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eHealth Practice in Europe: where do we stand?
The document discusses the current state of eHealth practices in Europe, emphasizing the adoption of information and communication technologies in healthcare, including electronic health records and telehealth. It highlights the challenges faced, such as interoperability issues, clinician workload, and the need for improved frameworks and standards in the digital health landscape. Additionally, it presents a vision for a learning health system that prioritizes patient-centered care, evidence-based practices, and enhances the usability of electronic health records.
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eHealth Practice in Europe: where do we stand?
- 1. eHealth Practice inEurope: where do we stand? Catherine Chronaki Secretary General, HL7 Foundation ESC e-Cardiology WG
- 2. eHealth Practice inEurope • eHealth as the use of Information and communication technologies in the practice of health care – Electronic health records (EHR) – Healthcare information exchange cross-jurisdictions – Personal health records – Telehealth, telemedicine and remote monitoring • Vision of the learning health system and issues with digital health • Benchmarking eHealth adoption – OECD eHealth study, WHO atlas • European Commission initiatives to support cross-border eHealth – eHealth Digital Services Infrastructure – eStandards, ASSESS CT, and openMedicine • Reflections on the role of the ESC and its members
- 3. Vision of theLearning Health System A healthcare system that • Draws on the best evidence to provide the care most appropriate to each patient, • Emphasizes prevention and health promotion, • Delivers the most value, • Adds to learning throughout the delivery of care • Leads to improvements in health. 2oo6, NIH Question: What is the role of e-health in the learning health system?
- 4. It's time toget doctors out of EHR data entry
- 5.
- 6. Concerns with wideadoption of EHRs Unintended clinical consequences of broad EHR adoption: • reduced time for patient-clinician interaction • new and burdensome data entry tasks to front-line clinicians • more patients, lengthened workdays Frustrations lead to decreased satisfaction with professional work life. Moreover: 1) Interoperability among EHR systems is nascent. 2) Electronic Health Record Systems have a steep learning curve and limited usability. Ref: Payne TH, et al. Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs. J Am Med Inform Assoc 2015;0:1–11
- 7. Atlas of eHealthCountry profiles • 126 countries, 2005, 2009, 2013, 2015, (2016) • eHealth foundations • Legal frameworks for eHealth • Telehealth • Use of eLearning in Health Sciences • Electronic Health Records (EHRs) • mHealth • Social media • Big Data
- 8. 31% 46% 78% 54% 34% 22% 40% 55% 96% 74% 55% 36% 46% 61% 93% 86% 75% 43% 0% 20% 40%60% 80% 100% Defines medical jurisdiction, liability or reimbursement of eHealth services such as telehealth Addresses patient safety and quality of care based on data quality, data transmission standards or clinical competency… Protects the privacy of personally identifiable data of individuals irrespective of whether it is in paper or digital… Protects the privacy of individuals’ health-related data held in an EHR Governs the sharing of digital data with health professionals in other health services within country with the use of an EHR Governs the sharing of digital data with health professionals in health services across countries with the use of an EHR Legal Frameworks for eHealth (1 of 2) WHO (126 countries) European Region EU+Norway+Swiss+UK
- 9. 39% 29% 32% 18% 28% 76% 65% 53% 43% 47% 34% 49% 81% 70% 68% 61% 68% 46% 68% 93% 79% 0% 20% 40%60% 80% 100% Governs the sharing of personal and health data between research entities Allows individuals electronic access to their own health-related data when held in an HER Allows individuals to demand their own health-related data be corrected when held in an EHR if it is known to be inaccurate Allows individuals to demand the deletion of health-related data from their EHR Allows individuals to specify which health-related data from their EHR can be shared with health professionals of their choice Governs civil registration and vital statistics Governs national identification management systems Legal Frameworks for eHealth (2 of 2) EU+Norway+Swiss+UK European Region WHO (126 countries)
