol.ac.th
http://groups.google.com/group/ThaiHealthIT
Research interests:
• EHRs & health IT applications in clinical settings
• Health IT adoption & eHealth development
• Health informatics education & workforce development

3
Outline
• Needs for better information in healthcare
• eHealth as a health system's component
• Thailand's eHealth situation
• Standards & interoperability
• HL7 standards
• The road ahead for Thailand's eHealth

4
Needs for
Better Information
in Healthcare

5
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.

6
Needs for Better Information
• Good information needed for quality care
– Past and present history
– Medication list
– Problem list
– Allergies
– Lab & imaging results
• Information gaps prevalent in healthcare
settings (e.g. Stiell A et al. CMAJ. 2003;169:1023-8.)

7
(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports

8
• Humans are not perfect and are bound to
make errors
• Highlight problems in U.S. health care
system that systematically contributes to
medical errors and poor quality
• Recommends reform
• Health IT plays a role in improving patient
safety
IOM Reports Summary

9
• Medication Errors
–Drug Allergies
–Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors

10
Back to
something simple...

11
To treat & to
care for their
patients to their
best abilities,
given limited
time &
resources
Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)
What Clinicians Want?

12
The Question Becomes...
How do we deliver better
information, by supplementing
human clinicians with ICT, so that
they make less errors and
perform better?

13
Outline
Needs for better information in healthcare
• eHealth as a health system's component
• HL7 standards

14
eHealth as a
Health System
Component

15
15
WHO (2009)
Components of Health Systems

16
16
WHO (2009)
WHO Health System Framework

17
Use of information and communications
technology (ICT) for health; Including
• Treating patients
• Conducting research
• Educating the health workforce
• Tracking diseases
• Monitoring public health.
Sources: 1) WHO Global Observatory of eHealth (GOe) (www.who.int/goe)
2) World Health Assembly, 2005. Resolution WHA58.28
Slide adapted from: Mark Landry, WHO WPRO & Dr. Boonchai Kijsanayotin
eHealth

18
 All components are essential
 All components should be balanced
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth Components: WHO-ITU Model

19
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Goal: Health Information Exchange

20
Outline
eHealth as a health system's component
• HL7 standards

21
Thailand’s
eHealth Situation

22
eHealth in Thailand: The current status. Stud Health Technol Inform
2010;160:376–80, Presented at MedInfo2010 South Africa
Thailand’s eHealth: 2010

23
 All components are essential
 All components should be balanced
Recalling eHealth Components

24Slide adapted from: Dr. Boonchai Kijsanayotin
Thailand: Unbalanced Development

25
 Silo-type systems
 Little integration and interoperability
 Mostly aim for administration and management
 40% of work-hours spent on managing reports and
documents
 Lack of national leadership and governance body
 Inadequate HIS foundations development
Boonchai Kijsanayotin et al. (2010)
Thailand’s eHealth Situation

27
Nationwide survey on hospital IT
adoption conducted in 2011
THAIS: Thai Hospitals’ Adoption
of Information Technology
Survey
Self-administered paper-based
survey mailed to 1,298 hospitals
in Thailand
Thailand’s Hospital IT Adoption

28Pongpirul et al., 2004
Vendor/Product Distribution (2004)

29Theera-Ampornpunt, 2011
Vendor/Product Distribution (2011)

30
Estimate (Partial or Complete
Adoption)
Nationwide
Basic EHR, outpatient 86.6%
Basic EHR, inpatient 50.4%
Basic EHR, both settings 49.8%
Order entry of medications,
outpatient
96.5%
Order entry of medications, inpatient 91.4%
Order entry of medications, both
settings
90.2%
Hospital IT Adoption Estimates

31
• High IT adoption rates
• Drastic changes in adoption landscape
• Adequate infrastructure for information
exchange
• Next question is on interoperability
THAIS: Discussion

33
Outline
Thailand's eHealth situation
• HL7 standards

35
Standards: Why?
• The Large N Problem
N = 2, Interface = 1
# Interfaces = N(N-1)/2
N = 100, Interface = 4,950

36
Clinic C
Government
Lab Patient at Home
Goal: Health Information Exchange

37
Objectives
• Interoperability
• Inter-operable
systems
Ultimate Goals
• Continuity of Care
• Quality
 Safety
 Timeliness
 Effectiveness
 Equity
 Patient-Centeredness
 Efficiency
Why Health Information Standards?

