EHRS Blueprint

出自医学信息学大百科

EHRS Blueprint内容编辑要求

Foreword

CONTENTS

1 VERSION TABLE..................................................................................................................................1

2 EHRS BLUEPRINT CONTEXT..............................................................................................................2

2.1 KEY DEFINITIONS AND OVERARCHING CONCEPTS ................................................................2

2.1.1 Design Levels (Conceptual vs. Logical vs. Physical)...............................................................................2

2.1.2 Enterprise................................................................................................................................................3

2.1.3 Jurisdiction..............................................................................................................................................3

2.1.4 Patient vs. Person vs. Client.....................................................................................................................3

2.1.5 EHRS.......................................................................................................................................................3

2.1.6 EHRi........................................................................................................................................................4

2.1.7 EHR Service ............................................................................................................................................5

2.1.8 LRS..........................................................................................................................................................5

2.1.9 EHR Data and Services (Domain Repositories) ......................................................................................5

2.1.10 Ancillary Data and Services .................................................................................................................5

2.1.11 Health Information Data Warehouse ...................................................................................................5

2.1.12 Registries .............................................................................................................................................6

2.1.13 HIAL: The Health Information Access Layer .......................................................................................6

2.1.14 EHRS Locator......................................................................................................................................6

2.1.15 Overarching Concepts.........................................................................................................................7

2.1.16 Primary Use vs. Secondary Use ...........................................................................................................8

2.2 USES AND BENEFITS OF THE EHRS BLUEPRINT ...................................................................10

2.2.1 Promoting EHR Standardization Across Canada ..................................................................................11

2.2.2 Reference For Strategic Planning..........................................................................................................11

2.2.2.1 For Provinces .................................................................................................................................11

2.2.2.2 For Healthcare Organizations .........................................................................................................12

2.2.2.3 For Provider Associations...............................................................................................................12

2.2.2.4 For Providers (Healthcare Professionals)........................................................................................13

2.2.2.5 For Healthcare Informatics Solution Vendors.................................................................................13

2.2.2.6 For Privacy and Security Initiatives................................................................................................13

2.2.3 Enabling Project Specific Architecture, Design and test Phases ...........................................................13

2.2.4 Critical to the Mission of Infoway..........................................................................................................14

2.2.5 Base to Engage In International EHR Standards Initiatives..................................................................14

2.2.6 Base to Engage In Pan-Canadian EHR Standards Initiatives ...............................................................14

2.2.7 Enabling education and training initiatives ...........................................................................................14

2.3 KEY ARCHITECTURAL DECISIONS............................................................................................15

2.4 BLUEPRINT VALUE PROPOSITION............................................................................................18

2.4.1 September 2004 Milestone .....................................................................................................................18

2.4.2 EHR in action........................................................................................................................................18

2.4.3 EHR Value.............................................................................................................................................20

2.4.4 Timing ...................................................................................................................................................21

2.4.5 EHR and telehealth ...............................................................................................................................22

2.5 BUSINESS CASE FOR THE EHR.................................................................................................22

2.5.1 The International Experience.................................................................................................................24

2.5.2 Interoperable EHR Benefits ...................................................................................................................26

2.6 GUIDING PRINCIPLES .................................................................................................................28

2.7 EHRS BLUEPRINT EVOLUTION..................................................................................................31

2.7.1 Objectives in Evolving the EHRS Blueprint ...........................................................................................32

2.7.2 Blueprint v2 Deliverables......................................................................................................................32

2.7.3 Process for Producing Blueprint Version 2 ...........................................................................................33

2.7.4 Blueprint v2.0 Validation with Stakeholders..........................................................................................36

2.7.5 EHRS Blueprint Version 2 Publication ..................................................................................................37

2.7.6 EHRS Blueprint - Beyond Version 2 ......................................................................................................37

2.8 STAKEHOLDER ENGAGEMENT..................................................................................................38

