Describe the major coding and interoperability systems in use in patient record systems in Ireland
Interoperability Standards Assignment
Describe the major coding and interoperability systems in use in patient record systems in Ireland
Interoperability Standards Assignment
Introduction
Health information allied with information and communications technology both play a critical role to ensure that the information to drive quality and safety of patient care is readily available when and where it is required. Unfortunately the current information communication technology (ICT) infrastructure in Ireland presents major gaps between the health and social care sector, resulting in service users having to provide the same personal information on multiple occasions at each visit. The Health Information and Quality Authority (HIQA) has a statutory remit to develop standards, evaluate information and make recommendations about deficiencies in health information based on international best practice. There is an opportunity to further develop and embrace technologies and systems during this current pandemic to progress further the coding and interoperability standards set out by HIQA. We will explore the standards that are available to assist with clinicians’ patient care with common language terminology and enable information to be shared electronically and the systems such as Healthlink, Medical Laboratory Information System (MedLIS), Maternal Neonatal – Clinical Management System (MN-CMS), Picture Archiving and Communication System (PACS) and Hospital InPatient Enquiry (HIPE) that are currently in use across the Irish healthcare setting.
Health information standards must cover both the syntax (structure) and semantics (meaning) of the data exchanged in order to support interoperability between healthcare ICT systems. These are blueprints that vendors can use to develop information systems that are compatible with other information systems in order to adhere to the same standards. The potential to share information is greatly increased with the implementation of initiatives such as the Individual Health Identifier (IHI) or a national electronic health record. Messaging standards have been developed that outline the structure, content and data requirements of messages and include Health Level 7 (HL7) for administrative data and Digital Imaging and Communications in Medicine (DICOM) for radiology images (HIQA, 2013).
HL7 was developed by HL7 international and concerned with the interoperability standards that govern the exchange, management and integration of electronic health information. There are set protocols for the exchange of information from one healthcare provider to another. Healthlink is a key resource that provides for a messaging service between GP practice management systems and healthcare providers to securely transfer patient information using the HL7 standard. Healthlink is compliant with the HIQA national guidance on messaging standards (Healthlink, 2019). A new standard that has been developed by a working group is Health Level 7 Fast Healthcare Interoperability Resource (HL7 FHIR). This is a web based standard that uses Representational State Transfer (REST) web services to communicate and provide interoperability between computer systems on the internet.
DICOM is defined file format and network communications protocol for storing, handling, printing and transmitting medical imaging. The National Electrical Manufacturers Association (NEMA) in the United States holds the copyright to this standard. DICOM enables the integration of scanners, servers, workstations, printers and network hardware into a picture archiving and communication system (PACS) and is used across various healthcare provider settings in Ireland. It is also known as International Standards Organisation (ISO) 12052:2006, Health Informatics where workflow and data management are defined.
Terminology standards can support collecting data on one occasion and then using this data multiple times, when and where possible. They can ensure that high quality data is recorded during a user service visit and that this data can be available for research and statistical reporting after a visit and are a fundamental part of any eHealth ecosystem (Stroetmann, V. et al., 2016). A reference terminology or nomenclature is a common medical language that has been shown to significantly improve the overall quality of clinical data. International reference terminologies such as Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC) are widely used across Irish healthcare. An aggregation terminology is a method of grouping concepts together in a systematic way for a specified purpose. Similar diseases and procedures are grouped into classes based on pre-determined categories such as the cause of the disease. The International Classification of Diseases (ICD-10) and International Classification of Primary Care (ICPC-2) are widely used in Irish healthcare. In addition the Australian Modification of ICD-10 (ICD-10-AM) is widely used to code diagnosis data included in the Hospital In-patient Enquiry Scheme (HIPE) in Ireland. Both of these terminology standards can benefit when they are linked by collecting clinical information during a service user visit and afterwards generating data for statistical analysis and reporting and measuring quality of care (HIQA 2017).
Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) is a common medical language terminology system that can be implemented in a healthcare provider’s computer system to provide clinical information reliably and reproducibly. This system can include diagnosis and care procedures to follow, symptoms and family history, allergies and assessment tools. Extensive clinical audit and research is facilitated while clinical decision making is supported. In 2014 HIQA published a report on the recommendations regarding the adoption of SNOMED CT for Ireland. The authority recommended that SNOMED CT be adopted as a national system immediately, that a license should be purchased and a national release centre created and resourced, to investigate entering into an agreement with a national release centre in another jurisdiction, the system should be introduced gradually with the active support of the national release centre, the requirement to support this system should be included in software procurement specifications in order to future proof ICT investments and finally a review should be undertaken to establish the most appropriate agency to operate this system (HIQA, 2014). SNOMED CT is maintained and distributed by the Irish National Release Centre (NRC) established in the enterprise architecture function of the Office of the Chief Information Officer (OoCIO).