38
Levels of Interoperability
Functional
Semantic
Syntactic

39
Various Kinds of Standards
• Unique Identifiers
• Standard Data Sets
• Vocabularies & Terminologies
• Exchange Standards
– Message Exchange
– Document Exchange
• Functional Standards
• Technical Standards
– Data Communications, Encryption, Security

40
Functional
Semantic
Syntactic
How Standards Support Interoperability
Technical Standards
(TCP/IP, encryption,
security)
Exchange Standards (HL7 v.2,
HL7 v.3 Messaging, HL7 CDA,
DICOM)
Vocabularies, Terminologies,
Coding Systems (ICD-10, ICD-9,
CPT, SNOMED CT, LOINC)
Information Models (HL7 v.3 RIM,
ASTM CCR, HL7 CCD)
Standard Data Sets
Functional Standards (HL7 EHR
Functional Specifications)
Some may be hybrid: e.g. HL7 v.3, HL7 CCD
Unique ID

41
Message Exchange
• Goal: Specify format
for exchange of data
• Internal vs. external
messages
• Examples
 HL7 v.2
 HL7 v.3 Messaging
 DICOM
 NCPDP
Document Exchange
• Goal: Specify format
for exchange of
“documents”
• Examples
 HL7 v.3 Clinical Document
Architecture (CDA)
 ASTM Continuity of Care
Record (CCR)
 HL7 Continuity of Care
Document (CCD)
Exchange Standards

42
Messages
• Human Unreadable
• Machine Processable
Clinical Documents
• Human Readable
• (Ideally) Machine
Processable
Exchange Standards

43
Clinic C
Government
Lab Patient at Home
Message Exchange
Message
Message
Message
Message
Message

44
Clinic C
Government
Lab Patient at Home
Clinical Document Exchange
Message containing
Referral Letter
Message containing
Claims Request
Message containing
Lab Report
Message containing
Patient Visit Summary
Message containing
Communicable
Disease Report

45
Standards National
1. Core data set standards 12 & 18 files standards
2. Semantic standards Personal ID,
Provider ID
ICD-10-TM, ICD-9-CM
3. Syntactic standards X
4. Security and privacy standards X
Existing Standards in Thailand

46
Standards National
1. Core data set standards Referral, Chronic Diseases
2. Semantic standards
Drug Terminology (TMT),
SNOMED-CT
Lab Code (LOINC)
Providers IDs
3. Syntactic standards HL7 Messaging, CDA
4. Security and privacy
standards
X
Standards Being Explored/Developed

47
Thai Health Information Standards
Development Center
www.this.or.th
http://www.facebook.com/thishsri
this@this.or.th
Standards Development Organization

49
• HL7 Certified Specialists
Kevin
Asavanant
HL7 V3 RIM (2009)
Supachai
Parchariyanon
HL7 CDA (2010)
Nawanan
Theera-Ampornpunt
HL7 CDA (2012)
49
Sireerat
Srisiriratanakul
HL7 V3 RIM (2013)
Capacity Building on Standards

50
URGES Member States:
(1) to consider, as appropriate, options to collaborate with
relevant stakeholders, including national authorities, relevant
ministries, health care providers, and academic institutions, in
order to draw up a road map for implementation of ehealth and
health data standards at national and subnational levels;
(2) to consider developing, as appropriate, policies and
legislative mechanisms linked to an overall national eHealth
strategy, in order to ensure compliance in the adoption of ehealth
and health data standards by the public and private sectors, as
appropriate, and the donor community, as well as to ensure the
privacy of personal clinical data;
... http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf
World Health Assembly Resolution WHA66.24 (2013) on
eHealth Standardization & Interoperability

51
Outline
Standards & interoperability
• HL7 standards

What is HL7?
• HL7 is an ANSI-accredited Standards
Development Organization (SDO)
operating in the healthcare arena.
• It is a non-profit organization made up of
volunteers – providers, customers,
vendors, government, etc.
52
Slide adapted from: Dr. Supachai Parchariyanon

What is HL7? (Cont.)
• HL7 is an acronym for Health Level Seven
– Seven represents the highest, or “application”
level of the International Standards
Organization (ISO) communications model for
Open Systems Interconnection (OSI) networks.
53

OSI Model
54

55
HL7 Standards
• HL7 V2.x
– Defines electronic messages supporting hospital
operations
• HL7 V3
• HL7 Clinical Document Architecture
(CDA) Releases 1 and 2
• HL7 Arden Syntax
– Representation of medical knowledge
• HL7 EHR & PHR Functional Specifications
• Etc.

