Monday, May 5, 2008

Semantic Interoperability for Electronic Health Records

Whenever I lecture about standards harmonization, I'm asked how far along we are on the journey toward interoperability. First a definition of interoperability:

Technical interoperability - the ability to send a human readable record from place to place. A fax machine, secure email, and sending of free text from EHR to a PHR are examples of technical interoperability. For example, at present, Microsoft Health Vault enables documents and photos to be sent from a hospital, clinic, lab or pharmacy to a secure personal health record. Once there, they are viewable by the patient. However, at present, Microsoft Health Vault cannot combine multiple documents together to create a single uniform medication list, problem list and allergy list for the patient. Health Vault supports technical interoperability but not semantic interoperability.

Semantic interoperability - the ability to send human readable and computable records from place to place. An electronic health record with vocabulary controlled, structured problem lists, medications, labs, and radiology studies sending this data into structured lists within a personal health record is an example of semantic interoperability. Semantic interoperability ensures that decision support software can interpret the transmitted data and perform quality and safety checks such as drug/drug or drug/allergy checking. Google Health supports semantic interoperability for problems, medications, allergies and laboratories. The Continuity of Care Document, the clinical summary which has been recognized by Secretary Leavitt and the American Health Information Community (AHIC) is semantically interoperable, as detailed below.

Process interoperability - Per my recent blog about Decision Support Service Providers, wouldn't it be great if the best practices for healthcare including protocols, guidelines, care plans, and rules were transferable from one organization to another? Sending a clinical summary from one organization to another would immediately result in event driven medicine based on all the new data provided. Unfortunately, we really have not achieved this degree of interoperability.

At this point in the standards harmonization work, based on the efforts of 500 organizations working in HITSP over the past 2 years, we have achieved semantic interoperability for Electronic Health Records and Personal Health Records using the Continuity of Care Document clinical summary Here's the state of the art of interoperability:

a. Problems - CCD contains human readable and semantically interoperable problem lists, using SNOMED CT as the problem list vocabulary.
b. Medications -CCD contains human readable and semantically interoperable medication lists, using RxNorm as the medication list vocabulary.
c. Allergies - CCD contains human readable and semantically interoperable allergy lists, using UNII as the vocabulary for Food and Substance allergies and RxNorm for Medications.
d. Notes - CCD contains human readable structured and unstructured clinical notes/reports. Additional HL7 ballots over the next few months will provide even more options for structured notes via the Clinical Document Architecture.
e. Labs - CCD contains human readable and semantically interoperable lab results using LOINC vocabularies to describe the lab test and UCUM to indicate the unit of measure of the result.
f. Radiology - CCD contains human readable reports, but does not yet include images. In 2008, the HITSP Consultation and Transfer of Care use case will require us to develop interoperability specifications to share images.
g. Vital signs - CCD contains human readable and semantically interoperable vital sign measurements, using LOINC as the vocabulary to describe the site and method of measurement for each vital sign.

Thus, in 2008, we have all the standards needed to send structured information from provider to provider, from provider to patient, and from provider to public health agency. Of course, this data must be sent with appropriate security to protect the privacy of the patient. My blog entry tomorrow will describe the national, regional and local efforts that ensure confidentiality is maintained per the wishes of the patient.

11 comments:

AndyS said...

John:

Your link to the Continuity of Care Document is broken -- somehow, an extra "." has ended up at the very end of the URL. Take that off and the link will work.

Thanks for your excellent blog!

Robert said...

re: CCD. The Continuity of Care Document (CCD) has been approved by the HL7 organization and ASTM International. Here is the link with information:

http://www.ehrva.org/ASP/CCD_QSG_20071112.asp

Also here is the link to John's CCD sample:

http://www.bidmc.harvard.edu/sites/bidmc/geekdoctor/johnhalamkaccddocument.xml

willrice said...

What considerations have you / HITSP given toward including microformat markup within the CCD?

John Halamka said...

Thanks all. The link is fixed.

This week, HL7 CDA ballots will add more structured formats to the clinical summary constructs. It's likely HITSP will include these in our annual maintenance of our interoperability specifications.

David said...

John,
Thanks for your always interesting and informative blog. This one is particularly relevant because of semantic interop's importance for both EHRS and PHRS systems.

But let me observe that perhaps the language may imply more than you intended. While we have the HITSP-approved standards defined for semantic interop using CCD, it seems a stretch to say that we "have achieved" semantic interop because most EHRS and PHRS still have work to do before they support the standard, so I dare say very few of these CCDs are actually flowing between systems today.

Also, re the statement that Microsoft HealthVault can't achieve semantic interop while Google Health can: isn't that premature and controversial, since Google Health is not a GA product yet? So are you saying that, based on the Google pilots, that they already support CCD with all the HITSP-endorsed coding that you listed in this article?

Thanks,

David Tao

jcooley said...

Regarding mental health data, what information falls within this scope? A diagnosis or clinical history (major depression with suicidal thoughts, as an example) would seem to be clearly on one side of the line, but what about medications used to treat the condition? Some meds are pretty much indicative of a certain diagnosis (anti-psychotics, for example), while others (such as those used to treat insomnia) may have been prescribed for either insomnia alone or to assist with underlying insomnia related to depression.

In either case, the medications may have drug interaction potentials, side-effects, or contribute to other medical conditions (such as weight gain contributing to diabetes).

How does the access system treat medications which may be linked to mental health? Does it use different rules based upon the types of encounters (standard office check-up vs. emergency room encounter, for instance).

As an example, a doctor attempting to treat a diabetic patient may wish to be able to discern that a patient's rapid weight gain and loss of glucose control began right after starting a new psych medication prescribed by another doctor. The potential for medication interactions between the two doctors may be present, yet the patient may still be reluctant to discuss their mental health issues. How do the access rules reconcile this desire for privacy vs. the doctor's need for information to safely and effectively treat?

Is the full list of meds available at the encounter, or does the doctor have to access the "lock-box" first?

And, how does the access system handle medications/mental health where addiction and substance abuse is present? The patient has a mental health issue (addiction), but there is also a medical interest in not supplying them with OxyContin to feed that addiction and perhaps cause an overdose. How do you balance this at BIDMC?

Thanks in advance.

DASD said...

The standards that define the semantic interoperability for electronic health records have been defined in the HITSP C32 construct with the underlying CCD. The NHIN trial implementations are just now trying to implement and exchange the patient summary record. When we have had successful exchange of summary patient records between the participating NHIEs, we can say we had a successful trial implementaion, but this still doesn't mean we have achieved semantic interoperability.

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