Clinical foundations and information architecture for the implementation of a federated health record service

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multi-media entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but its realisation is proving to be a long and complex journey. This Thesis explores the history and evolution of clinical information systems, and establishes a set of clinical and ethico-legal requirements for a generic EHR server. A federation approach (FHR) to harmonising distributed heterogeneous electronic clinical databases is advocated as the basis for meeting these requirements. A set of information models and middleware services, needed to implement a Federated Health Record server, are then described, thereby supporting access by clinical applications to a distributed set of feeder systems holding patient record information. The overall information architecture thus defined provides a generic means of combining such feeder system data to create a virtual electronic health record. Active collaboration in a wide range of clinical contexts, across the whole of Europe, has been central to the evolution of the approach taken. A federated health record server based on this architecture has been implemented by the author and colleagues and deployed in a live clinical environment in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. This implementation experience has fed back into the conceptual development of the approach and has provided "proof-of-concept" verification of its completeness and practical utility. This research has benefited from collaboration with a wide range of healthcare sites, informatics organisations and industry across Europe though several EU Health Telematics projects: GEHR, Synapses, EHCR-SupA, SynEx, Medicate and 6WINIT. The information models published here have been placed in the public domain and have substantially contributed to two generations of CEN health informatics standards, including CEN TC/251 ENV 13606

The open health information mediator : an architecture for enabling interoperability in low to middle income countries.

M. Sc. University of KwaZulu-Natal, Durban 2015.Interoperability and system integration are central problems that limit the effective use of health information systems to improve efficiency and effectiveness of health service delivery. There is currently no proven technology that provides a general solution in low and middle income countries where the challenges are especially acute. Engineering health information systems in low resource environments have several challenges that include poor infrastructure, skills shortages, fragmented and piecemeal applications deployed and managed by multiple organisations as well as low levels of resourcing. An important element of modern solutions to these problems is a health information exchange that enable disparate systems to share health information. It is a challenging task to develop systems as complex as health information exchanges that will have wide applicability in low and middle income countries. This work takes a case study approach and uses the development of a health information exchange in Rwanda as the case study. This research reports on the design, implementation and analysis of an architecture, the Health Information Mediator, that is a central component of a health information exchange. While such architectures have been used successfully in high income countries their efficacy has not been demonstrated in low and middle income countries. The Rwandan case study was used to understand and identify the challenges and requirements for health information exchange in low and middle income countries. These requirements were used to derive a set of key concerns for the architecture that were then used to drive its design. Novel features of the architecture include: the ability to mediate messages at both the service provider and service consumer interfaces; support for multiple internal representations of messages to facilitate the adoption of new and evolving standards; and the provision of a general method for mediating health information exchange transactions agnostic of the type of transactions. The architecture is shown to satisfy the key concerns and was validated by implementing and deploying a reference application, the OpenHIM, within the Rwandan health information exchange. The architecture is also analysed using the Architecture Trade-off Analysis Method. It has also been successfully implemented in other low and middle income countries with relatively minor configuration changes which demonstrates the architectures generalizability

Modelo interoperable del dominio de la variabilidad de la frecuencia cardíaca

Las instituciones sanitarias tienen actualmente entre sus objetivos, debido en parte al fenómeno de globalización que vivimos, el adoptar sistemas de información que les permitan realizar una gestión más e ciente y centrada en el paciente. Para ello, estos sistemas deben poder integrar y compartir la información generada en torno a un paciente con todos los sistemas implicados en el cuidado del mismo. Para poder realizar un correcto procesamiento de la información intercambiada, los sistemas, además de compartir la información, tienen que ser capaces de entenderla. Esto es lo que se conoce como interoperabilidad semántica y, a día de hoy, existen diferentes estándares que tratan de dar respuesta a esta necesidad. Entre los bene cios de aplicar estos estándares a la Historia Clínica Electrónica de un paciente (EHR, Electronic Health Record), que es el núcleo esencial de los Sistemas de Información Sanitarios, se encontrarían: redución de errores de medicación y de duplicación de pruebas, reducción del tiempo que es necesario invertir en la obtención de información crítica, mejora en la calidad de las investigaciones y posibilidad de ofrecer a los profesionales sanitarios apoyo decisorio. A pesar de que aún no se ha de nido a nivel gubernamental un marco común que establezca cual es el conjunto de estándares que deben utilizarse para alcanzar la interoperabilidad semántica, algunos parecen más prometedores que otros, como es el caso de openEHR. Este estándar se basa en una Arquitectura de Modelo Dual que permite representar de forma estructurada conceptos de un dominio de conocimiento clínico a través de lo que denomina Arquetipos. El uso de arquetipos, dentro de un contexto de investigaci ón cardiológica, para modelar el dominio de conocimiento de la Variabilidad de la Frecuencia Cardíaca (HRV, Heart Rate Variability), el cual es un parámetro que aporta información relevante sobre el estado del Sistema Nervioso Vegetativo Cardiovascular (SNVCV), permitiría realizar grandes avances ya que, aunque existen numerosos estudios en los que se utiliza este marcador, las técnicas de medida no suelen describirse correctamente en éstos y con frecuencia, debido a la complejidad de las correlaciones siológicas y siopatológicas existentes, no se tienen en cuenta todas las variables que pueden afectar a la HRV. Debido a esto, la utilidad de los resultados es limitada y se di culta el poder realizar comparaciones entre estudios para extraer conclusiones, además de que las poblaciones estudiadas no suelen ser lo su cientemente representativas. En el proyecto se aborda el objetivo de modelar el dominio de la HRV a través de arquetipos y aplicar éstos posteriormente a un caso de uso de investigación del efecto de algunas familias de fármacos en pacientes con patología cardíaca diagnosticada. El modelo nal generado, a partir de un conjunto de variables que se han validado clínicamente, se compone de 17 arquetipos desarrollados en el ámbito del proyecto, 3 arquetipos que se han especializado para el dominio objeto del proyecto y 16 arquetipos reutilizados del repositorio internacional de arquetipos de openEHR. Para documentar los conceptos del dominio clínico en el contexto especí co de nuestro caso de uso, se ha generado lo que en openEHR se conoce como Plantilla, la cual nos permite describir una estructura de datos basada en el conjunto de arquetipos que modelan el dominio de la HRV.Ingenieria de Telecomunicació

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