56
HL7 V3 Standards
• A family of standards based on V3
information models and development
methodology
• Components
– HL7 V3 Reference Information Model (RIM)
– HL7 V3 Messaging
– HL7 Development Framework (HDF)

57
Sample HL7 v.2 Message (Lab Result)
OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml|
0-1.3|H||H|F|19980309…

58
Sample HL7 v.3 Message
(Patient Registration)
<?xml version="1.0" encoding="UTF-8"?>
<PRPA_IN101311UV02 xmlns="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
ITSVersion="XML_1.0" xsi:schemaLocation="urn:hl7-org:v3
../schemas/PRPA_IN101311UV02.xsd">
...
<name use="SYL" >
<given>นวนรรน</given>
<family>ธีระอัมพรพันธุ</family>
</name>
<name use="ABC">
<given>Nawanan</given>
<family>Theera-Ampornpunt</family>
</name>
<administrativeGenderCode code="M"/>
...
</PRPA_IN101311UV02>
Message source adapted from Ramathibodi HL7 Project by Supachai Parchariyanon,
Kavin Asavanant, Sireerat Srisiriratanakul & Chaiwiwat Tongtaweechaikit

59
HL7 Reference Information Model (RIM)
Source: HL7 CDA R2

60
Source: “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012

61
HL7 V3 Messaging
• V3 provides messaging standards for
– Patient administration
– Medical records
– Orders
– Laboratory
– Claims & Reimbursement
– Care provision
– Clinical genomics
– Public Health
– Etc.

62
What Is HL7 CDA?
• “A document markup standard that
specifies structure & semantics of “clinical
documents” for the purpose of exchange”
[Source: HL7 CDA Release 2]
• Focuses on document exchange, not
message exchange
• A document is packaged in a message
during exchange
• Note: CDA is not designed for document
storage. Only for exchange!!

63
A Clinical Document (1)
• A documentation of clinical observations
and services, with the following
characteristics:
 Persistence - continues to exist in an
unaltered state, for a time period defined by
local and regulatory requirements
 Stewardship - maintained by an organization
entrusted with its care
 Potential for authentication - an assemblage
of information that is intended to be legally
authenticated Source: HL7 CDA R2

64
• A documentation of clinical observations
and services, with the following
characteristics:
 Context - establishes the default context for its
contents; can exist in non-messaging contexts
 Wholeness - Authentication of a clinical
document applies to the whole and does not
apply to portions of the document without full
context of the document
 Human readability - human readable
Source: HL7 CDA R2

65
• A CDA document is a defined & complete
information object that can include
 Text
 Images
 Sounds
 Other multimedia content
Source: HL7 CDA R2

66
CDA Releases
• CDA Release 1 (ANSI-approved in 2000)
– First specification derived from HL7 RIM
• CDA Release 2 (2005) - Current Release
– Basic model essentially unchanged from R1
• Document has a header & a body
• Body contains nested sections
• Sections can be coded using standard vocabularies and can
contain entries
– Derived from HL7 RIM Version 2.07
Source: HL7 CDA R2

67
Key Aspects of CDA
• CDA documents are encoded in XML
 When alternative implementations are feasible,
new conformance requirements will be issued
• CDA documents derive their machine
processable meaning from HL7 RIM and
use HL7 V3 Data Types
• CDA specification is richly expressive &
flexible
 Templates can be used to constrain generic
CDA specifications
Source: HL7 CDA R2

68
Scope of CDA
Lab Technician Physician
Lab Report
Create
document
Process &
Store
document
Transmit
document
CDA

69
CDA & HL7 Messages
• Documents complement HL7 messaging
specifications
• Documents are defined and complete information
objects that can exist outside of a messaging
context
• A document can be a MIME-encoded payload
within an HL7 message

