Using the ResearchEHR platform to facilitate the practical application of the EHR standards

Possibly the most important requirement to support co-operative work among health professionals and institutions is the ability of sharing EHRs in a meaningful way, and it is widely acknowledged that standardization of data and concepts is a prerequisite to achieve semantic interoperability in any domain. Different international organizations are working on the definition of EHR architectures but the lack of tools that implement them hinders their broad adoption. In this paper we present ResearchEHR, a software platform whose objective is to facilitate the practical application of EHR standards as a way of reaching the desired semantic interoperability. This platform is not only suitable for developing new systems but also for increasing the standardization of existing ones. The work reported here describes how the platform allows for the edition, validation, and search of archetypes, converts legacy data into normalized, archetypes extracts, is able to generate applications from archetypes and finally, transforms archetypes and data extracts into other EHR standards. We also include in this paper how ResearchEHR has made possible the application of the CEN/ISO 13606 standard in a real environment and the lessons learnt with this experience. © 2011 Elsevier Inc..This work has been partially supported by the Spanish Ministry of Science and Innovation under Grants TIN2010-21388-C02-01 and TIN2010-21388-C02-02, and by the Health Institute Carlos in through the RETICS Combiomed, RD07/0067/2001. Our most sincere thanks to the Hospital of Fuenlabrada in Madrid, including its Medical Director Pablo Serrano together with Marta Terron and Luis Lechuga for their support and work during the development of the medications reconciliation project.Maldonado Segura, JA.; Martínez Costa, C.; Moner Cano, D.; Menárguez-Tortosa, M.; Boscá Tomás, D.; Miñarro Giménez, JA.; Fernández-Breis, JT.... (2012). Using the ResearchEHR platform to facilitate the practical application of the EHR standards. Journal of Biomedical Informatics. 45(4):746-762. doi:10.1016/j.jbi.2011.11.004S74676245

The Iranian Integrated Care Electronic Health Record

E-health plays a crucial role in E-government by proposing healthcare services based on information technology. However, the way to administer these services by using E-health solutions is one of the challenging issues. One of these significant challenges is how one integrates heterogeneous healthcare information of the different point of care systems. This paper introduces the Iranian integrated care electronic health record using the information gathered from several point-of-care systems in healthcare enterprises in Iran. This service-oriented architecture has a remarkable characteristic - its accessibility to medical knowledge and medical concepts through archetypes and ontology, respectively. The Ministry of Health and Medical Education of the Islamic Republic of Iran has designed and implemented this national architecture

Messaging standard requirements for electronic health records in Islamic republic of Iran: A delphi study Critères des normes de messagerie pour les dossiers de santé électroniques en République islamique d�Iran: Une étude selon la méthode de Delphes

The present descriptive�comparative study was conducted to give an overview of the messaging standards that are necessary for interoperable electronic health records (EHRs). We designed a preliminary model after data collection and compared the messaging standards of Health Level Seven (HL7) and the International Organization for Standardization (ISO). The data were assessed with the Delphi technique. A comprehensive model for the messaging standards of EHRs in the Islamic Republic of Iran was presented in three pivots: structural characteristics (standard for all EHRs, XML-based and object-oriented messages, and dual model); model specifications (reference model, archetypes and classes of reference model), and general features (distinct ontology, mapping with other standards, and using reference archetypes for exchanging documents). In conclusion, we gave an overview of messaging standards for the interoperability of EHRs and experts selected ISO13606 as a suitable standard for the Islamic Republic of Iran. © 2016, World Health Organization. All rights reserved

Principles and Standards for Designing and Managing Integrable and Interoperable Transformed Health Ecosystems

The advancement of sciences and technologies, economic challenges, increasing expectations, and consumerism result in a radical transformation of health and social care around the globe, characterized by foundational organizational, methodological, and technological paradigm changes. The transformation of the health and social care ecosystems aims at ubiquitously providing personalized, preventive, predictive, participative precision (5P) medicine, considering and understanding the individual’s health status in a comprehensive context from the elementary particle up to society. For designing and implementing such advanced ecosystems, an understanding and correct representation of the structure, function, and relations of their components is inevitable, thereby including the perspectives, principles, and methodologies of all included disciplines. To guarantee consistent and conformant processes and outcomes, the specifications and principles must be based on international standards. A core standard for representing transformed health ecosystems and managing the integration and interoperability of systems, components, specifications, and artifacts is ISO 23903:2021, therefore playing a central role in this publication. Consequently, ISO/TC 215 and CEN/TC 251, both representing the international standardization on health informatics, declared the deployment of ISO 23903:2021 mandatory for all their projects and standards addressing more than one domain. The paper summarizes and concludes the first author’s leading engagement in the evolution of pHealth in Europe and beyond over the last 15 years, discussing the concepts, principles, and standards for designing, implementing, and managing 5P medicine ecosystems. It not only introduces the theoretical foundations of the approach but also exemplifies its deployment in practical projects and solutions regarding interoperability and integration in multi-domain ecosystems. The presented approach enables comprehensive and consistent integration of and interoperability between domains, systems, related actors, specifications, standards, and solutions. That way, it should help overcome the problems and limitations of data-centric approaches, which still dominate projects and products nowadays, and replace them with knowledge-centric, comprehensive, and consistent ones

