Experiences of Introducing International Standards HL7 in Healthcare Interoperability in Greece' Pas

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Experiences of Introducing International
Standards (HL7) in Healthcare Interoperability in
Greece. Past Efforts, Present Benefits, Future
Prospects
Computer Control Systems SA
Tassos Tagaris , PhD Medical Informatics
Engineer CCS SA HL7 Hellas
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Who we are. Computer Control Systems S.A.

• Is a company with activities in the area of
  Information Technology offering a range of
  software products and services in the domains of
  
• Medical Informatics 
• Applied Engineering 
• CAD/CAM 
• Internet
• Was established in 1987 and has been officially
  certified as a High-Technology company by the
  Greek Ministry of Industry and Technology.
• Possesses certification of very advanced
  technology delivered by the Ministry of
  Development.
• Is certified with ISO 9001-2000 for the design,
  development, installation, support of software
  products and solutions and services

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Computer Control Systems S.A.

• Specialists in Medical Informatics
• CCS SA is the pioneering company that established
  L.I.M.S. software in Greece
• It has more than fifteen years of know-how in
  the laboratory field
• It has trained more than 2000 person of
  laboratory personnel
• Installations
• More than 70 Hospitals
• more than 600 installations
• Insurance Funds
• Diagnostic Centres
• Microbiology Labs / Doctors Offices

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History of Technology in Healthcare

• 1960-1970, Mainframe based systems
• No IT in Healthcare in Greece
• 1980 Mini computers, PCs
• Proprietary SW
• HIS systems
• Laboratories (RIS / LIS) and Pharmacies
• Delayed introduction of IT in Healthcare
• Either none or horrible batch and cobbled
  interfaces to collect data
• 1990 Windows Revolution! Relational DBMS Client
  Server Applications
• Low investment of Healthcare services
• Still, each application is in its own world
• Late 90s The Internet
• Systems Interoperability
• Open Standards
• Users are now Physicians, nurses and other
  non-technical stuff
• But

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Medical Records without Standards
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What to do?

• We Need an easier way
• Standards
• Systems communication
• EDI, EDIFACT, HL7, DICOM
• Clinical Codification
• ICD9, Read Codes
• Dictionaries Registries
• Integrating Healthcare Enterprise IHE
  Initiative

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The Problems- What lead us to Standards

• Main Product MEDILAB LIMS with
• Over 70 installations in Hospitals
• Need for data exchange with
• HIS Systems
• Stock Management Systems
• ERP Systems

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What lead us to Standards

• Main Need
• Accept Lab Orders (from physicians, clinics, etc)
• Return Lab Results
• Each time we had to come over and over the same
  discussions with the other side
• Modify the previous interface to come up with
  the current communication scenario
• Need a standard to
• Define the dataset to exchange
• Create cross map tables to identify entities of
  the organization (Physicians, Clinics, Services,
  etc)
• Define the rules of communication
• Reduce man-hours needed to establish a
  communication

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Need Standards to Identify the Entities

• To Accept an Order we need to know
• Who is the Placer
• Doctor, Clinic, Hospital gt Registries,
  Terminology Servers
• Whom it concerns
• Patient gtPatient Identification System
• What it includes
• Which tests (examinations) gtLOINC

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What we did?

• Standards available
• Systems communication
• HL7 (v2.3.1)
• Clinical Codification
• ICD9 / ICD10
• LOINC (Tests codification)
• Dictionaries Registries
• Unfortunately, still no National Standard
• Patient Identification
• No National policy.
• PIDS by OMG

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Why HL7?

