trillium bridge demo boston_20141020v7

Trillium Bridge: Bridging Patient Summaries across the Atlantic

EU and US Providers Exchanging Patient Summaries The case of Martha, a US Citizen and Paolo, an Italian from Lombardy

technical feasibility, live demo

Zachary Gillen, Kaiser PermanenteGiorgio Cangioli, HL7 FoundationAna Estelrich, PhastCatherine Chronaki, HL7 Foundation

2

Trillium Bridge Project: a builder perspective…

The problem The Solution

What can we do to lower the

cost of transatlantic business

engagement in eHealth?

Reduce barriers for transatlantic

coordination, health care, trade

Decrease standards development

and implementation costs

Accelerate convergence towards

global standards

Support right of citizens to their

health data and safety

Well, perhaps we could try

building..

…a Transantlantic Bridge for

EHR summaries!

• Pragmatic Feasibility study on the

exchange of Patient Summaries

across the Atlantic

• Compare, analyze, and map EU/US

patient summaries starting with

Meaningful Use 2 C-CDA/CCD and

EU patient summaries (epSOS)

• July 2013 to February 2015

• Stellar consortium of EU member

state provider networks,

associations, SDOs US Health Care

Providers

Innovative Entrepreneurs

3

Trillium Bridge: status and work aheadBuilding the Transatlantic bridge for EHR patient summaries

Completed Gap analysis

D2.2. user stories, use cases, business architecture

Identified interoperability Assets

Established STS terminology

service associating EU/US terms, D3.1

proof of concept transformer of EHR structures

and semantics

Inform and support standardization efforts

ground work of an Intl EHR patient summary

Aligning infrastructure

Refine assets, work on the puzzle through validation

Test with EU countries and US providers

Set the tone and pace for interoperability

in the global eHealth ecosystem.

Attain the vision and aims of EU-US of the

eHealth MoU and roadmap!

Selecting Grounds

Building the Bridge

Testing the Bridge

Policy Alignment

We are here

CTS-2

Trillium transformer

4

Trillium Bridge Use CasesOne Value proposition:

When patient needs unplanned care overseas, a EHR summary fit for the purpose of safe and efficient health care is available.

After the health care encounter, patient receives encounter report in a format and language that can be understood back home.

Two use cases:

Provider mediated (citizen controlled, provider initiated)

Patient mediated (citizen initiated, citizen controlled)

Blazing the transatlantic path – constraints and assumptions

Translation of narrative unstructured content (not in scope)

Incorporate patient summary elements in EHR or PHR (not in scope)

Preconditions: citizen empowerment

EU Citizens have access to their EU Patient Summary (e.g. epSOS PAC, HECR)

US Citizens have access to their Clinical Summary in C-CDA/ CCD

5

September 30th, 2014 Trillium Bridge ATR

5

Portuguese Portal

(epSOS Patient Access)

Italian (Lombardy)

Portal (epSOSPatient Access)

Spanish Portal(epSOS Patient Access Service)

EU MS National Portal(epSOS Patient

Access)

Trilliu

m

Ga

tewa

y

Tethered Personal Health Record, Health App orBlueButton+

CTS-2

Terminology Services• EU epSOS master values (MVC/MTC)• US core value sets (NLM)

Doctor visualizespatient summaryIn local language prepares report (HCER)

Get EU patientsummary Request

transform..

Martha getsher CCDVia bluebutton

Provide clinical summary

Paolo receives encounterreport in CCDA/CCD

Request transform..

Reference OpenNCP

Portal

1 2 3

4

5

6

7

Paolo has his EU Patient Summary epSOS pivot (EN)

12

Request transform..

3 4

6

Provider Mediated Case: Technical Architecture Overview

National Contact Point

(Italy)


(Spain)


(Portugal)

Trillium Bridge

Gateway(based on the epSOS Open

NCP)

IHE XCAIHE XCPDIHE ATNA

(epSOS)

Local Connector & eHealth Exchange

Gateway

Transformer

CTS-2

IHE XCAIHE XCPDIHE ATNA(eHealth Exchange)

National Contact Points

otherinterested MS

Lux, Finland, Greece, Slovenia..