2.8.1 Structure................................................................................................................................................38

2.8.2 Key Events.............................................................................................................................................39

2.8.3 Looking to the Future............................................................................................................................40

3 BUSINESS ARCHITECTURE..............................................................................................................41

3.1 BUSINESS AND SOCIO-ECONOMIC DRIVERS .........................................................................41

3.1.1 Base Business Requirements ..................................................................................................................41

3.1.1.1 Life-long longitudinal record of clinical data..................................................................................41

3.1.1.2 Focused on clinically relevant data shared beyond organizational boundaries...............................41

3.1.1.3 Support for accurate, complete and timely delivery of information................................................42

3.1.1.4 Shared across multiple organizations and jurisdictions...................................................................43

3.1.1.5 Private and secure ...........................................................................................................................46

3.1.1.6 Adaptive to the future of healthcare delivery in the 21st Century...................................................47

3.1.1.7 Requires governance and operation management ...........................................................................48

3.1.2 Key Economic Driver............................................................................................................................49

3.1.2.1 A large integration problem ............................................................................................................50

3.1.2.2 Different approaches have different costs.......................................................................................53

3.1.2.3 The only economically viable approach..........................................................................................57

3.1.3 BAH Study on 10 years cost ...................................................................................................................58

3.1.4 Complexity of EHR Solutions.................................................................................................................59

3.1.5 Supporting Availability and Scalability .................................................................................................60

3.1.6 Semantic Interoperability......................................................................................................................61

3.1.7 Integrating Information Flow Across Jurisdictions ...............................................................................65

3.2 BUSINESS DOMAINS ...................................................................................................................66

3.2.1 Healthcare Delivery ...............................................................................................................................66

3.2.2 Healthcare Management.......................................................................................................................69

3.2.3 Healthcare Research.............................................................................................................................71

3.2.4 Public Health ........................................................................................................................................72

3.2.5 Telehealth..............................................................................................................................................76

3.3 THE PROPOSED SOLUTION.......................................................................................................80

3.3.1 Overview of diagram.............................................................................................................................81

3.3.2 Components...........................................................................................................................................81

3.3.3 Objectives..............................................................................................................................................82

3.4 EHR GENERATION ROADMAP ...................................................................................................83

3.4.1 A common language for generations of EHR capabilities .....................................................................83

3.4.1.1 Gartner Generations Model for CPR Systems ................................................................................83

3.4.1.2 Context for use of the Gartner model in the EHRS Blueprint.........................................................85

3.4.2 Incremental Approach...........................................................................................................................85

3.4.3 EHR Infostructure as a service ..............................................................................................................90

4 CONCEPTUAL ARCHITECTURE .......................................................................................................92

4.1 OVERVIEW...................................................................................................................................92

4.2 CLINICAL WORK PROCESS ARCHITECTURE...........................................................................94

4.2.1 Document Business Process.................................................................................................................101

4.2.2 Capture Process Flow..........................................................................................................................102

4.2.3 Capture Structure: Domain Analysis Model and Glossary..................................................................103

4.2.4 Capture Business Rules: Relationships, Triggers, and Constraints.....................................................103

4.2.5 Harmonize the Domain Analysis Model with HL7 Reference Models .................................................103

4.3 SYSTEM ARCHITECTURE.........................................................................................................104

4.3.1 Service Oriented Architecture (SOA)...................................................................................................107

4.3.2 Key Areas of System Responsibilities...................................................................................................108

4.3.3 Registry Services .................................................................................................................................110

4.3.3.1 Client Registry ..............................................................................................................................111

4.3.3.2 Provider registry...........................................................................................................................113

4.3.3.3 Location registry ...........................................................................................................................114

4.3.4 EHR Data & Services..........................................................................................................................115

4.3.4.1 Shared Health Record Domain......................................................................................................116

4.3.4.2 Drug domain ................................................................................................................................119

4.3.4.3 Diagnostic Imaging Domain .........................................................................................................120

