HL7 Version 3 in Europe A Standard in Practice

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					                HL7 Version 3 in Europe
                       A Standard in Practice

                                         Strategies & Concepts to
                                          Real Implementations

Dr. Kai U. Heitmann M.D.
Managing Consultant, Heitmann Consulting and Services (The Netherlands)
Institute for Medical Statistics, Informatics & Epidemiology, University of Cologne (Germany)
Director International Affiliates - Board of Directors HL7 USA
Chair HL7 Germany


BALTIC IT&T 2006 FORUM: eBaltics – Riga (LV) April 5-7, 2006
HL7 Version 3 in Europe
       A Standard in Practice

  eHealth Questions (and answers):
 What is HL7? And why do we need it?
            How to start?
    HL7 “Europe” and Worldwide:
       What happened so far?
          How to conclude?
eHealth Concepts - Questions
• Applications?
  – Prioritize functionality for patients & providers
• Communication?
  – Facilitate electronic data exchange
  – Allow cross-sectoral communication
• Infrastructure?
  – Highway for healthcare information
  – Dealing with Transport & Security
• Plan and Vision?
  – Analysis of Care Processes
  – Strategy and steps towards an EHR
                                                        3
Health Level Seven - The Organization
• HL7, founded 1987
• ANSI-accredited
  Standards Development
  Organization
• Approx. 2200 members
• First non-US country       ISO’s Open Systems
                             Interconnect (OSI) model:
  „joined“ early 90s         Application Level” – level 7

• Official first affiliates in 1992 (Germany,
  Canada, the Netherlands)

                                                            4
Who is HL7?
• Over 500 organizational members, about 2200
  total members
• Up to 500 attend Working Group Meetings -
  including about 20% international attendees at
• International: 33 countries
  – US
  – Affiliates in Canada, Europe, Asia-Pacific, Latin
    America, Africa




                                                        5
   HL7 International (more than 30 countries)


                        The Netherlands
                      United Germany Finland
   Canada             Kingdom Denmark Lithuania
                                     Poland
                    Ireland Switzerland Czech R     China Korea
United States         France Italy Croatia Bulgaria
                    Spain Greece Turkey       India          Japan
                                                      Taiwan
 Mexico
                                                  Malaysia
      Argentina
   Uruguay
               Brazil       Southern Africa            Australia
    Chile

                                                         New Zealand
                                                                     6
      HL7 in Europe
    • Starting point (1995) of International Activities / Affiliates
    • 16 European Affiliates                  Sweden Finland
                                                2006
                                                                  1996

                                                           Denmark
                      UK                                           2003
                      2000
                                                                         Latvia
                                                                          2006?
       Ireland                                                    Lithuania
             2003                                                        2002


      Netherlands                                                 Poland
                                                                     2003
               1996

  Germany                                          Czech Republic
      1995
                                                                  2001

        France                                      Austria
Portugal 2004                                             2006?

  2006?
        Spain
         2003
              Switzerland Italy                  Croatia Bulgaria
                                                           2005
                           2003                    2001
                      2000                                                        7
HL7 Version 3
• Basically
  – HL7 Version 3 is a family of object-oriented
    communication standards, based on the
    HL7 Reference Information Model (RIM)
  – The RIM is a worldwide accepted model for health
    information
  – Also basis for other SDOs (CEN, ISO)
  – Used in many projects and real world environments for
    more than 3 1/2 years now (Early Implementers)
• Models as a base of all products within HL7 V3
  – Symbolic structured representation of parts of the reality
  – UML (Universal Modeling Language) used
                                                                 8
Version 3 is based on models
• Models are the “common” language to express
  content, structure and interactions for
  communication
  – Content: Data types, Vocabulary
  – Structures and Semantics of the information
  – Interactions between communicating parties
• Messages are the result when putting together
  – The static model
  – The dynamic model
• Answers the question: When do I
  exchange/share what?
                                                  9
HL7 Version 3
• „Building bricks“ for
  communication models
  – Reference Information Model RIM
  – All objects, activities and their
    relationship in ONE generic
    healthcare model



  Entity        Role         Participation   Act




                                                   10
  What‘s exciting about HL7 Version 3?
• Supports cross-sectoral Care Process Chains
• Reflects international contributions/standards
• Reflects expert knowledge collected over decades
        Healthcare System
       Patient                      Aftercare


        Information flow

 General Pract                    Lab

                                        Hospital     Surg
          Specialist
                                          Rad

                                                            11
How is Version 3 “better”?
• Conceptual foundation
  – a single, common reference information model to be
    used across HL7
• Semantic foundation
  – in explicitly defined concept domains drawn from the
    best terminologies
• Abstract design methodology that is
  technology-neutral
  – able to be used with whatever is the technology de jour
    (e.g. XML, UML, etc.)


