Transcript Document

Integration projects
and HL7 implementation
at
Wrightington, Wigan & Leigh
NHS Trust
Philip Firth
IM&T Strategy Implementation Manager
Wrightington, Wigan & Leigh NHS Trust
[email protected]
Introduction

Background to projects in Wigan Acute

Look at some of the integration issues that Acute
Hospital NHS Trusts typically need to address

Look at an example project with complex
integration needs – Accident & Emergency

Look at requirements for linking Acute Hospital
NHS Trust systems to LSP solutions and the
Spine
Existing Systems Integration
- Maximizing local IT investment
- Delivering functionality which meets
local requirements
- Delivering functionality which maybe
out of scope for NPfIT
Current integration
architecture at WWL
Acute Systems
Integration
Typical Issues
Standards - what standards???

Interface standards/output formats in Wigan
– HL7 v2 (various implementations of)
– EDIFACT
– ASTM
– System specific output – eg. Torex PAS
openlink
 Acute
Trusts need to learn to work
with what’s available !!!
Implementation issues - PAS

PAS ‘real-time’ interface

No guarantee that messages would be delivered in
the right order
– Could get an Admission message prior to a Patient
Registration

Had to introduce a 15 minute time delay

Result: bed-status in EPR system slightly out of sink
Implementation issues - Pathology

Handling previous results – append or overwrite?
– Microbiology – overwrite
– Haematology, Chemistry – currently append

Collection date and time not always supplied
 Reference ranges can change
– Implication for graphing

Sensitive tests
– What is the best way to deal with HIV, GUM, pregnancy
tests etc?
Implementation issues - Pathology

Multiple patient IDs (NHS number, Hospital number)
 Multiple casenote numbers (Trust mergers)
– Need to establish systems for cross referencing patient IDs

Missing patient ID
 Pathology system sending internal patient ID
 Missing key patient data – DOB, Gender
– Unable to guarantee a match – need to Dump message
Data Quality

Biggest issue by far is unique person referencing

Major education / change mgmt task to
– Get patient administration staff to register patient
details accurately and avoid duplicates
– Get clinicians to use the Hospital / NHS Number

Problem especially big in emergency care

Issue has a huge knock on effect for the
remainder of each episode care
Data Quality
Example:
A consultant asked me to investigate why a particular chemistry result
did not appear in the patient’s EPR record
In this instance the patient ID recorded in the Hospital Number field
turned out to be the patient’s telephone number
MSH|^~\&|MLAB||||20040519113446||ORU^R01|X99156|P|2.3
PID|1||217779^^^^PAS~773702^^^^DEP||SURNAME^FORENAME^^^||19371113|M|||999 ACACIA AVENUE^ORRELL^WIGAN^^WN9
9XX|||||
ZMP|G3417810^^NAT^SS^^L|^^L
ZPV|AE|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|CAS^^^MLAB&RAEI&L^^W|&AP^PINTO^A.^^^Mr.|ACC|CC|CH|20177803|2004
0519|200405191026||FITS.|U||P
OBR|1||20177803^CCMLAB|CC_RUEGK^Urea, Elects. Gluc
(urgent)^L^^^L|||20040519||||||FITS.|200405191026||&AP^PINTO^A.^^^Mr.||||||||CH|F||^^^20040519^S|
OBX|1|ST|CC_TONA^Sodium^L^44I5.^^RC||140|mmol/L|135-145|N|||F
Lesson: CANNOT use patient ID as the sole identifier – also need
to cross reference with patient’s DOB, Gender, Surname …
Addressing data quality
issues in Casualty

Solution Integrated emergency floor system

New emergency floor system is integrated with
PAS to enable staff to retrieve up-to-date patient
demograhics, including NHS Number

New emergency floor Pathology / X-ray requests
automatically include patient ID
- improvement departmental system data quality

New emergency floor system will be able to
automatically register new patients on PAS
- improvement 24 hour bed status
Addressing data quality
issues in Casualty
Integrated
emergency system
live
Patient ID data quality
Percentage requests
with valid patient ID
100
80
60
40
20
0
1.1.04
1.3.04
1.5.04
1.7.04
Time
1.9.04
1.11.04
Addressing data quality
issues in Casualty
Issues that are not so easy to address …

Real-time data capture
– Not easy when an A&E receptionist is face to face with
a patient who is either
•
•
•
•
Confused
Uncooperative
Abusive
Unconscious
– Addressing these issues is proving to be a much more
challenging task!!!
Addressing presentation issues
using XSL Stylesheets
Rapid application development approach :
(1) Present the HL7 results in the EPR test system
environment via a stylesheet, and ask the
domain experts for comments
(2) Amend stylesheet, and repeat (1) until domain
experts are happy to sign off stylesheet design
(3) Implement stylesheet in live EPR system
Microbiology example - Legacy Pathology System view
Sensitivities in a
fairly non userfriendly cross
tabulation format
HL7v2 messages
A Culture and Sensitivity result is reported using multiple OBX segments.
A single organism result comprises an Organism OBX segment with subID N
followed by an Organism Growth OBX segment with subID N followed by zero, one
or more Organism Sensitivity OBX segments also with a subID value of N.
Microbiology
The final stylesheet
design was deemed
an improvement to
the legacy system
text based screen
More user-friendly
cross tab for
Organism vs
Sensitivities
Critical issue - TIME

