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Interoperability & standards

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Presentation for UP Health Informatics HI201 under Dr. Iris Tan and Dr. Mike Muin. The topic for discussion Interoperability & Standards, a healthcare scenario was given regarding two disparate information systems, one found in a clinic, another with a hospital information system. #MSHI #HI201

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Interoperability & standards

  1. 1. Interoperability and Standards Healthcare Scenario 1 Admitting Orders from a Clinic to a Hospital J. Don M. Soriano, MD MBA
  2. 2. Healthcare Scenario 1 Dr. Santos (Internal Medicine) uses an EMR called ClinicSys. He uses it for SOAP notes, clinical abstracts, referral letters and admitting notes. He is a consultant at Reyes General Hospital (RGH). RGH has a Hospital Information System (HIS) called HospitalSys. Dr. Santos wants to send a patient for admission (with admitting orders) to RGH. Dr. Santos wants to get notice that patient has been admitted. • I chose Scenario 1 because it is the one I am most familiar with and can relate to. My discussion though is limited by my current knowledge of IT applications and terminologies. • I tried to deconstruct the problem, seen from the perspective of a hospital administrator faced with an issue, looking for solutions. Research notes were included to supplement my answers.
  3. 3. Points to Consider • Interoperability is “the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged.” • There are two parts to that definition - the exchange of data and the use of that data that has been exchanged. Interoperability issues can arise from any part of this equation. • “Data has to move between two or more systems – the exchange of information. The receiving system and users must be able to process and use the data. To “use” the data we need to ensure that it’s delivered in a way that can be easily understood by the receiving system and users so it can be applied. That’s where semantic interoperability enters the picture.” - Dennis Giokas
  4. 4. • In my previous blogs, I discussed the issues with regard to people, processes, technology and financial resources. Looking at it from another perspective, these factors can be seen in the Ishikawa Fishbone diagram for root cause analysis. • Modifying this a bit to fit the context of the discussion, we can come up with these diagrams: People Process Technology Content Interoperability Issues
  5. 5. Interoperability Issues People Process No clear strategic direction for evolutionary changes in overalll technology environment of HIS Limited IT knowledge of medical staff Limited IT knowledge of admitting section staff EHR may need upgrade or replacement HIS may need upgrade or replacement Poor integration between components of HIS Poor quality of information - lack of consistency, duplication, out-of-date information Poor Database Design - table of data elements may need normalization Technology Content We then use this diagram to determine project goals
  6. 6. What entities are involved? • Dr. Santos • Doctor’s EMR (ClinicSys) • Reyes General Hospital HIS (HospitalSys) • Admitting Section, Reyes General Hospital Information System 1 (EMR ClinicSys) creates admitting order, sends admitting order to Information System 2 (HospitalSys) Information System 2 (HospitalSys) receives admitting order, sends notice when patient is admitted to Information System 1 (ClinicSys) Assumption: Notice of patient admission is sent once the patient has a room
  7. 7. What applications need to talk to each other? • Doctor’s EMR (ClinicSys) • Reyes General Hospital HIS (HospitalSys) • Integrated components of HIS: 1. Databases - Patient Registry and Medical Staff with admitting privileges 2. Room Management System Patient Registry Directory Medical Staff Room Management System
  8. 8. Project goals for making applications talk to each other • Evaluate cause and effect factors by reviewing Fishbone diagram • Create an IT support group for medical staff • Form a technical working group which includes medical staff, hospital management, IT support group to discuss ways to integrate disparate doctors’ systems and hospital system • Determine standards needed such as data content standard, data exchange standard • Identify and prevent data level conflicts • Re-train hospital staff regarding data collection and coding “ Data level conflicts are differences in data which can be caused by multiple representations and interpretations of similar data. Examples of data level conflicts are data-value conflicts, data representation conflicts, data-unit conflicts, and data precision conflicts. Data-value conflicts are conflicts in data values. Data values may mean different things depending on their relationships to other factors. Data representation conflicts happen when the same data is represented in different ways (dates can be represented as 9/17/2006, 17-9-2006 and/or September 17, 2006). Data-unit conflicts are those where the same values are represented in different units – feet, yards, meters, etc. Data precision conflicts happen when the same type of data is represented in ways that differ conceptually.” - From System Interoperability by Jennifer Macaulay
  9. 9. How can we make disparate systems and applications talk to each other? • Database translation approach “ The database translation approach is a point-to-point solution based on direct data mappings between pairs of information systems. The mappings are used to resolve data discrepancies among the systems. The database translation approach is most appropriate for a small-scale information-processing environment with a reduced number of participants. The number of translators grows with the square of the number of components in the integrated system. The corresponding translators must be placed between the information systems.” Information in IS1 is represented by vertical lines, while the information in IS2 is shown as horizontal lines representing a disparate system.
  10. 10. How can we make disparate systems and applications talk to each other? • Federated systems approach “Federated systems consist of a set of heterogeneous databases in which federation users can access and manipulate data transparently without knowledge of the data location. Each federation database includes a federated schema that incorporates the data exported by one or more remote information systems. There are two types of federations: A tightly coupled federation is based on a global federated schema that combines all participant schemas. The federated schema is constructed and maintained by the federation administrator. A loosely coupled federation includes one or more federated schema that are created by users or the local database administrator. The federated schema incorporates a subset of the schema available in the federation. This approach becomes rapidly complex when the number of translators required becomes large. The federated system is made only of horizontal and vertical lines that IS1 and IS2 want to exchange.”
  11. 11. How can we make disparate systems and applications talk to each other? • Ontology approach “ The ontology-based interoperability approach uses ontology to provide an explicit conceptualization of the common domain of a collection of information systems. An ontology defines a common vocabulary that can be used by users from different systems. The construction of an ontology for a domain is a difficult task and often requires merging existing overlapping ontologies. The interoperability solutions based on ontology describe the semantics of information rather than their organization or their format.”