MU2 C-CDA/ CCDEU Patient

Summary epSOS pivot document (EN)

Terminology Services• EU epSOS master values (MVC/MTC)• US core value sets (NLM)

7

Provider Demonstration Scenarios

Martha KP patient in Italy (cancer survivor)

Martha Faces health Emergency

Italian doctor retrieves her patient summary from US

Italian doctor sends her encounter report to the US

Paolo, an Italian in San Fransisco

Paolo looses his *new* hypertension medication

KP doctor retrieves his patient summary from Lombardy

Context

Feasibility study

Evidence-based policy development

Scope

Trillium Bridge Demonstration 8Thursday, October 23, 2014

• Demonstrate the Provider Mediated Use Case

• Show with real systems (test environment) how the European epSOS and the US eHealth Exchange networks now may technically cooperate for the purpose of

– Discovering Patients

– Exchanging Patient Summaries

Who

Provider Mediated Logical View


US -KP

THETRILLIUM GATEWAY

Architectural Overview


cmp Prov ider Mediated Ov erv iew

CTS2 based

Terminology Serv er

Name: Provider Mediated Overview

Author: Giorgio

Version: 1.1

Created: 18/10/2014 07:20:56

Updated: 18/10/2014 07:22:36

EU Terminology

Serv er

KP

Infrastructure

EU National Infrastructure

(Country X)

KP::KP

gateway

epSOS Portal

Trillium GatewayepSOS::NCP

eHealth Exchange Circle of Trust epSOS Circle of TrustKP Circle of Trust EU Country X Circle of Trust

EU PS, EU HCER

C-CDA CCD

C-CDA (Transformed)

EU PS (Transformed)

The «Magic» Team

11Thursday, October 23, 2014

Trillium Gateway(*)

with the support of

(*) EU Reference implementation funded from the

project - Gnomon


MARTHA TOKEN A KAISER PERMANENTE PATIENT

TRAVELING TO EUROPE

PAOLO CERRUTIAN ITALIAN CITIZEN TRAVELING

TO THE USA

Trillium Bridge: Behind the scenes:

WP3 - Assembling Interoperability Assets

Ana ESTELRICH

[email protected]

mailto:[email protected]

Transcoding

Wednesday Oct 22, 2014 14

Transcode – Transcoding involves finding the closest equivalent of a concept belonging to one code system in another code system. The significance of the target concepts is desired to be as identical as possible to the source concept.

Concept A Concept B

Code System SNOMED CT Code System ICD-10

OID 2.16.840.1.113883.6.96 OID 2.16.840.1.113883.6.3

version 20130901 version 20100101

Concept code 254837009 Concept code C50

Designation Malignant tumor of breast (disorder) Designation Malignant neoplasm of breast

Maps available in terminology server (http://extension.phast.fr/STS_UI) part of Trillium Gateway connection• Transcoding (mapping) – Part of a larger activity of the

Trillium Bridge WP3: Assembling Interoperability Assets

• Compared clinically, syntactically and semantically the European PS and CCD

http://extension.phast.fr/STS_UI

Section Comparison

15

epSOS/EU Directive

EU Patient

Guidelines epSOS PS CCD

Section Optionality Optionality Optionality Optionality

Allergy R R Allergies R

List of current medicines R R Medications R

List of current problems /

diagnoses R R Problem R

Surgical Procedures prior to

the past six months R O Procedures

O (R only for

inpatients)

Major Surgical Procedures in

the past six months R R Procedures

O (R only for

inpatients)

Medical Devices and

implants R R Medical Equipment O

Vaccinations O O Immunizations O

Social History Observations O O Social History O

Pregnancy history (Expected

date of delivery) O O Social History (Pregnancy Observation) O

Physical findings (Vital

Signs Observations) O O Vital Signs O

Diagnostic tests (Blood

group) O O Results Section R

Treatment Recommendations R O Plan of Care O

Autonomy / Invalidity R O Functional Status O

List of resolved, closed or

inactive problems Advance Directives O

Family History O

Payer O

Encounters O

Using same template OID, can be grouped together, only difference is the date

Text only

Not equivalent in regular specification CCD, can add as an open template, not included

4 sections not present in epSOS PS

Wednesday Oct 22, 2014

Common Denominator

16

AllergiesMedications

Problems

Pregnancy History Expected date of delivery

Vaccinations

Social History

Medical Devices

Vital Signs

Blood group

Procedures


Mapped data elements

100s of data elements, 2 types:• Structural data elements– they come across as they are: moodCode, classCode, typeCode

• Value data elements (bound to specific value sets)*

17Wednesday Oct 22, 2014

Syntactic Mapping

• XSLT transformation for the value data elements• Can range from very simple (only changing the template ID) to complex (change

template ID, change structure, map from two possible ways of expressing a data element to one or vice versa).