• International Standard since 1991
• Used Worldwide (23 HL7 Affiliates)
• Used in EU (Germany, Holland, Finland, Italy etc)
  HL7-TC251 Task Force
• ANSI Standard
• Used in Real-life for more than 10 years
• Open Standard continuously updated
• Latest Version 2.5 (Conformance Statements)
• Ballots of V3.0 - XML

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Version 2 Message Definition
RECEIVING APPLICATION (Lab System)
Trigger Event (Admit)
MESSAGE(Admission Message - ADT)
SENDINGAPPLICATION (Patient Administration)
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HL7 Has two Transaction Types
Ack
Patient is Admitted
Admit
Unsolicited Update
Trigger Event
Ack
MD request
Query
Query
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Trigger Event

• A real world event that initiates an exchange of
  messages

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Unsolicited Update

• When the transfer of information is initiated by
  the application system that deals with the
  triggering event, the transaction is termed an
  unsolicited update.
• Example Lab Manager approves results of patient
• Results are sent to the placer.

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Query and Response

• When the transfer of information is initiated by
  an application requesting information from
  another system, the transaction is termed a
  query.
• Example Request all results of a Patient.

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Message

• An atomic unit of data transferred between
  systems
• Has a Message Type that defines its purpose.
• Has a Trigger Event that defines the event.

HL7 MessageADT MessageA01 Admit
HL7 MessageADT MessageA03 Discharge
HL7 MessageADT MessageA02 Transfer
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Talking HL7

• Two systems use the same 3 messages of ver. X,
  this does not mean that these systems are able to
  communicate.
• They have to define
• exact usage of the messages
• which segments and fields of the messages are
  used,
• under what meaning and scope.

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Conformance Statement

• Is Needed to describe
• Messages supported by a product
• Messages needed by an installation
• Implementable message profiles
• Removes the abstraction of the standard
• Allows interoperability of heterogeneous systems

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(CF) An Example Order Placement

• Define the Actors
• Patient
• Doctor
• User
• Orders Sub-system
• Messaging Sub-system
• Laboratory Information System (LIS)

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Order Placement Use Case
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Dynamic Interaction Model
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Conformance Statement Example

• Preconditions
• The communication tables within the placer and
  filler systems must be configured and the routing
  of exams must be configured before orders can be
  entered and transmitted.
• Flow of Events
• The doctor will examine the patient and identify
  the examinations required and samples to be
  taken.
• The doctor/user will log on to the main system
  and select the order subsystem. The patient is
  selected and a new order is created against the
  patient.
• The examination and sample details are selected
  from the stored examination and sample lists.
• When order entry is complete the doctor/user can
  review the details and elect to confirm the
  order.
• When the order is confirmed in the order
  subsystem it is saved and the order is passed to
  the messaging subsystem.
• The messaging subsystem breaks down the order by
  examination and groups the examinations by
  destination filler system.
• Post conditions
• The order will be held in the Orders subsystem
  until it is cancelled, discontinued or the
  results are returned by the filler system and it
  gets the status complete.

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Example - Error Conditions
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Example PID Segment
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Problems we faced

• Managers of IT Departments in Hospitals cannot
  express an opinion
• Not a known Technology among Healthcare Solution
  Providers
• Partners of other Vendors-Companies say "What!
  HL7 ? What is this? Forget it... Let's build 3-4
  more tables and exchange our data...!
• Standards and Codification (LOINC etc)
• Who will map LOINC codes to Examinations used?
• Integration Solutions (Middleware) at Extreme
  costs for the Greek Market
• Investment in time, people and money

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LOINC example

• Searching GLUCOSE to map LOINC Code

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Decision to take
Peer-to-peer
Middleware

• Difficulties when need to change protocol version
• n(n-1) Interfaces needed where n Systems
  involved in the communication
• Low cost when having a maximum of 3 systems
• In House Know-How

• Each system needs a single interface
• Efficient solution More than 3 systems need to
  exchange data
• Facilitates addition of new systems
• Facilitates upgrading to newer versions

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CCS Messaging Interface

• Message A character string that contains data
  encoded according to a particular set of encoding
  rules.
• Encoding rules determine how (i.e. using what
  syntax) data elements are stored within messages.
• Messaging Interface Identifies the part of an
  application that is responsible for
• Receive, decode and process of messages
• Store the data elements of the message
• Retrieve data elements from db, encode, compose
  and transmit a new message

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First Step

• Requirement Analysis
• functional requirements and testing plan
• Use cases for data interchange
• Event-triggers
• Scope of data to exchange (dataset)

