Estonian ehealth Integration. Artur Novek Estonian ehealth Foundation Implementation manager / Architect

Transcription

1 Estonian ehealth Integration Artur Novek Estonian ehealth Foundation Implementation manager / Architect

2 Tartu University 1999 BSc in Mathematical Statistics 1998 AS Piksel Programmer AS Medisoft Programmer AS Medisoft Development Director 2008 Estonian ehealth Foundation Implementation Manager / Architect Artur Novek I have worked in ehealth related projects Health board IS Healthcare IS for Family Doctor Healthcare IS for Hospital Estonian State Agency of Medicines IS Estonian Genome Project s Data Collection Module Estonian Health Information System Electronic Health Records Module Digital Registration Module Statistics Module Authentication and Authorization Module

3 Estonian ehealth Foundation organization Ministry of Social Affars Society of Family Doctors Tartu University Clinic East Tallinn Central Hospital Union of Estonian Medical Emergency North Estonian Regional Hospital Estonian Hospital Association Estonian ehealth Foundation Board Standards development Services development Management board ENHIS Operation Support (Communication, accounting, HR, lawyer, security ) Administrators IT management Helpdesk Programmers, testers

4 Estonian ehealth, where do you come from? 4

5 90-s. Local systems, focus on insurance bills Restoration of Estonian independence Association of insurance funds Central insurance fund AS Medisoft program for family doctors Central Health insurance fund with 4 departments HIS ESTER in Mustamäe hospital HIS ESTER2 by social ministry HIS ESTER3 by social ministry Mandatory electronic bills to insurance fund

6 health information exchange, focus on health data Planning initiated Project preparation ( ) ehealth Foundation established ehealth Projects ( ) eprescription X-road first services Funding decision by Ministry of Economic Affairs National HIS Electronic Health Record Digital Images Digital Prescription Digital Registration

7 Legal environment of ehealth The Health Information System Act (parliament ) Regulates maintenance of the Health Information System Lay down the necessary requirements to the health service provider and patient rights Government regulatory act of Health Information System Ministerial act for digital documentation Documentation data sets, implementation schedules Updated regulary

8 Estonian ehealth, where are you?

9 ehealth services in Estonia Cross Border Data Exchange services (epsos 2013) Digital registration services econsultation services Digital picture archiving services Data and statistics services (2013) eambulance services (2015) Medical certificate services (2014) Services for dental care (2015) elaboratory services (2015) EHR services for physician and patient Supporting services Infrastructure services vi External services Subservices Services for blood center (2016) Services for Social Insurance Board Health insurance information eprescription Services Services for nurse Services for registers E-learning services for medical staff Health information services for patient Decision support services Services for homecare Existing services Near future services Future services

10 Three-layer development model of Estonian Health Information System Institutional and user level cooperation End-user software development and data exchange services Central System Database and related services User needs Process Descriptions Data sets Standards Legal Framework Training programs End-user software User Interface Data input Data Visualisation Data filters Data transmission Data transmission Central services External services Database model Infrastructure

11 Major architectural decisions of HIS Integration through Central system (Opt-out) XML based HL7 v3 (extended) messages Documents are kept in XML format (HL7 CDA R2) All structured data fields have OID-s Only final versions of clinical documents are sent into central system Reuse of national infrastructure ID card for authentication and digital signature Xroad for secure communication

12 STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists POPULATION REGISTER BUSINESS REGISTER HOSPITALS 2009 FAMILY DOCTORS 2009 PHARMACIES 2010 january SCHOOL NURSES 2010 september Estonian ehealth architecture PRESCRIPTION CENTRE 2010 january HEALTH INSURANCE FUND REGISTER X-Road, ID-card, State IS Service Register PATIENT PORTAL v2 DOCTOR PORTAL 2013 SOCIAL INSURANCE BOARD PORTAL 2012 X-ROAD GATEWAY SERVICE 2009 PHARMACIES AND FAMILY DOCTORS X-ROAD GATEWAY FOR EMERGENCY SERVICES 2014 EMERGENCY SERVICE MOBILE WORKSTATITIONS NATION- WIDE HEALTH INFORMATION SYSTEM 2008 december ANONYMIZED HEALTH DATA FOR STATISTICS 2013 STATISTICS PORTAL 2013

13 ehealth copies e-state architecture 13

14 HIS integration through X-Road HL7 CDA document Digidoc HL7 interaction Healthcare provider IS National Central HIS X-Road message

15 Document processing Lab notice Swineflu Üldandmed notice Mari-Liis Infection Üldandmed Mari-Liis notice Männi 1-2 Üldandmed Mari-Liis Tallinn Männi 1-2 Demographics Mari-Liis Diagnoos Tallinn Männi punetised Diagnoos Tallinn Männi Allergia punetised 1-2 Tallinn Diagnoos õietolm Allergia punetised Diagnosis õietolm chickenpox Allergia õietolm Allergy pollen Discharge letter Agents Health record agent Event: Medication, Diagnosis, Procedure Infection disease agent Diagnosis: chickenpox Demographics agent Address: Männi 1-2, Tallinn Timecritical report agent Allergy: pollen Health record Demographics Timecritical reports

16 Query processing Query Patient Mari-Liis Record type Diagnosis Agents Health record agent Find all diagnosis type records Health record Patsient Mari-Liis Security agent Document open? Diagnosis Diagnosis Diagnosis Diagnosis: chickenpox Document no: 103 Hospital: PERH Consolidate records Warning, some documents are closed!