- 10. 0% 10% 20%30% 40% 50% 60% 70% 80% 90% 100% primary care facilities manage patients online Radiology images exchange in acute care Synchronous telehealth capability in acute care access to test results online by patients e-appointment booking by patients e-request perscription renewal refill secure messaging with patients 26 10 7 0 3 3 0 5 12 8 0 2 2 4 2 9 15 31 26 26 27 Maturity of eHealth solution in 30 European Countries (OECD, EU) >75% 50-75% <50% Ref: Zelmer J, et al. International health IT benchmarking: learning from cross-country comparisons. J Am Med Inform Assoc 2016;0:1–8
- 11. European Interoperability framework •eHealth Digital Services infrastructure – Organizational framework – National Contact points – Multilateral agreements – Master value set catalogue (MVC) – Use cases • patient summaries • electronic prescription • Registries • Reference networks www.estandards-project.eu
- 12. eHealth Digital ServicesInfrastructure eHDSI or eHealth DSI is the initial deployment and operation of services for cross-border health data exchange under the Connecting Europe Facility (CEF). Focus: Patient Summary, ePrecription/eDispensation (2015-2019)
- 13. How to doeStandards for the Digital Age? At a rapid face of just-in-time disruption, Standards Developing Organizations need to cooperate • to deliver timely, affordably quality, interoperability, knowledge • to look outside • to listen to the users • to rethink standards and tools that support their full lifecycle • To deliver live eStandards June 24, 2015 eStandards Annual Review 13 Base Standards Use Case based Standards Sets Assurance and Testing Live Deployment Feedback and Maintenance Tooling and Education Forums and Monitoring
- 14. Assessing SNOMED CTfor Large Scale eHealth Deployments in the EU: recommendations. 1. need for a coherent EU Strategy for eHealth addressing adoption of terminology resources and optimizing benefits of semantic interoperability in health data 2. SNOMED CT best candidate for a core reference terminology for large-scale eHealth – part of a terminology ecosystem with WHO ICD and others, multilingualism, and clinical communication with multidisciplinary professional and lay language – Be adopted incrementally with terminology subsets for priority use cases 3. Mechanisms should be established to facilitate and co-ordinate European Member State co-operation on terminology and semantic interoperability, – common areas of governance across Terminology centres and eHealth competence centres
- 15. Equivocal identification ofmedicines When scanning the medication barcode, enhanced information appears: – Whether it is the right medication – Medication product characteristics are highlighted for the patient (e.g. Considering allergies, preconditions, etc). ID ... ... ... ... ... ... ... ... Prescribing App Patient App European Medicines Database Treatment data Product data Personal Product data
- 16. EU Patient SummaryGuideline EU patient summary guideline defines patient summary as the “minimum set of information needed to assure healthcare coordination and continuity of care” • Emergency or unplanned care refers to “the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly” • Other EHR summaries – Emergency data set – Continuity of care record – Encounter report – Discharge summary – 2nd opinion – Clinical patient summary – Disease specific summaries • Around the world many variants of the same basic types of patient summaries Dec 4, 2014
- 17. Patient Summary Clinicaldata for unscheduled care • Alerts – Allergy: Allergy description, Agent – Medical Alert information • Medical history – Vaccinations (Disease, Brand, Date) – Problem (Problem, Onset, Resolution) – Surgical Procedures (Type, Date)
- 18. Patient Summary Clinicaldata (con’t) Medical Problems • Current problems / diagnoses (description, id, onset) • Medical devices and implants (Device & implant description, id, date) • Major surgical procedures (<6 mon) • Treatment recommendations • Autonomy/Invalidity
- 19. Patient Summary Clinicaldata (con’t) Medication summary • List of current medicines – active ingredient, – brand name, – strength, – dose, – units per intake, – frequency, – duration, – onset
- 20. Patient summary forunscheduled care (con’t) • Social history • Pregnancy history • Physical findings (e.g. ABP) • Diagnostic tests – blood group Is this patient summary sufficient to you?