  12. 12. How can we make disparate systems and applications talk to each other? • Standardization approach “ In the standardization approach, the information sources use the same model or standard for data representation and communication. The use of a standard metamodel reduces the number of translators (this number grows linearly with the number of components) to resolve semantic differences. However, the construction of a comprehensive metamodel is difficult; the manipulation of high-level languages is complex; and there are no unified database interfaces. A centralized information system can be built to replace the original information systems (IS1, IS2). The global centralized schema is a combination of the data (horizontal and vertical lines) contained in IS1 and IS2.”
  13. 13. How can we make disparate systems and applications talk to each other? • Multi base approach “ Language-based multibase systems consist of a loosely connected collection of databases in which a common query language is used to access the contents of the local and remote databases. In this approach, in contrast to the distributed and federated systems, the burden of creating the federated schema is placed on the users, who must discover and understand the semantics of the remote databases. This solution is well adapted for information systems that are based on the same family of data models and do not require complex query translators.”
  14. 14. How can we make disparate systems and applications talk to each other? • Mediation approach “ The mediation approach is based on two main components: mediator and wrapper. The mediator is used to create and support an integrated view of data over multiple sources. It provides various services to support query processing. For instance, a mediator can cooperate with other mediators to decompose a query into subqueries and generates an execution plan based on the resources of the cooperating sites. The wrapper is used to map the local databases into a common federation data model. The wrapper component provides the basic data access functions. In the diagram, a translator, which acts as a wrapper, is placed between the conceptual representation of the mediator and the local description of each information source.”
  15. 15. How can we make disparate systems and applications talk to each other? • WS approach “ As new data models are developed for Web-based information systems, there is a need to extend interoperability solutions to take into account requirements and specifications of the new models. The existing Web technologies are not initially intended to address some of the issues involved in database integration. For instance, the Web-browsing paradigm is efficient for data lookup in a large environment, but it is inadequate for database integration support. To use this paradigm to locate and merge data requires costly applications that are often tailored to specific integration needs. New challenges have arisen from the development of Web-based information systems. One of the challenges is the need to develop Web-oriented tools to support information integration and allow access to local as well as remote information sources. Recently, Web services (WS) have been proposed as a method to address some of the challenges of Web-based integrated systems. A Web service can be viewed as a set of layers contained in a stack. The layers are dynamically defined following user needs and are called through a set of Internet protocols.”
  16. 16. What’s next? • “Health Level-7 or HL7 refers to a set of international standards for transfer of clinical and administrative data between Hospital information systems. These standards focus on the application layer, which is "layer 7" in the OSI model.” - HL7.org • “SNOMED CT or SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. It is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. Its comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimen.” - ihtsdo.org SNOMED
  17. 17. Proposed solutions • Option - Check if an upgrade for both Information Systems would resolve the problem • Option - Upgrade the Hospital Information System, find out which Clinic Systems are interoperable then inform doctors of these systems, have them switch • Option - Replace present Hospital Information System with another having a strategic intent of interoperability with other systems • Option - Use Database translation approach if only the ClinicSys of Dr. Santos is to be considered • Option - Use Standardization approach if several other doctors have their own disparate information systems • Option - Consider a Web-based platform information system for everyone to use
  18. 18. Data elements • Date • Doctor’s name • Specialty • Status (category of doctor’s Hospital Admitting Privileges eg. Active Rotating, Visiting Staff with admitting privileges etc.) • Patient’s name • Patient Hospital ID number • Patient’s birthday • Account number (number which serves as unique identifier for present admission) “Data elements are the smallest named item of data that conveys meaningful information or condenses lengthy description into a short code. It is called data field in the structure of a database.” “The data that is stored in tables is organized in a logical manner based on a particular purpose to help minimize duplication, reduce data anomalies, and reinforce data integrity. The process by which data is logically organized is called normalization; it not only simplifies the way data is defined, but it also regulates its structure.” “Stored data is manipulated using a programming language called Structured Query Language, or SQL. Many varieties of SQL exist, but most are based on set theory relational operators such as and, or, not, and in, all of which are used to perform operations on the data. The operations that can be used in relational databases include insert, select, update, and delete privileges. Since the early 2010s, the relational database management system (RDBMS), is the most commonly used database format.”- wisegeek.org/what is a relational database
  19. 19. Trigger events • At what point (activity or event) in the process should the transfer of information happen? The trigger event could be the creation of the admitting orders. • At what point in the application/software process should the transfer of information happen? The trigger event could be the transmission of the admitting order. “In a digital health care system, applications create HL7 messages because of a real-world event. The HL7 organization has written the HL7 standard based on the assumption that an event in the real world of health care creates the need for data to flow among applications, even when these applications span heterogeneous systems. The HL7 standard calls this real-world event a trigger event. An automated system must systematically recognize the trigger event. Trigger events always result in the creation of one or more messages that trigger an action in the application that processes the message.” - msdn.microsoft.com
  20. 20. Reference • http://what-when-how.com/ information-science-and-technology/ interoperability-of-information- systems/ “Standards are enablers. Interoperable systems are what support the business and clinical requirements in a typical e-health agenda.” Dennis Giokas Emerging Technology Group