70
CDA & Message Exchange
• CDA can be payload (or content) in any kind of
message
– HL7 V2.x message
– HL7 V3 message
– EDI ANSI X12 message
– IHE Cross-Enterprise Document Sharing (XDS)
message
• And it can be passed from one kind to
another

71
CDA & Message Exchange
Clinical Document
(Payload)
HL7 V3 Message
(Message)
HL7 V2 Message
(Message)
Source: Adapted from “What is CDA R2? by Calvin E. Beebe

72
CDA As Payload
Source: From “What is CDA R2? by Calvin E. Beebe

73
CDA Model

74
A Closer Look at a CDA Document
<ClinicalDocument> ... CDA Header ...
<structuredBody> <section> <text>... Single
Narrative Block ...</text>
<observation>...</observation>
<substanceAdministration>
<supply>...</supply>
</substanceAdministration> <observation>
<externalObservation>...
</externalObservation> </observation>
</section> <section> <section>...</section>
</section> </structuredBody>
</ClinicalDocument>
Source: HL7 CDA R2
Human Readable Part
Machine Processable Parts

75
Rendering CDA Documents (1)

76

77
Human Readability &
Source: HL7 CDA R2
<ClinicalDocument> ... CDA Header ...
<structuredBody> <section> <text>... Single
Narrative Block ...</text>
<observation>...</observation>
<substanceAdministration>
<supply>...</supply>
</substanceAdministration> <observation>
<externalObservation>...
</externalObservation> </observation>
</section> <section> <section>...</section>
</section> </structuredBody>
</ClinicalDocument>
Text to be rendered

78
Some Possible Use Cases of CDA
 Intra-institutional
 Exchange of parts of medical records (scanned or
structured electronic health records)
 Lab/Imaging requests & reports
 Prescriptions/order forms
 Admission notes
 Progress notes
 Operative notes
 Discharge summaries
 Payment receipts
 Other forms/documents (clinical or administrative)

79
Some Possible Use Cases of CDA
 Inter-institutional
 Referral letters
 Claims requests or reimbursement documents
 External lab/imaging reports
 Visit summary documents
 Insurance eligibility & coverage documents
 Identification documents
 Disease reporting
 Other administrative reports

80
Achieving Interoperability
 CDA is a general-purpose, broad standard
 Use in each use case or context requires
implementation guides to constrain CDA
 Examples
 Operative Note (OP)
 Consultation Notes (CON)
 Care Record Summary (CRS)
 Continuity of Care Document (CCD)
 CDA for Public Health Case Reports (PHCRPT)
 Quality Reporting Document Architecture (QRDA)

81
Outline
HL7 standards

82
Back to Thailand’s
eHealth status: Workforce

84
• Certificate & Diploma Level
• Undergraduate Level
• Graduate Level
84
Informatics Workforce Programs

85
Faculty of Medicine Ramathibodi Hospital, Mahidol University
http://med.mahidol.ac.th/has/85
Healthcare CIO Certificate Program

86Faculty of Tropical Medicine, Mahidol University86
Diploma & Master Graduates in Biomedical &
Health Informatics, First Batch

87
• In January 2013, the Thai Medical
Informatics Association (TMI) approved
establishment of the “Biomedical and
Health Informatics Education Special
Interest Group” within TMI (BHI-ED-SIG)
87
Informatics Education SIG

89
• International Medical Informatics
Association (IMIA)
– MEDINFO & APAMI
• HIMSS AsiaPac
• Asia eHealth Information Network (AeHIN)
• American Medical Informatics Association
(AMIA)
89
Internationalization

90http://www.aehin.org/Meetings/2013AeHINGeneralMeeting.aspx90
Participation in AeHIN

91
Outline
HL7 standards

92
The Road Ahead for
Thailand’s eHealth

93
• Addressing
– Lack of national leadership & governance,
strategy & investment, policy & regulation
– Shortage of informatics workforce
– Accelerating standards development
– Harmonizing applications
– Facilitating local research in informatics
93
The Road Ahead

94Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/
The Journey Beyond

HL7 & Health Information Exchange in Thailand

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