An experimental study and evaluation of a new architecture for clinical decision support - integrating the openEHR specifications for the Electronic Health Record with Bayesian Networks

Healthcare informatics still lacks wide-scale adoption of intelligent decision support methods, despite continuous increases in computing power and methodological advances in scalable computation and machine learning, over recent decades. The potential has long been recognised, as evidenced in the literature of the domain, which is extensively reviewed. The thesis identifies and explores key barriers to adoption of clinical decision support, through computational experiments encompassing a number of technical platforms. Building on previous research, it implements and tests a novel platform architecture capable of processing and reasoning with clinical data. The key components of this platform are the now widely implemented openEHR electronic health record specifications and Bayesian Belief Networks. Substantial software implementations are used to explore the integration of these components, guided and supplemented by input from clinician experts and using clinical data models derived in hospital settings at Moorfields Eye Hospital. Data quality and quantity issues are highlighted. Insights thus gained are used to design and build a novel graph-based representation and processing model for the clinical data, based on the openEHR specifications. The approach can be implemented using diverse modern database and platform technologies. Computational experiments with the platform, using data from two clinical domains – a preliminary study with published thyroid metabolism data and a substantial study of cataract surgery – explore fundamental barriers that must be overcome in intelligent healthcare systems developments for clinical settings. These have often been neglected, or misunderstood as implementation procedures of secondary importance. The results confirm that the methods developed have the potential to overcome a number of these barriers. The findings lead to proposals for improvements to the openEHR specifications, in the context of machine learning applications, and in particular for integrating them with Bayesian Networks. The thesis concludes with a roadmap for future research, building on progress and findings to date

Creating archetypes for patient assessment with nurses to facilitate shared patient centred care in the older person

The process of what information is captured in documenting patient care assessment and how it is summarised, communicated and interpreted by nurses across different healthcare services is the main focus of this thesis. Currently in Ireland, systems within the domain of healthcare are undergoing transformation. Existing practices where health information is collected at one local health organisation level and often duplicated across differing services will not support the strategic goals of the newly established clinical directorates. The political vision is simple: Ireland must move towards a nationally integrated electronic record to support patient centred care. Whilst the political vision may be simple, the process of implementation is not and forms the main topic of this thesis. Strategic goals to move nationally towards integrated electronic records are motivated by the global concerns of an ageing population associated with an increase in the prevalence of chronic illness and co-morbidity. The main objective of this thesis is to evaluate the impact of a pilot study which identified the semantic and syntactic clinical requirements for the testing and implementation of a shared discharge/transfer summary assessment record for persons over the age of 65. This summary record was designed in accordance with ISO 13606, the International standard for Electronic Healthcare Record (EHR) communication and is underpinned by ISO 18104, the international standard for Categorial Structures for Representation of Nursing Diagnosis and Nursing Actions in Terminological Systems. A participatory action research approach was adopted, using an exploratory mixed methods research study design. This translational study was completed in two local health organisation areas in Dublin with six service providers across the primary, acute and continuing care services over a two year period. The qualitative element of the study involved 17 interviews, 7 focus group sessions with participants including policy makers and nurses from each of the participating services. Quantitative data included questionnaires from nurses (n = 14) and patients (n=5) evaluating the effectiveness of the summary record. The quantitative data also analysed information from a set of cumulative assessment records (n = 16) which were interpreted in tandem with the qualitative data and then analysed statistically. The shared discharge/transfer summary care record was piloted on 16 patients over an extended timeframe. The quantitative data showed a statistical significance commensurate with the qualitative data collected on patient participants. An evaluation of the pilot study produced qualitative data which was used to gain insight into the differing contexts that healthcare professionals practice within. This data was illustrated in graphical configurations to make evident to policy makers the various roles that nurses engage with in the course of their care delivery. Data collected from both the qualitative and quantitative analysis suggest that the test implementation of the record template was fit for purpose. Identification of the clinical requirements and testing of the summary record over a two year period was a labour intensive process which was logistically difficult to implement. One consequence of this study was the education of the nursing participants on gaining a common understanding of what needs to be measured in patient assessment to inform future theory testing for outcome based research. A second consequence was the empowerment of the nursing participants to develop archetypes for inclusion in future electronic healthcare records in Ireland. The prototype archetypes designed for assessment of the older person in this study are at present informing a number of practical applications within the nursing community in Ireland. Over the course of the study the participatory action research design altered in its focus and emerged as a dominant qualitative mixed methods study