4.3.4.4 Laboratory domain........................................................................................................................122

4.3.4.5 EHR Index Notification Process ...................................................................................................123

4.3.5 Ancillary Data & Services....................................................................................................................124

4.3.6 Data Warehouse..................................................................................................................................126

4.3.7 Longitudinal Record Services (LRS) ....................................................................................................127

4.3.7.1 Business Services.........................................................................................................................129

4.3.7.2 Data Services ...............................................................................................................................130

4.3.7.3 Transaction Handling and LRS Operators ....................................................................................131

4.3.8 Health Information Access Layer (HIAL) ............................................................................................135

4.3.8.1 HIAL Communication Bus Services.............................................................................................136

4.3.8.2 HIAL Common Services...............................................................................................................138

4.3.9 The EHR Viewer..................................................................................................................................143

4.3.9.1 Gen 2 Solutions (EHR Thin Client) ..............................................................................................144

4.3.9.2 Gen-2 (plus) Solutions ..................................................................................................................148

4.3.9.3 Gen-3 (light) Solutions..................................................................................................................149

4.3.9.4 Gen-3 Solutions ............................................................................................................................149

4.3.9.5 EHR Viewer Services Architecture Breakdown ...........................................................................150

4.3.9.6 Visual Integration with PoS applications via CCOW...................................................................150

4.3.9.7 EHR Viewer Requirements...........................................................................................................151

4.3.10 Interoperability Profiles ...................................................................................................................154

4.4 INFORMATION ARCHITECTURE...............................................................................................160

4.4.1 EHRi Conceptual Data Model .............................................................................................................163

4.4.2 EHRi Data Domains ............................................................................................................................164

4.4.3 Clinical Terminologies........................................................................................................................167

4.4.3.1 What do we mean by clinical terminologies? ...............................................................................167

4.4.3.2 What groups of information will be the object of clinical terminology standards? ......................168

4.4.3.3 What is the process to standardize clinical terminologies? ...........................................................169

4.4.4 Data Communication ...........................................................................................................................170

4.4.5 Data Persistence .................................................................................................................................171

4.4.6 Data Integrity......................................................................................................................................172

4.5 TECHNICAL ARCHITECTURE ...................................................................................................173

4.5.1 Functioning Principles: .......................................................................................................................174

4.5.1.1 “No home” EHR framework.........................................................................................................174

4.5.1.2 EHRi Identifier Management (Client, Provider, Location)...........................................................176

4.5.1.3 HL7 V3 (Messaging and templates)..............................................................................................178

4.5.1.4 EHR Index ...................................................................................................................................180

4.5.1.5 EHRS Locator..............................................................................................................................186

4.5.1.6 PoS to EHRi interface ...................................................................................................................196

4.5.1.7 Level of parameterization .............................................................................................................204

4.5.1.8 Other uses of the HIAL (PoS to PoS) ...........................................................................................207

4.5.1.9 Multi-lingual capabilities ..............................................................................................................208

4.5.1.10 Runtime environment....................................................................................................................210

4.5.1.11 Level of transparency of EHR to PoS applications.......................................................................212

4.5.1.12 Performance principles – targets...................................................................................................213

4.5.1.13 PoS Integration environment.........................................................................................................217

4.5.1.14 Transaction scope..........................................................................................................................221

4.5.1.15 Error Handling ..............................................................................................................................226

4.5.1.16 Trust Models Valid for an EHRi...................................................................................................229

4.5.1.17 Authentication & Authorisation....................................................................................................230

4.5.1.18 Informational Consent Directives .................................................................................................232

4.5.1.19 OIDS as a principle .......................................................................................................................233

4.5.1.20 Normalization ...............................................................................................................................234

4.5.1.21 Auditing, Logging and the Use of Logs........................................................................................235

4.5.1.22 Prospective Events ........................................................................................................................237

4.5.1.23 Primary Purpose of EHRi data......................................................................................................238

