© 2009 HL7 Anwendergruppe Österreich – An implementation guide for CDA laboratory reports in the Austrian electronic health record (“ELGA”) IHIC, Mense, Sabutsch, Sauermann

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Agenda  The Austrian EHR: „ELGA“  CDA Standardization – the laboratory report  Problems  Q&A

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – The Austrian EHR: „ELGA“

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – What is ELGA? ELGA (Elektronische Gesundheitsakte = EHR)  ELGA contains relevant multimedia-based and health related data and information referring to a precisely identified person.  Data und information originate from different health service providers and from the patient himself/herself and are stored in one or several different information systems (virtual health record).  Data are available independently of place and time (cost-saving) at the place of treatment for all authorized persons according to the tasks and needs of these persons and in compliance with data protection rules

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – History  2004 E-health action plan by European Commission Each member has to develop an eHealth roadmap  2005 eHealth initiative with 150 experts in 6 groups  2006 Feasiblility study for a nationwide EHR Operational unit ARGE ELGA founded  2007 Masterplan, Architecture, Standards for the first implementation phase  2008 Start of development of CDA documents

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – International Standards  IHE IT Infrastructure (ATNA, XDS, PIX, …) Patient Care Coordination  HL7 RIM CDA Rel.2  DICOM WADO (Web Access to DICOM Persistent Objects)  LOINC (Laboratory domain)

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Projects

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – ELGA Infrastructure zentraler Pat-Index GDA-Index Dokumenten Register Gateway (CCB) Protokoll- System Berechtigungs System lokaler Patienten-Index Dokumenten- Register Gateway (CCB) Berechtigungs- Verwaltung Protokoll- System aggregiert GDA System ConsumerSource GDA System Consumer Source Datenspeicher Service-Provider Datenspeicher zentraler Patienten- Index Protokoll- System Portal Consumer Source Information Berechtigungs- System Gateway (CCB) Grundversorgungsbereich ELGA lokaler Patienten- Index RLS Service-Provider Datenspeicher Externe Verbund- Ebene GDA- Ebene

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – CDA Standardization – the laboratory report

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Report Standardization  Delegated to expert groups members covering all involved occupational groups (medical experts and technicians)  Basic CDA implementation guide + addenda

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Laboratory  Experts group of about 50 persons mainly specialists in laboratory medicine (private or hospital laboratory), but also laboratory IT vendors, experts for medical informatics, and HL7 experts  Goal: develop a nationwide harmonized report definition for laboratory and microbiological studies CDA document with fully defined level 2 and level 3  Two phases Harmonizing medical content based on requirements of Austrian Society for Laboratory Medicine January 2008 – May 2008 Finish definition of harmonized medical content + microbiology studies, technical implementation December 2008 – March 2009

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Laboratory report (medical content)

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Special requirements medical content  Report structure Report sections (are not batteries)  Advanced handling of specimen information Condition, comment, responsible persons, …  Chief complaint or admission diagnosis Taken from order  Multiple reference ranges with different preconditions for one test  Subcontracting laboratory Tests have to be marked  Complex comment structure specimen, test, report section, whole report

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Evaluation …  Evaluated international work on CDA lab reports Germany (VHitG / HL7) Italy Finland IHE …  Decision for IHE XD-Lab (Lab TF – Vol. 3) VHitG model was firstly preferred but does not fulfill the Austrian requirements IHE covers most of Austrian use cases Multinational solution Also includes microbiology studies

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Vocabulary  LOINC Test codes, laboratory specialities, antibiotics  HL7 Specimen type: “SpecimenType” - German translation Specimen Collection: “SpecimenCollectionMethod” - German translation Anatomical locations: “ActSite” - German translation Specimen Condition: “SpecimenCondition” - German translation Interpretation of test results: “ObservationInterpretation” - constrained and translated to German  Unified Code for Units of Measure (UCUM)

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Constraining level 2  IHE XD-LAB contains only a number of recommendations  Acc. to IHE sections are “DRIV”  rules for mapping level 3 to level 2 required  To get a similar structure and layout for the laboratory report all over Austria it was necessary to strictly constrain the level 2 coding and the associated display of the medical content. Type of elements (e.g. specimen information) Fields (order, coding) Order of elements …

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Problems …

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Observation  Observation range (normal range) depends on preconditions for some tests Sex, age, hormonal status, …  IHE enhances model based on HL7 lab domain  Not longer CDA 2 conformant  Correct solution?

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Chief complaint & admission diagnosis  Not covered by IHE – implemented according to definitions in Germany as a own section

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Further challenges …  Coding and order of report sections List of specialities not fitting the requirements  Microbiology studies Coding “same” isolate with different cultures (ongoing discussion)  Rendering footnotes: unclear definition of and in the CDA definition. No appropriate example could be found  Hard to fulfill IHE requirements e.g. on address and telecom

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Problems Vocabulary  LOINC and other code lists: Quality assurance for translation and adoption process for Austria is neither fully defined nor finished  Coding of microorganisms (isolates) no candidate vocabulary for the coding of microorganisms, since SNOMED CT is not available in a German version and in addition: Austria is not a member of the IHTSDO  Semantics of interpretation codes

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich –  Example … Example …

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich –

© 2007 HL7 Anwendergruppe Österreich – © 2009 HL7 Anwendergruppe Österreich – Thanks for your attention