Building interfaces is not a 5 minute job

Tasks
–
–
–
–
–
–

Find funding to initiate project
Design interface, agree end-to-end requirements
Supplier set-up / configure interface
NHS Trust set-up / configure interface
End-to-end testing
On-going Stylesheet development
TIME
? (show-stopper?)
1-3 months ?
1-3 months ?
1-3 months ?
1-3 months ?
?
In summary, even a bog-standard unidirectional HL7 interface
could take anything from 3 to 15 months, from start to finish
Key benefit of basing your
integration architecture
around XML
EXCHANGE OF BOTH
DATA AND
PRESENTATION
Data and Presentation

Web technology is enabling the Trust to
benefit from both
Data exchange: development of interfaces which
move XML patient data between an EPR (an
XML clinical repository) and other departmental
systems
Presentation: development and sharing of
stylesheets which present a common view of
departmental system data across multiple
applications
Data and Presentation
Discharge Letters,
Emergency Care summary
EPR
Electronic Patient
Records
Pathology results,
Patient demographics
JOIN
Example
Bi-directional
transfer of data
and presentation
between EPR
and A&E
Emergency Floor
Electronic Patient
Records
Shared XML data
and stylesheets
Haematology result
in the EPR system
Haematology result
in the A&E system
Addressing data quality
and change issues
Planning ahead for
NPfIT / LSP integration
The clinician's perspective on electronic health records
and how they can affect patient care.
BMJ 2004;328:1184-1187 (15 May)
Many attempts to get clinicians to use electronic health records have
failed, often because of difficulties with data entry.
Kay and Purves maintain that narratives are at the heart of clinical
decision making and refers to this concept as "narrative reasoning
Van Ginneken states that many computerised medical record systems
are rejected by clinicians because they are not based on a story
metaphor
Challenge: How to get clinicians to enter ‘coded’ information into a
computer when they would prefer to hand write on paper or type essays
into a free text box?
Emergency Floor system design

Change management issues
– A&E clinicians had never previously entered clinical data into a
computer – all notes were recorded on a paper cascard
– Solution had to be QUICK and USER-FRIENDLY !!!

Single screen to record all discharge information

Order comms – all requests for investigations recorded

Treatment given – point and click

Drugs administered – point and click

Diagnosis – point and click

Clinician notes – free text
Emergency Floor system design
Simple / Quick point and click data capture
Emergency Care System
Emergency floor
system
Discharge screen
auto generates an
XML discharge
summary message
Stylesheets to
produce 2
documents on
discharge:
(a) Patient letter
(b) GP letter
Emergency floor discharge summaries

Discharge summaries are currently stored in
XML format and presented on screen using
an XSL stylesheet (A&E and EPR systems)

Diagnosis values are coded ICD10, but can
easily be coded in SNOMEDCT as well

XML data could be transformed into valid
HL7v3 Provision of care messages using
XSLT prior to routing to the Spine
NPfIT Integration
Challenges
Scope - NPfIT clinical messaging

The scope of Phase 1 clinical messaging is
very big and complex

It is HL7 version 3 which is new to the
majority of people in health informatics
Phase 1 Clinical Messaging Flow Summary
Medication Updates
Adm
Disch
CPA Summary
ETP
PSIS
SAP Encounter
(PoC Care
Event Report)
Mental Health
Full / Partial
Dispense
DI
Encounter
Diagnostic
Imaging
Prescribe
Cancel
DI Report
DI
Report
Adm / Disch /
CPA Summary
Notifications
Pharmacy
DI Requestor
GP2GP
OOH
Encounter **
PSIS Query
PoC
Discharge
Report
(Inpatients)
or
PoC
Care Event
Report
(Out Patients)
SAP
PoC
Care Event
Report
(Primary Care)
PoC Disch or Care Event Report
Primary Care
LSP / Existing
Emergency Admission Notification **
A&E Report **
Secondary Care
LSP / Existing
A&E
Encounter **
NHSD
Referral
EBS
Slots (provide and fill)
NOTE: Flows marked with ** are also sent to PSIS but not shown on this diagram for ease of reading
Any PSIS / NCRS
Accredited
System
Existing Systems Integration

Replacement of NHS IT systems will not
happen overnight in Acute Hospital Trusts

Key department systems may not be
replaced before 2010

Existing systems integration is therefore a
key issue for Acute Hospital Trusts
Existing specialist or departmental systems will interface to the
LSP core solution NOT directly to the Spine
Potential LSP Interfaces
Spine
compliance
NCRS Spine
LSP enables interface
and publishes
specifications and
updates (ongoing process)
LSP Core Solution
LSP Interface Engine
LSP
compliance
Trust Interface Engine
Specialist or
Departmental
Systems
LSP
Specialist or
Departmental
Systems
Other systems
(not connected)
Trust
Appropriate interfaces
developed and
implemented for
existing trust systems
LSP Existing Systems Integration

Single logical link between LSP data centre
and the Authority Service Recipient via N3

Messages HL7 V2.4 and encrypted

Integration engine required (Seebeyond
license is free for CSC TIE use only)

Inbound messages must be agreed with
NPfIT
(conforming to the rules referenced in CRS Interactions with
Existing System (NPFIT-FNT-TO-TAR-0004) and Principles
for CRS Clinical Data Access by Local NHS Systems (NPFITFNT-TO-TAR-0006.01))
WWL / CSC NPfIT integration approach