4.5.2 Mapping Services to Standards and Technology (Use of COTS).........................................................239

4.5.2.1 COTS and Standards.....................................................................................................................240

4.5.2.2 Categories of technology solutions in an EHR Infostructure........................................................241

4.5.2.3 Key COTS Considerations for EHR Infostructure solutions ........................................................245

5 USING THE BLUEPRINT IN EHRS PROJECTS ..............................................................................250

5.1 TOOLS: ARTEFACT REPOSITORY ...........................................................................................250

5.2 METHODOLOGY: EHR DESIGN AND SPECIFICATION...........................................................253

5.2.1 Infoway Investment Project Phases......................................................................................................254

5.2.2 HL7 Message Development..................................................................................................................258

5.2.3 IHE Integration Profile Development ..................................................................................................259

5.2.4 Standard Security Management Interface Development ......................................................................261

5.2.5 Standard system management interface development..........................................................................262

5.3 DESIGN ARTEFACTS.................................................................................................................262

5.3.1 Clinical Activity Use Case....................................................................................................................263

5.3.2 EHR Interoperability Profile (EHR IP)................................................................................................264

5.3.3 EHR Communication Step (EHRCS)....................................................................................................266

5.3.4 Infostructure Interoperability Profile (I-IP).........................................................................................267

5.3.5 EHRi System Services ..........................................................................................................................269

5.3.6 Data Model .........................................................................................................................................272

5.4 ONGOING SOLUTION DEVELOPMENT....................................................................................274

5.4.1 Diversity of EHR solution development settings ..................................................................................274

5.4.2 An evolutionary path ............................................................................................................................275

5.5 ONGOING STANDARDS DEVELOPMENT................................................................................276

5.5.1 Scope of Standards Related Work ........................................................................................................278

5.5.2 The Standards Development Lifecycle .................................................................................................278

5.5.3 Ongoing Work Timeline .......................................................................................................................279

5.5.4 Accessibility of EHR Standards Work..................................................................................................280

6 DEPLOYMENT MODELS ..................................................................................................................281

6.1 EHRI DEPLOYMENT MODELS ..................................................................................................281

6.1.1 Assumptions ........................................................................................................................................281

6.1.2 Deployment Architecture.....................................................................................................................281

6.1.2.1 The Logical View..........................................................................................................................281

6.1.2.2 Physical View ...............................................................................................................................282

6.1.3 Deployment Model Examples...............................................................................................................284

6.1.3.1 Model 1: Single EHR Infostructure ..............................................................................................285

6.1.3.2 Model 2: Shared EHR Infostructure..............................................................................................286

6.1.3.3 Model 3: Distributed EHR Infostructures .....................................................................................286

6.2 OPERATIONAL CONSIDERATIONS FOR THE EHRI ...............................................................287

6.2.1 Governance .........................................................................................................................................290

6.2.2 Functional Requirements of EHRi Operation ......................................................................................294

7 POTENTIAL APPLICATIONS ...........................................................................................................297

7.1 ENABLING THE EHR INFOSTRUCTURE ..................................................................................297

7.2 EXTENDING CURRENT APPLICATIONS ..................................................................................298

7.3 NEW CLASSES OF APPLICATIONS..........................................................................................300

7.4 SECONDARY USES....................................................................................................................302

8 APPENDIX A – MODEL BY HEALTH CANADA ..............................................................................303

9 APPENDIX B - INTERNET 2025 .......................................................................................................313

10 APPENDIX C - GLOSSARY...........................................................................................................325

11 APPENDIX D - ACKNOWLEDGEMENTS .....................................................................................364

12 APPENDIX E - FUTURE CHANGES..............................................................................................367

13 APPENDIX F - CONTACT INFORMATION ...................................................................................368

14 APPENDIX G - LEGAL DISCLAIMER ...........................................................................................369

15 APPENDIX H – INDEX ...................................................................................................................371

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