Logical Observation Identifiers Names and Codes (LOINC) was first developed by Regenstrief Institute as a common terminology for laboratory and clinical observations with the goal to facilitate the communication and grouping of test results for care, management and research. LOINC is primarily used to identify laboratory tests when results are exchanged electronically from laboratories to clinicians. When hospitals or other healthcare providers receive messages using LOINC codes from multiple laboratories, they can automatically file the results in the correct location of the patient’s record and use the data for clinical care and management. Using the LOINC Document Ontology (LOINC DO), healthcare providers can group documents as needed that can support a more consistent navigation in a document viewer while ensuring the retrieval of relevant documents when a user requests them adding to an efficient workflow. There are five attributes classified to ensure documents can be understood across healthcare settings and include; the subject matter, the role (clinician), the healthcare setting, the type of service and the type of document. LOINC was selected as the terminology to support the identification of laboratory orders for the Standardisation of Laboratory Test Codes project (HIQA, 2014).
In Irish general practice the ICPC-2 clinical/diagnostic classification system is available in patient software management systems. ICPC-2 allows viewing the process of care and is used to code patient’s that presented with complaints, record clinical findings and assess the care process. It was originally created as an epidemiological tool to enable providers to use a single system to code information for the assessment and process of care. It is unique as it enables a clinician to classify the initial episode of care from the time the patient first presents with a problem to the final encounter with the same problem, resulting in a more definite diagnosis. ICPC-2 was designed for use in electronic information systems for both encounters and episodes of care while mappings are provided from other aggregation terminologies such as ICD-10.
Also used in general practice is the ICD-10 classification system that provides a comprehensive listing and definition of diseases, disorders, injuries, symptoms and the reason for the encounter. Definitions are organised into standard groups that can help to analyse health information for decision making. ICD is the international standard for defining and reporting diseases and health conditions and for mortality and morbidity statistics. ICD is also used for health information in public health, primary, secondary and tertiary healthcare settings. A wide variety of healthcare professions that include; clinicians, policy makers and health program managers use ICD. The World Health Organization has adopted ICD-11 to come into effect on January 1st 2022. This system provides for a more detailed recording of classifications that have proliferated over time to assist with a framework for statistical use (WHO, 2021).
Across Ireland, all acute healthcare providers use HIPE that is an electronic health information database designed to collect data on coded discharge summaries and morbidity information. Clinical coders that operate in HIPE departments use the ICD-10-AM system of classification. Each month the coded data is exported to the Economic and Social Research Institute (ESRI) who monitor and maintain the national database. This database enables the Department of Health to compare and contrast each healthcare provider’s activity and costs and can assist with budget planning and assessing efficiency. All inpatient and day care information is manually input onto this database that allows healthcare providers management to assess activity and to assist with clinical research (Murphy, D. 2010).
MedLIS involves the integration of a nationwide healthcare provider laboratory system to ensure access is always available to accurate laboratory information across all sites in the Irish state. The system will replace the existing and independent systems that are currently in use. MedLIS will allow for laboratory information to be shared between healthcare providers and will have full audit trail capability to support data breach detection. The system will benefit the reduction in test duplication, accessibility of results through an Electronic Health Record (EHR) that is robustly stored (eHealthIreland, 2021). This system utilises the LOINC terminology standard for workflow efficiency.