Quality framework for semantic interoperability in health informatics: definition and implementation

Aligned with the increased adoption of Electronic Health Record (EHR) systems, it is recognized that semantic interoperability provides benefits for promoting patient safety and continuity of care. This thesis proposes a framework of quality metrics and recommendations for developing semantic interoperability resources specially focused on clinical information models, which are defined as formal specifications of structure and semantics for representing EHR information for a specific domain or use case. This research started with an exploratory stage that performed a systematic literature review with an international survey about the clinical information modelling best practice and barriers. The results obtained were used to define a set of quality models that were validated through Delphi study methodologies and end user survey, and also compared with related quality standards in those areas that standardization bodies had a related work programme. According to the obtained research results, the defined framework is based in the following models: Development process quality model: evaluates the alignment with the best practice in clinical information modelling and defines metrics for evaluating the tools applied as part of this process. Product quality model: evaluates the semantic interoperability capabilities of clinical information models based on the defined meta-data, data elements and terminology bindings. Quality in use model: evaluates the suitability of adopting semantic interoperability resources by end users in their local projects and organisations. Finally, the quality in use model was implemented within the European Interoperability Asset register developed by the EXPAND project with the aim of applying this quality model in a broader scope to contain any relevant material for guiding the definition, development and implementation of interoperable eHealth systems in our continent. Several European projects already expressed interest in using the register, which will now be sustained by the European Institute for Innovation through Health Data

Combining ontologies and rules with clinical archetypes

Al igual que otros campos que dependen en gran medida de las funcionalidades ofrecidas por las tecnologías de la información y las comunicaciones (IT), la biomedicina y la salud necesitan cada vez más la implantación de normas y mecanismos ampliamente aceptados para el intercambio de datos, información y conocimiento. Dicha necesidad de compatibilidad e interoperabilidad va más allá de las cuestiones sintácticas y estructurales, pues la interoperabilidad semántica es también requerida. La interoperabilidad a nivel semántico es esencial para el soporte computarizado de alertas, flujos de trabajo y de la medicina basada en evidencia cuando contamos con la presencia de sistemas heterogéneos de Historia Clínica Electrónica (EHR). El modelo de arquetipos clínicos respaldado por el estándar CEN/ISO EN13606 y la fundación openEHR ofrece un mecanismo para expresar las estructuras de datos clínicos de manera compartida e interoperable. El modelo ha ido ganando aceptación en los últimos años por su capacidad para definir conceptos clínicos basados en un Modelo de Referencia común. Dicha separación a dos capas permite conservar la heterogeneidad de las implementaciones de almacenamiento a bajo nivel, presentes en los diferentes sistemas de EHR. Sin embargo, los lenguajes de arquetipos no soportan la representación de reglas clínicas ni el mapeo a ontologías formales, ambos elementos fundamentales para alcanzar la interoperabilidad semántica completa pues permiten llevar a cabo el razonamiento y la inferencia a partir del conocimiento clínico existente. Paralelamente, es reconocido el hecho de que la World Wide Web presenta requisitos análogos a los descritos anteriormente, lo cual ha fomentado el desarrollo de la Web Semántica. El progreso alcanzado en este terreno, con respecto a la representación del conocimiento y al razonamiento sobre el mismo, es combinado en esta tesis con los modelos de EHR con el objetivo de mejorar el enfoque de los arquetipos clínicos y ofrecer funcionalidades que se corresponden con nivel más alto de interoperabilidad semántica. Concretamente, la investigación que se describe a continuación presenta y evalúa un enfoque para traducir automáticamente las definiciones expresadas en el lenguaje de definición de arquetipos de openEHR (ADL) a una representación formal basada en lenguajes de ontologías. El método se implementa en la plataforma ArchOnt, que también es descrita. A continuación se estudia la integración de dichas representaciones formales con reglas clínicas, ofreciéndose un enfoque para reutilizar el razonamiento con instancias concretas de datos clínicos. Es importante ver como el acto de compartir el conocimiento clínico expresado a través de reglas es coherente con la filosofía de intercambio abierto fomentada por los arquetipos, a la vez que se extiende la reutilización a proposiciones de conocimiento declarativo como las utilizadas en las guías de práctica clínica. De esta manera, la tesis describe una técnica de mapeo de arquetipos a ontologías, para luego asociar reglas clínicas a la representación resultante. La traducción automática también permite la conexión formal de los elementos especificados en los arquetipos con conceptos clínicos equivalentes provenientes de otras fuentes como son las terminologías clínicas. Dichos enlaces fomentan la reutilización del conocimiento clínico ya representado, así como el razonamiento y la navegación a través de distintas ontologías clínicas. Otra contribución significativa de la tesis es la aplicación del enfoque mencionado en dos proyectos de investigación y desarrollo clínico, llevados a cabo en combinación con hospitales universitarios de Madrid. En la explicación se incluyen ejemplos de las aplicaciones más representativas del enfoque como es el caso del desarrollo de sistemas de alertas orientados a mejorar la seguridad del paciente. No obstante, la traducción automática de arquetipos clínicos a lenguajes de ontologías constituye una base común para la implementación de una amplia gama de actividades semánticas, razonamiento y validación, evitándose así la necesidad de aplicar distintos enfoques ad-hoc directamente sobre los arquetipos para poder satisfacer las condiciones de cada contexto