- 21. What do theMemberStates think about the Patient Summary Guideline? In terms of its value, availability of infrastructure, and sustainability
- 22. Status and Futuredirections of EHRs (AMIA 2020 EHR task force) • Simplify and speed documentation – decrease data entry burden for the clinician – separate clinical data entry from data reporting – EHRs enable systematic learning and research during routine practice • Refocus on regulation – improve data exchange and interoperability – reduce the need for re-entering data – prioritize patient outcomes over new functional measures • Increase transparency and streamline certification & Foster innovation – EHR vendors use standards-based application programming interfaces (APIs) and data standards to be open • EHR In 2020 must support person centered care delivery – promote the integration of EHRs into the full social context of care – Improve the designs of interfaces so that they support and build upon how people think What would be your recommendations? Ref: Payne TH, et al. Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs. J Am Med Inform Assoc 2015;0:1–11
- 23. Electronic Health Record:wish list • researchers, so they can advance our understanding of disease and health care processes; • clinicians, so they can provide safe and effective health care; • administrators, to reduce their reliance on a single-source EHR; • software developers, so they can develop innovative solutions to address limitations of current EHR user interfaces and new applications to improve the practice of medicine; and • patients, so they can access their personal health information no matter where they receive their health care. Extract Transmit Move Embed Exchange Ref: What makes an EHR “open” or interoperable? Sittig DF, Wright A J Am Med Inform Assoc 2015;0:1–3.
- 24. Learning Health SystemGoal • By 2020, 90 % of clinical decisions will be supported by accurate, timely, and up- to-date clinical information, and will reflect the best available evidence. 2oo6, NIH What can we do to make this happen? Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates (460-370BC) “. . . For the secret of the care of the patient is in caring for the patient.” Dr. Francis W. Peabody, October 21, 1925
Editor's Notes
- #3 The EHR is a shared record between the patient, the care provider teams and the institutions that pay for and provide care
- #4 I would like to start with the vision of the Learning Health System as a system that draws on best evidence to provide the most appropriate care to earch patient Emphasizing prevention and health promotion, delivering most value and adding to organization and individual learthing throughtout the delivery of care Leading to impovements in health. EHRs changes as health care itself changes: Genomic information is incorporated in care People are increasingly involved in their own care Reimbursement models are changing What are issues of concern for EHRs use in the next 5 years? What will set the stage for future innovation?
- #8 Governing the use of big data in the health sector Yes 17% Governing the use of big data by private companies Yes 8%
- #11 What is the extend to which healthcare professionals use electronic systems to store ad manage patient health information and data, as well as functionalities to support health care delivery What types of clinical and other activities are supported by electronic means
- #14 Grassroots identification of areas for cooperation among SDOs & eHeealth Stakeholders (see attached document to provide comments). #1: link the use cases for standards sets explicitly to professional clinical guidelines #2: encourage mature and shared clinical information models in health guidelines and digital health apps #3: enable the flow and mixed use of health data across jurisdictions, health record systems, and personal devices (“break down the silos”) to promote safe and effective health management and secondary use of health data. #4: Provide clarity and guidance on the regulatory framework relating to information from personal health and wellness #5: Ensure that shared European Health Terminology Service initiatives have to be extended to cover terminology for patient generated, sensor and medical device data. A standards set incorporates a use case on the care process layer and references the relevant standards, conformance assessment and implementation guidance on the underlying layers of interoperability. ). Given its global nature, a JIC standards set will not cover the details of local implementations and will not make any assumptions on the overall systems architecture. Those choices are in the realm of realisation scenarios, as detailed in the ReEIF. #5: Ensure that shared European Health Terminology Service initiatives have a scope that can be extended to cover also terminology for patient generated, sensor and medical device data. #6: Enable appropriate localisation of policy guidelines, standards sets, and realisation scenarios by supporting knowledge exchange and by strengthening conformance testing, thus preventing unintended adaptation of the underlying standards that “break” cross border or cross-realm interoperability. #7: Make sure eHealth standards and specifications are referenced in (public) procurement by making available a state-of-the-art toolkit with standards sets and realisation scenarios that also tracks their maturity. #8: Support the development and usage of open-access tools that facilitate implementation and deployment and increase the accessibility and usability of standards and specifications. #9: Detail a clear governance and maintenance process for each standards set in line with the relevant policy or professional review, the health informatics standards life cycle, and evolving processes of participating SDOs.