17 Client systems withoud Xroad server Technical solution Client systems X-road gateway X-roads security Validation and surveillance data collection Business Logic Data Services Data Storage Segmented LAN Activity Surveillance Portals VPN access gate Monitoring Statistics Client systems - HIS, GPIS Patient portal - Oracle Portal, 2013 change to Tomcat xroad Gateway MISP (Tomcat) Activity Surveillance - Tomcat, Sybase IQ, Webfocus Business Logic - Webmethods Integration Server and Broker Data Services - Oracle DBMS with Advanced Security and Database Vault Monitoring - Nagios, Cacti Statistics Iway Service Manager, Sybase IQ, Webfocus

18 SECURITY & AUTHENTICATION

19 The 6 main principles 6 whales of security of Estonian ehealth system 1. A secure authentication of all users with ID-card or Mobile ID 2. Digital signing or stamping of all medical documents 3. A maximum accountability (transparency): all actions will leave an unchangeable (and unremovable) secure trail 4. Coding of personal data: separating of personal data from medical data 5. Encrypted database that allows to remove the confidentiality risk from the technical administrators 6. Monitoring of all actions together with the corresponding countermeasures (both organizational and technical)

20 Patient portal new design (live 2013 june)

21 STANDARDS

22 Standards HL7 and DICOM (Picture Archive) International classifications Diseases ICD-10 Laboratory analysis LOINC Medical procedures NCSP Medicines - ATC Estonian ehealth s OID registry Local ehealth classificators Published in publishing centre Classificators are regulated by government act

23 Acceptance eprescription covers 100% of issued prescriptions. 98% of prescriptions are issued digitally, remaining 2% is entered by pharmacies Over 95% of inpatient consultation notes are sent to the central DB Outpatient consultation notes sending No certain rules for sending Outpatient consultation notes! person have documents 23

24 HIS document count ( ) Document type Count Out-patient consultation notes Other 3 % Referral answer DICOM image references In-patient consultation notes Referral Immunization notification Children Health check notifications Emergency care summary Home nursing summary Referral answer 25 % DICOM image references 14 % In-patient consultation notes 8 % Out-patient consultation notes 50 % Total

25 eprescription (94%) ISSUED SOLD

26 HIS documents per month

27 Healthcare Professionals HIS queries per month

28 Patient portal queries per month

29 European Hospital Survey: Benchmarking Deployment of е-health Services 2012 Deployment Composite Indicator comparison with 2010 index

30 European Hospital Survey: Benchmarking Deployment of е-health Services 2012 The Availability and Use Composite Indicator

31 Estonian ehealth, where do you get the money? 31

32 HEALTHCARE IN ESTONIA 30 hospitals 512 family doctors (juridical persons) Healthcare expenditures % from GDP mlj. EUR

33 ehealth Foundation financing Year Expenditure ( ) Health Insurance Fund Healthcare Provider Taxes Ministry of Social Affairs ehealth Foundation EU Funds Ministry of Economic Affairs and Communication 12% 64% 24% 2013 Without EU financing 1/3 from HCP-s and 2/3 from Social Ministry

34 EU funded projects Estonian ehealth Foundation Electronic Health Record (1.6 mln ) Digital Registration (0.2 mln ) Digital Images (0.2 mln ) Activity surveillance module (0.4 mln ) Statistics module (0.4 mln ) Authentication and authorization module (0.2 mln ) elaboratory (0.2 mln ) Health Insurance Fund Digital Prescription (0.24 mln )

35 Estonian ehealth, what did you learn?

36 Lessons learned Resources were planned only for central development. Usability. Developing process has to include medical competence users Data quality is important Complete and quality data give value Balance between security and usability PIN for every document

37 Digital stamp for family doctors Documents Sent by GPs in 2012 and 2013 (1st Quarter)

38 IT lessons learned Stronger service definitions and agreements support later implementation and maintenance Scope, level, owner and user of a service defined Data quality measures should be there from the beginning Close the feedback loop early Pay attention to canonical datastructure strategy to support long term development Cross standard version data queries, classification and datastructure versions Have PoCs and pilots for faster learning Collect low-hanging fruits fast Reuse existing infrastructures and services Beware of limited service level of existing services though! Keep IT portfolio under control Build internal know-how on strategic platforms/applications

39 Estonian ehealth, where are you going?

40 Estonian E-health strategy 2020 in development Domains in focus Quality of health data and infrastructure Orientation to person and personalized medicine Integral case handling and organizational cooperation Performance and quality of services evaluation / analytics Remote services Workgroups - services, architecture, justice, research and development, international cooperation, management and financing

41 E-services development principles in strategy Data usage should be open Person has right to give his data in machine-readable format to anyone. The prerequisite is the patient s informed consent. Privacy and data protection should be guaranteed in crossusage environment. Person has to know, who and why is using his data and manage access rights Data quality Collected data has to conform to the standards Single data input, multiple usage

42 Requirements from architecture workgroup Data is stored and computed by multiple participants system should be distributed, avoid data copying Data is stored in automatically processable data groups full document is too big data group Centrally managed workflow of authorization of IT solutions is needed Central management of access rights is needed Data from multiple providers should be combined to be used as unified health story Repository of medical guidlines for doctor and patient Machine-readable guidlines for decision support Ensure that data used in medical treatment decisions is fixed and later available

43 Better services from ehealth Foundation Faster data input Voice recognition, statistics based text input assistant Faster and better output Important information on one screen Combining information from multiple sources Graphical solutions Precaching Single sign on

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45 App Store Tablet PC PC Mobile Integration platform Notebook ehealth central system Hospital information system RIS / PACS

46 App Store Speciality based applications

47 Personalized medicine proposes the customization of healthcare - with medical decisions, practices, and/or products being tailored to the individual patient. The use of genetic information has played a major role in certain aspects of personalized medicine, Over donors in database Combining information from these two systems creates possibilty to develope personal medicine applications. Over citizens have documents in database

48 Questions?

49 Thank you!