                                                              12
How is Version 3 “better”?
• Maintain a repository (database) of the
  semantic content
  – assure a single source
  – enable development of support tooling
• Tools to auto-generate XML schemas
  – for messages once the semantic content is final (via
    ballot and conformance constraints)
• Tools for documentation of constraints
  – for both message definition and conformance
    specifications

                                                           13
HL7 Version 3 in Europe
       A Standard in Practice

  eHealth Questions (and answers):
 What is HL7? And why do we need it?
            How to start?
         HL7 in “Europe”:
       What happened so far?
          How to conclude?
  Starting V3
  • Starting real life project means
    ...dealing with all these challenges & layers
     – Content
     – Exchange Format (=XML..., what else!?)
     – Transport & Security (Infrastructure / Framework,
       International solutions / standards, Legal requirements)

“payload”      “proprietary”          HL7 v3            CDA       …
content
exchange
                   HL7 |^~                     XML                …
format
transport
            MLLP     ebXML     WS-*   FTP/S    S/MIME    HTTP/S   …
security
                                                                      15
“Layers” of activities in Europe
    XML          • XML encoding and application
                   building
   HL7 v3        • V3 messaging standard
                   – early implementor projects
    CDA          • V3 based documents
Infrastructure
   Security
                 • Infrastructure and Framework
  Training       • Education



                                                  16
Drivers for v3 adoption
• Need of support for large scale integration
• V3 has “built-in” support for Complex
  Datatypes
  – “universally unique” instance identifiers for persons,
    places, organizations, practitioners, URL’s, orders,
    observations, etc.
  – internationally feasible name datatype (persons and
    organizations)
  – time and date-related datatype forms
  – codes (binding standard vocabularies to RIM attributes)


                                                              17
Drivers for v3 adoption
• V3 has “built-in” support for large scale
  integration (city, region, province, nationwide,
  international)
  – a coherent set of (structures) models guaranteeing
    semantic interoperability and re-usability
  – identifier strategy supporting wide integration
  – models and tools based design and implementation
• Support of decision support and rules-based
  processing



                                                         18
HL7 Version 3 in Europe
       A Standard in Practice

  eHealth Questions (and answers):
 What is HL7? And why do we need it?
            How to start?
         HL7 in “Europe”:
       What happened so far?
          How to conclude?
Short Trip through Europe
• Visiting some EU Activities and Activists
• HL7 Version 3 in Practice
                                   Finland
             UK
                                      Lithuania
                    Germany
                  Netherlands



                         Croatia

                                                  20
HL7 Activities in…

      Croatia
Croatia                               Infrastructure
                          HL7 v3                       Training
                                         Security

• HL7 Croatia in September 2002
  – Croatian Society for Medical Informatics (CSMI) and
    Croatian Society for Medical and Biological Engineering
    (CROMBES)
  – Supported by
     • Ministry of Health of the Republic of Croatia
     • Croatian State Office for Standardization and Metrology
     • Croatian Public Health Institute
  – Education
• National Infrastructure Project
     • WebService Based Infrastructure for the Exchange of
       Information
     • Large Mobile Phone vendor
                                                                  22
HL7 Activities in…

      Finland
Finland                                CDA
                                                Infrastructure
                                                   Security

• Use of HL7‘s Clinical Document Architecture
   – Start of activities around 2000
   – Connection implementation within four health districts in
     Finland
• HL7 Finland defined application level protocol
   – Based on ebXML
• Currently: exchange of other documents like
  referrals, prescriptions and health certificates



                                                                 24
Finland                               CDA
                                               Infrastructure
                                                  Security
• CDA Release 2
  – specifications started 2004
  – funded by MoHSW and HL7 FI (together 260 k€)
  – standarization activites build in a broad sense around
    HL7 TC (formal mandate)
• areal funding for 2004-2005 towards 2007
  – MoSHW will distribute 20 + 10 M€ for the areas
  – one technical requirement is to use HL7 CDA...




                                                                25
Specialized care epicrisis




                             26
HL7 Activities in…

  United Kingdom
United Kingdom                            Infrastructure
                                HL7 v3
                                             Security
• GP 2 GP Project
  – Early Implementor Project based on Version 3
• Infrastructure Framework
  – Support by NHS
• NHS in England:
  – Funding for several years
  – Many bn‘s of money
  – aims to connect more than 30,000 GPs and 270 acute,
    community and mental NHS Trusts in a single national
    system.

                                                           28
HL7 Activities in…

     Germany
Germany                 HL7 v3          CDA
                                                   Infrastructure
                                                      Security


• Content: SCIPHOX Project (CDA)
• Infrastructure Framework
  – Project by Ministry of Health




  – Consortium of 5 vendors/organisations
  – Introduction of the Health card for patients
  – Health professional card for providers
• HL7 Version 3 messaging (Dialysis, Lab)
                                                                    30
Germany: Cards as the key
For a Telematic Infrastructure




                                 31
The SCIPHOX project and CDA                        CDA

• uses CDA R1 model as a start
• framework for basic shared
  information (CDA Header)
  – sender, recipient, patient, event etc.
• definition of structures (CDA Body)
  – Structure of information units based on analysis
  – Story boards (discharge/referral documents, long term
    diabetes documentation, emergency info)
• Formal voting procedures for specifications
• Also activities in version 3 messaging
                                                            32
Care Record Summary (Arztbrief)
Recent development
• „discharge letter“
• Based on CDA R2
• Implementation
  Guideline
  –   150 pages
  –   Four defined use cases
  –   Numerous examples
  –   Implementation
      rules (formalized)
• Industry Driven!
                                  33
HL7 Activities in…

  The Netherlands
  Let us think about
having stable shelves...
  or a stable EHR...