Combining ontologies and rules with clinical archetypes

Al igual que otros campos que dependen en gran medida de las funcionalidades ofrecidas por las tecnologías de la información y las comunicaciones (IT), la biomedicina y la salud necesitan cada vez más la implantación de normas y mecanismos ampliamente aceptados para el intercambio de datos, información y conocimiento. Dicha necesidad de compatibilidad e interoperabilidad va más allá de las cuestiones sintácticas y estructurales, pues la interoperabilidad semántica es también requerida. La interoperabilidad a nivel semántico es esencial para el soporte computarizado de alertas, flujos de trabajo y de la medicina basada en evidencia cuando contamos con la presencia de sistemas heterogéneos de Historia Clínica Electrónica (EHR). El modelo de arquetipos clínicos respaldado por el estándar CEN/ISO EN13606 y la fundación openEHR ofrece un mecanismo para expresar las estructuras de datos clínicos de manera compartida e interoperable. El modelo ha ido ganando aceptación en los últimos años por su capacidad para definir conceptos clínicos basados en un Modelo de Referencia común. Dicha separación a dos capas permite conservar la heterogeneidad de las implementaciones de almacenamiento a bajo nivel, presentes en los diferentes sistemas de EHR. Sin embargo, los lenguajes de arquetipos no soportan la representación de reglas clínicas ni el mapeo a ontologías formales, ambos elementos fundamentales para alcanzar la interoperabilidad semántica completa pues permiten llevar a cabo el razonamiento y la inferencia a partir del conocimiento clínico existente. Paralelamente, es reconocido el hecho de que la World Wide Web presenta requisitos análogos a los descritos anteriormente, lo cual ha fomentado el desarrollo de la Web Semántica. El progreso alcanzado en este terreno, con respecto a la representación del conocimiento y al razonamiento sobre el mismo, es combinado en esta tesis con los modelos de EHR con el objetivo de mejorar el enfoque de los arquetipos clínicos y ofrecer funcionalidades que se corresponden con nivel más alto de interoperabilidad semántica. Concretamente, la investigación que se describe a continuación presenta y evalúa un enfoque para traducir automáticamente las definiciones expresadas en el lenguaje de definición de arquetipos de openEHR (ADL) a una representación formal basada en lenguajes de ontologías. El método se implementa en la plataforma ArchOnt, que también es descrita. A continuación se estudia la integración de dichas representaciones formales con reglas clínicas, ofreciéndose un enfoque para reutilizar el razonamiento con instancias concretas de datos clínicos. Es importante ver como el acto de compartir el conocimiento clínico expresado a través de reglas es coherente con la filosofía de intercambio abierto fomentada por los arquetipos, a la vez que se extiende la reutilización a proposiciones de conocimiento declarativo como las utilizadas en las guías de práctica clínica. De esta manera, la tesis describe una técnica de mapeo de arquetipos a ontologías, para luego asociar reglas clínicas a la representación resultante. La traducción automática también permite la conexión formal de los elementos especificados en los arquetipos con conceptos clínicos equivalentes provenientes de otras fuentes como son las terminologías clínicas. Dichos enlaces fomentan la reutilización del conocimiento clínico ya representado, así como el razonamiento y la navegación a través de distintas ontologías clínicas. Otra contribución significativa de la tesis es la aplicación del enfoque mencionado en dos proyectos de investigación y desarrollo clínico, llevados a cabo en combinación con hospitales universitarios de Madrid. En la explicación se incluyen ejemplos de las aplicaciones más representativas del enfoque como es el caso del desarrollo de sistemas de alertas orientados a mejorar la seguridad del paciente. No obstante, la traducción automática de arquetipos clínicos a lenguajes de ontologías constituye una base común para la implementación de una amplia gama de actividades semánticas, razonamiento y validación, evitándose así la necesidad de aplicar distintos enfoques ad-hoc directamente sobre los arquetipos para poder satisfacer las condiciones de cada contexto