Value Sets Mapping (1)

• Incorrect, we never map the value sets, we see if the value sets are equivalent in their significance, then we see if the concepts they contain can be mapped between themselves.

• We will only focus on value sets that can be “mapped”

• 2 situations present:

– Value sets based on the same code system

– Value sets based on different code systems

Value set based on the same code system:1. Value sets are based on the same code system, they contain exactly the same concepts



20

2. Value sets are based on the same code system, there is partial overlap



Value Sets based on different code systems1. Official mapping exists, however it is limited

• Mapping exists between

• SNOMED CT International –ICD-10 version 2010

• SNOMED CT US Extension – ICD-10 CM version 2013 (other ICD-10 CM versions also available).

• NDF-RT – ATC

• RxNorm – ATC



• Official mapping in uni-directional (SNOMED CT-ICD10), the reverse does not exist

• The official map was used in reverse to get the mapping ICD-10-SNOMED CT

• Initially we wanted to look at one-to-one, many-to-one and one-to-many mappings

• It quickly became evident that the one-to-many mappings must be excluded as it introduces ambiguity (which term to choose to send? All? If receiving 4 terms, which one is the correct one?)

• Synonyms were counted only once

• Stringent rules were chosen in the mapping of SNOMED CT


2. In-house mapping, done one concept by one concept, in both directions:

23


ISCO-08 epSOSHealthcareProfessionalRoles ISCO_NUCC_epSOSHealthcareProfessionals_VS

NUCC CCD_Provider Type NUCC_ISCO_ProviderType_VS

SNOMED CT epSOSAllergenNoDrugs UNII_to_SNOMED CT_IngredientName_VS

UNII CCD_Ingredient Name SNOMED CT_UNII_epSOSAllergenNoDrugs_VS

EDQM Standard Terms epSOSRoutesofAdministration EDQM_NCI_epSOSRRouteofAdministration_VS

epSOSDoseForm EDQM_NCI_ epSOSDoseForm _VS

NCI Thesaurus CCD_Medication Route FDA NCI_EDQM_ Medication Route FDA _VS

CCD_Medication Product Form NCI_EDQM_ Medication Product Form _VS

SNOMED CT CCD_Problem CVX_SNOMED CT_ Vaccine Administered_VS

CVX CCD_Vaccine Administered SNOMED CT_CVX_ epSOSVaccine_VS

*Code system contains over 63, 000 concepts, only 5,300 were mapped due to limited resources


Statistics (1)

24

ATC

CVX

EDQM Standard Terms

HL7 AddressUse

HL7 AdministrativeGender

HL7 Confidentiality

HL7 EntityNamePartQualifier

HL7 RoleClass

HL7 RoleCode

ICD-10

ICD-10-CM

ISCO-08

ISO 3166-1 Country Codes

ISO 639-1

LOINC

NCI Thesaurus

NDF-RT

NUCC

RxNorm

SNOMED CT

UCUM

UNII

22 Code Systems 25 CCD value set (out of 65) 26 epSOS value set (out of 46)

CCD_ HITSP Vital Sign Result Type

CCD_Administrative Gender (HL7)

CCD_AgePQ_UCUM

CCD_Allergy/Adverse Event Type

CCD_CountryValueSet

CCD_EntityNamePartQualifier

CCD_HealthStatus

CCD_HITSPProblemStatus

CCD_HL7 BasicConfidentialityKind

CCD_INDRoleclassCodes

CCD_Ingredient Name

CCD_Language

CCD_Medication Brand Name

CCD_Medication Clinical Drug

CCD_Medication Drug Class

CCD_Medication Product Form

CCD_Medication Route FDA

CCD_Personal Relationship Role Type

CCD_Problem

CCD_Problem Type

CCD_Provider Type

CCD_Social History Type Set Definition

CCD_Telecom Use (US Realm Header)

CCD_UCUM Units of Measure

CCD_Vaccine Administered

epSOSActiveIngredient

epSOSAdministrativeGender

epSOSAdverseEventType

epSOSAllergenNoDrugs

epSOSBloodGroup

epSOSBloodPressure

epSOSCodeProb

epSOSConfidentiality

epSOSCountry

epSOSDoseForm

epSOSEntityNamePartQualifier

epSOSHealthcareProfessionalRoles

epSOSLanguage

epSOSMedicalDevices

epSOSPersonalRelationship

epSOSPregnancyInformation

epSOSProcedures

epSOSReactionAllergy

epSOSResolutionOutcome

epSOSRoleClass

epSOSRoutesofAdministration

epSOSSocialHistory

epSOSStatusCode

epSOSTelecomAddress

epSOSUnits

epSOSVaccine


Statistics (2)