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Second Step

• Design of the Interface
• Message format
• HL7, DICOM, EDIFACT
• Good understanding of the protocol!
• Transport protocol
• TCP/IP, HTTP, File System
• Handle transfer protocol issues such as
• System and interface restarts, recovery,
  re-synchronization

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Third Step

• Implementation of the Interface
• Use a message parser to facilitate complex
  messaging
• Develop procedures to control the order and
  frequency of table maintenance
• Agree on Master Files creation and maintenance
• Create interface documentation
• Message structure
• Transport protocols

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Registries and Master Files

• Registry The application that manages the
  reference tables
• Reference tables maintain identifiers concerning
• Locations (Wards/Clinics/Healthcare providers)
• Services Results (Tests/Exams)
• Order set definitions
• Physicians (and/or Users)
• Healthcare Providers
• Define a clear procedure that maintains the
  registry
• Manual or Automated
• Example HIS System adds a new Test to the
  registry but LIMS has no knowledge of that

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Messaging Interface (Orders-Results)
Messages Received
Messages Sent

• Patient Details
• Identification (ID, Name, DOB)
• Visit Details (Visit ID, Clinic, Room etc)

• Order Details
• Test (ID, Name)
• Placer (Physician, Clinic, Comments etc)

• Order Ack
• Test (lab section to execute the test, Specimen
  ID and Bar-Code Value

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Messaging Interface (Orders-Results)
Test Vitamin B12Result 432 pg/mlNormal Values
120-970 pg/mlApproval User ADMIN
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HL7 based Installations

• Onassis Cardiac Surgery Centre
• YGEIA Hospital
• Herakleion General Hospital - Venizeleion
• 414 M. Hospital
• Ygia Polyclinic (Cyprus)

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What we need?

• More Healthcare solution providers to adopt
  Standards
• HL7, DICOM
• Services to support the MASTER FILES using
  National or International Standards
• Services (Tests, Medical Acts etc)
• Protocols, Treatment Plans
• Diagnosis
• Charge Descriptions
• Pharmaceutical products
• Unique patient identification number (PIDS?)
• Healthcare Providers
• Master Files CODIFICATION
• LOINC, ICD, Read Codes, SNOMED, ?

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Again we need codification
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What do we expect from the future?

• Interoperability
• Open Systems
• Use of International Standards
• Integration of systems and Services
• Compose the puzzle!

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HL7 Hellas

• Founded September 2003 with the mission to
• To support the development, promotion and
  implementation of HL7 standards in ways which
  meet the needs of healthcare organizations,
  health professionals and healthcare software
  suppliers in the Greece and Northeastern Europe
• Sets out to
• educate the Greek healthcare community and
  healthcare information system developers about
  HL7 standards, and promote effective and
  consistent implementation of HL7 standards in
  Greece and Northeastern Europe.
• identify and analyze Greek healthcare business
  requirements for electronic communication of
  healthcare information.
• match Greek national requirement with HL7
  messages, and if necessary, identifying the need
  for specific messages, profiles and
  implementation guides for Greece.
• report to HL7 on any specific needs of the area
  that are not met by existing HL7 standards.
• prototype and pilot with clinical and business
  validation
• Support and disseminate the standard
• Provides
• information about HL7 in a manner that is
  accessible and intelligible to a Greek healthcare
  audience through a web site containing relevant
  documents and links tutorials and meetings
  occasional papers and publications.
• education and training for systems developers
  healthcare organizations healthcare
  professionals those concerned with compliance
  requirements and conformance certification.
• encouragement for subgroups concerned with Greek
  interests in specific aspects of HL7 standards.

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Basic Principles

• is a voluntary association of interested parties
• conducts its business according to the
  requirements of its affiliation agreement with
  HL7 and the aims expressed in its mission
  statement
• Day-to-day management of HL7Hellas is carried out
  through a Management Board, drawn by election
  from the membership
• Non profit Organization

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Board
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• Thank you for your patience

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MEDILAB LIMS Architecture