The MN-CMS project is the implementation of an EHR for all women and babies that avail of maternity services across the country. This record will allow all information to be shared with healthcare providers as and when required. The key benefits will include; improved care as a result of improved communication, effective and efficient recording of information reflecting best standards, enhanced clinical audit and research locally as a result of better quality data and informed business intelligence that will drive local and national management decisions (eHealthIreland, 2021). This system incorporates the SNOMED CT terminology standard to assist with workflow. MN-CMS has HL7 integrated (messages) to support the following; Healthlink where patient information is securely transferred from a hospital to a patient’s GP system, IHI used to safely identify a patient and their health information, Patient Management System (iPMS) for Admission, Discharge and Transfer (ADT) messages in all sites, Laboratory electronic orders to systems and result messages and finally Colposcopy reports, results and images sent directly to the system (eHealthIreland.ie, 2021). As a clinical engineer in the National Maternity Hospital, I have experience of integrating medical devices into MN-CMS. A vendor software tool, iCommand that incorporates the HL7 standard is available to build each device into the system and to provide support to confirm the flow of patient vital sign parameters from bedside monitors and ventilation parameters from ventilation devices in real time. This tool allows a user to capture raw HL7 parameters before they are populated into the electronic patient chart.
Conclusion
Terminology and Interoperability standards and systems should be used for the purpose of which they were designed in combination to achieve the full benefits of healthcare delivery and need to be expanded across the state. There are many different systems in use currently and these vary between each healthcare provider where a standard exchange format and semantics is required in order to safely send and receive sensitive information. Substantial gains have been made with the implementation of Healthlink that incorporates interoperability messaging standards, MedLIS to allow for laboratory information to be shared between healthcare providers and MN-CMS to allow all information to be shared with healthcare providers as and when required for all women and babies that avail of maternity services across the country. In Ireland there is experience and expertise with clinical coders that use ICD-10-AM in acute settings and general practitioners that use ICPC-2 and ICD-10 in primary care settings. However standards such as LOINC and SNOMED CT have yet to be utilised to their full potential due to the lack of a national shared electronic record or patient summary. National strategic projects need to be rolled out on an accelerated basis as an improved patient safety measure that will benefit society.
References
eHealthIreland.ie, (2021). HL7 Integration (Messages). eHealth Ireland’s Official Website. [online] Available at: https://www.ehealthireland.ie/strategic-programmes/mncms/information-sharing-and-integration/hl7-integration-messages/ [Accessed 3 May 2021].
eHealthIreland.ie, (2021). Maternal & Newborn Clinical Management System. eHealth Ireland’s Official Website. [online] Available at: https://www.ehealthireland.ie/Strategic-Programmes/MNCMS/ [Accessed 3 May 2021].
eHealthIreland.ie, (2021). National Medical Laboratory Information System (MedLIS). eHealth Ireland’s Official Website. [online] Available at: https://www.ehealthireland.ie/Strategic-Programmes/National-Medical-Laboratory-Information-System-MedLIS-/ [Accessed 3 May 2021].
Healthlink.ie, (2019). Healthlink System. Healthlink’s Official Website. [online] Available at: https://www.healthlink.ie/healthlinkhome/ [Accessed 3 May 2021].
HIQA, (2013). Overview of Healthcare Interoperability Standards. Healthcare Information and Quality Authority’s Official Website. [online] Available at:https://www.hiqa.ie/sites/default/files/2017-01/Healthcare-Interoperability-Standards.pdf [Accessed 3 May 2021].
HIQA, (2014). Recommendations regarding the adoption of SNOMED Clinical Terms as the Clinical Terminology for Ireland. Health Information and Quality Authority’s Official Website. [online] Available at: https://www.hiqa.ie/sites/default/files/2017-01/HIQA-recommendations-SNOMED-CT.pdf [Accessed 3 May 2021].
HIQA, (2017). Guidance on Terminology Standards for Ireland. Health Information and Quality Authority’s Official Website. [online] Available at: https://www.hiqa.ie/sites/default/files/2017-07/Guidance-on-terminology-standards-for-Ireland.pdf [Accessed 3 May 2021].
Murphy, D. (2010). Coding in Ireland: time for recognition. Health Information Management Journal, 39 (3), pp. 42-46.
Stroetmann, V., Kalra, D., Schulz, S., Karlsson, D., Stichele, R., Cornet, R., Rosenbeck Goeg, K., Cangioli, G., Chronaki, C., Thiel, R. and Thun, S. (2016). Assessing SNOMED CT for Large Scale eHealth Deployments in the EU. [online] Available at: https://assessct.eu/fileadmin/assess_ct/final_brochure/assessct_final_brochure.pdf [Accessed 3 May 2021].
WHO.org, (2021). International Statistical Classification of Diseases and Related Health Problems (ICD-11). World Health Organisation’s Official Website. [online] Available at: https://www.who.int/standards/classifications/classification-of-diseases [Accessed 3 May 2021].
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Dara Keeley
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