25

ATC_NDF-RT_epSOSActiveIngredient_VS

ATC_RxNorm_epSOSActiveIngredient_VS

CVX_SNOMED CT_ Vaccine Administered_VS

EDQM_NCI_ epSOSDoseForm _VS

EDQM_NCI_epSOSRRouteofAdministration_VS

ICD 10 CM_SNOMED CT_epSOSIllnesses_VS

ICD 10_SNOMED CT_epSOSIllnesses_VS

ISCO_NUCC_epSOSHealthcareProfessionals_VS

NCI_EDQM_ Medication Product Form _VS

NCI_EDQM_ Medication Route FDA _VS

NDF-RT_ATC_Drug_Class_VS

NUCC_ISCO_ProviderType_VS

RxNorm_ATC_Clinical_Drug_VS

RxNorm_ATC_Medication_Brand_VS

SNOMED CT_CVX_ epSOSVaccine_VS

SNOMED CT_to_ICD 10 CM_CCD_Problem_VS

SNOMED CT_to_ICD 10_CCD_Problem_VS

SNOMED CT_UNII_epSOSAllergenNoDrugs_VS

UNII_to_SNOMED CT_IngredientName_VS

19 Association or Mappings

Terminology Assets present in the CTS2-based terminology server: http://extension.phast.fr/STS_UI/


Statistics (3)

26

Applicability of the maps to the value sets – examples:


epSOS Value Set epSOS Code

System

concepts with

corresponence/con

cepts present/

(% covered)

CCD Value Set CCD Code

System

concepts with

corresponence/con

cepts present/

(% covered)

epSOSActiveIngredient ATC 606/5592 (6%) Medication Drug

Class

NDF-RT 1365/10699 (13%)

epSOSActiveIngredient ATC 2836/5592 (51%) Medication Brand

Name

RxNorm 3329/13885 (24%)

epSOSActiveIngredient ATC 2836/5592 (51%) Medication Clinical

Drug

RxNorm 9642/31214 (31%)

epSOSAllergenNoDrugs SNOMED CT 79/112 (71%) Ingredient Name UNII 5315/63996 (8%)*

epSOSRoutesofAdminis

tration

EDQM Standard

Terms

55/73 (75%) Medication Route

FDA

NCI Thesaurus 57/118 (48%)

epSOSDoseForm EDQM Standard

Terms

28/457 (6%) Medication Product

Form

NCI Thesaurus 99/153 (65%)

epSOSIllnessesandDisor

ders

ICD-10 1775/9525 (19%)

IHTSDO maps

Problem SNOMED CT 7204/16443 (44%)

IHTSDO maps

epSOSIllnessesandDisor

ders

ICD-10 1147/9525 (12%)

NLM maps

Problem SNOMED CT 6914/16443 (42%)

NLM maps

epSOSVaccine SNOMED CT 27/31 (87%) Vaccine Administered CVX 87/163 (53%)

Common Denominator has been established!

• Files exchanged with ONC, we need to plan a rigorous QA process, subject matter experts needed in various areas

• Original code is always be sent for safety reasons

• The translated and transcoded Trillium document bears the indication that it has undergone a transformation, the original document is always available in its entirety

• Trillium Bridge WP3 performed an important Feasibility Study to prepare the road for future projects and harmonization efforts


Lessons Learned


• Alignment on vision and roadmap critical to demonstration success

• Same exchange standards (IHE XCPD and XCA) in use across networks. Different implementations of those standards observed.– Detailed gap analysis of messages to identify processing issues

– Agreement on remediation (EU or KP) for purposes of demonstration

– Teamwork

– Developed message translation engine to bridge difference between eHealth and Epsos messages and gateway requirements

• Opportunity to provide feedback to standards bodies

• Demonstrated technical feasibility. Trust, Legal, Compliance and Governance questions a greater challenge.

What’s next?

• First and foremost it is about people – You have seen that it is technically feasible to exchange

EHR data and make EU and US citizens feel safe and secure.

– Business is ready to invest, states ready to pilot

• Trillium Bridge is a paradigm that scales globally– International Patient Summary

• It is about evidence that can help shape policy– Incentives, education, clinical research, business models,

security and privacy, standardization, cross-vendor integration

• Stay tuned for the Trillium Bridge policy workshop in the beginning of 2015.


The “Trillium” Team:believers, builders, enterpreneurs

30

EU Member StatesEntrepreneursUS Health Care Providers Standards Developing Organizations