- #15 Any decision about the adoption and role of terminological resources, including SNOMED CT, must be part of a wider, coherent and priority-driven strategy for optimizing the benefits of semantic interoperability in health data, and of the overarching eHealth Strategy of the European Union and its Member States. SNOMED CT is the best candidate for a core reference terminology for cross-border, national and regional eHealth deployments in Europe. SNOMED CT should be part of an ecosystem of terminologies, including international aggregation terminologies (e.g., the WHO Family of Classifications), and including national user interface terminologies, which address multilingualism in Europe and clinical communication with multidisciplinary professional language and lay language. The adoption of SNOMED CT should be realised incrementally rather than all at once, by developing terminology subsets that address the interoperability requirements for prioritised use cases, and expanding this set over some years. Mechanisms should be established to facilitate and co-ordinate European Member State co-operation on terminology and semantic interoperability, including common areas of governance across national terminology centres, eHealth competence centres (or equivalent national bodies).
- #17 Understand. What is health care specific? Connect. Who do we reach out from the health system to give information? How do we reach in the health system to get information Advance. How do make digital health innovation part of the system Document. Keep track of best practice so that we don’t reinvent the wheel.
- #23 Simplify and speed documentation R1: Decrease data entry burden for the clinician R2: Separate clinical data entry from data reporting R3: EHRs should enable systematic learning and research at the point of care during routine practice Refocus regulation 1) clarifying and simplifying certification procedures and MU regulations 2) improving data exchange and interoperability 3) reducing the need for re-entering data 4) prioritizing patient outcomes over new functional measures R5: Changes in reimbursement regulations should support novel changes and innovation in EHR systems Increase transparency and streamline certification in order to improve usability and safety, to foster innovation R6. to empower providers and EHR purchasers, how a vendor satisfies a certification criterion, such as for the CEHRT program, should be flexible and transparent. R7. health care organizations, providers and vendors should be fully transparent about unintended consequences and new safety risks introduced by health information technology systems, including EHRs, as well as best practices for mitigating these risks. R8. EHR vendors should use public standards-based application programming interfaces (APIs) and data standards that will enable EHRs to become more open to innovators, researchers and patients. These standards should support extension and innovation from both the academic informatics community as well as from innovators inside and outside traditional health IT communities. Access to EHR data and functionality will drive innovation and research into better systems and empower patients to engage in their care. The public APIs and data standards should be consensus based, transparent, well documented, and openly available in a fair and non-discriminatory way. EHR In 2020 Must Support person centered care delivery R9. Promote the integration of EHRs into the full social context of care, moving beyond acute care and clinic settings to include all areas of care: home health, specialist care, laboratory, pharmacy, population health, long-term care, and physical and behavioral therapies R10. Improve the designs of interfaces so that they support and build upon how people think (i.e., cognitive-support design).
- #24 EXTREME use cases (EXtract) enables any health care organization to create a new secondary-use database (e.g., for population health management or clinical research). The second (Transmit) enables a clinician to send a copy of a patient’s record to another physician as part of a referral or to a patient’s personal health record. The third (Exchange) enables a health care organization to participate in a community-wide health-information exchange regardless of which EHR they or anyone else in the community uses. The fourth (Move) enables a health care organization to switch EHR developers without incurring extraordinary data extraction and conversion costs. The fifth (Embed) enables an organization to develop new EHR features or functionality and incorporate this new software into clinicians’ workflow within their existing EHR.
- #25 In the same NIH roundtable that articulated this vision, it was noted that by 2020, 90% of clinical decisions be supported by accurate, timely, and uptodate clinical information reflecting the best available evidence. And here we come back to patient summaries and the main question to be addressed in talk today predominately for Europe: How can patient summaries and the associated technology standards, exchange, structure, semantic ones help us support this goal of the LHS? How can we infuse patient summary standards into the experience of the workforce reinfrorcing the iterative cycle of learning? How can we make quality and safety part of the backbone of a learning health system? How do the results of the Trillium Bridge project inform this question?