                           35
The Netherlands                           Infrastructure
                               HL7 v3                       Training
                                             Security
• HL7 Project Office
   – Projects, Training (focussed on Version 3)
• National IT Institute for Healthcare
• Projects (among others)
   – Modelling the perinatology domain
      • Domain analysis, Modelling
      • Implementation guidelines
      • Proof of concept: Modelling
   – Medication Registry as one of the first steps to a EHR
     in the Netherlands
      • Implementations with several vendors at large exhibition
                                                                       36
37
HL7 Activities in…

     Lithuania
Lithuanian eHealth                                Infrastructure
                                     HL7 v3/CDA
                                                     Security

• National Infrastructure Project
• Funded by the World Bank
• HL7 Version 3
  – Facilitate electronic data exchange
  – To allow cross-sectoral communication
  – Implementation Guidelines
• Stepwise approach
  – Communication Backbone
  – “high priority” applications first
  – Preparing steps towards an EHR
                                                                   39
Lithuanian eHealth Concept
• Registries
  – Also designed as switch points
    for communication
  – Patients                      h
  – Providers
  – Generic Activities                          h                g
  – Specific Activities  Registry
  – Key roles:
     • A transportation infrastructure            Registry
       including security (“backbone”)
     • (a network of) Integration Engines       g                  s
     • connecting Hospitals (h), General Practitioners (g), Specialist
       (s) in an interoperable way
                                                                         40
HL7 Version 3 in Europe
       A Standard in Practice

  eHealth Questions (and answers):
 What is HL7? And why do we need it?
            How to start?
         HL7 in “Europe”:
       What happened so far?
          How to conclude?
 Architecture (UK, CA, DE, NL, HR, LT)
              Central/National/Regional                  GP Facility
Provider                                                 Registration Office
Portal        Service Point                              •CID/Demographics
                                                         •Social Insurance Verification
                                                         •Subscription to HCF
               Identification             Patient        •Provider Assignment
Patient                                   Registry       •Consent
Portal         Authorization                             Provider (GP)
                                                         •(appointment)
                                          Provider       •Medical history
Public
               Authentication                            •Subject./Object./Ass./Plan
                                          Registry       •Referral
Health
               Logging
Reporting                                 Organization   Specialist Facility
               Other functions            Registry       Provider (Specialist)
Legacy                                                   •Consultation Request
                                                         •Medical history
Systems        Act Reference Registry                    •Subject./Object./Ass./Plan
...                                                      •Referral


Database       Act Repository                            Lab Facility
Content        (later: „the EHR“)                        •Order
                                                         •Result
Maintenance
                                                         Pharmacy
                                                         •Prescription/Dispense


                                                         Hospitals/...
                                                         • ...
                                                                             ...
                                                                                          42
HL7 Activities Worldwide – Conclusion
• HL7 Migration in the past several years
  – ...from an US „based“ standard used mainly in hospitals
  – ...to a globally defined suite of international standards
  – ...implemented locally
  – ...with major international contribution as a feedback to
    the development process
  – ...ready (and proven) to support care process chains
• More than 80 implementation projects
  – Version 3 Messaging and Documents
  – Practical implementations
  – Feedback for the standard

                                                                43
HL7 Activities Worldwide – Conclusion
• Education required!
  – Modeling Methodology
  – Version 3 Messaging and CDA Documents
• Early implementor projects
  – Version 3 Messaging and CDA Documents
  – Practical implementations
  – Feedback for the standard
• Infrastructure Framework needed
• Funding
  – collaboration with national bodies (Ministry of Health)
                                                              44
             HL7 Calendar 2006
International HL7
Interoperability Conference




Cologne (Germany),
August 24+25, 2006
                                 45
         Paldies
   Tänan Achiu-


                           Thank you -
                           Questions?
Later? mailto: hl7@kheitmann.nl
                                         46
A word about myself
             • Dr Kai U. Heitmann
                   – Studies of medicine 1982-1988, doctor of medicine
                   – Complementary education in Medical Informatics
                   – Works in standards developing areas since 1995,
                     internationally since 1998
                   – Board Member of HL7 International, Chair HL7
                     Germany Germany
–   Contributions to HIS of University of Cologne 1994-1997, system
    introduction and integration
–   Deputy head of Medical Informatics Unit of the University of
    Cologne (Germany) 1998-2005
–   Independent Healthcare IT Consultant with head office in the
    Netherlands since January 2004
–   Involved in and finalized many communication and integration
    projects in the Netherlands, Germany, Lithuania, Australia...
                                                                         47