Christopher Feahr wrote: >Thomas, >This sounds workable to me. If I am understanding you correctly, we >need one (and only one??) registry in which anyone, anywhere (who is >authorized, of course) could look up a patient and determine which >"region" had master control at the moment over his record. > logically it could work like this - but note: this query would most likely be for people already out of their normal area.
> If I'm a >provider living in the region where the records are primarily managed, >then when my system attempted to look up, say, the date of his last >Tetanus vaccination, it would find it immediately. > It should be able to interrogate the shared EHR in he patient's home area to get this. Now, taking Australia as an example, let's say or patient has hurt themselves in Idaho while seeing their brother. The local doctor's openEHR-capable system sends a request to this "health resource location server" (a well-known address) and gets an answer back that info is available, and some kind of electronic consent form, which the patient will be asked to sign. Now, if this is Austarlia in a few years' time, the HealthConnect system might be in place - a national "summarised health record" containing things like therapeutic precautions, vacc hist, etc. Just what you want. However, if the Idaho doctor wants to see information not in healthConnect, but in some lower level shared EHR, it should be possible too, although the consent & security hand-shaking might be more involved. So you can see that the idea of the shared EHR could be multi-level. > If I was a provider >visited while the patient was traveling outside his "home" region, then >the same local query about his tetanus shot would tell me: "hold on a >minute, while we search all known registries to see where this guy's >home-region is... where his most current records will be located". ... >and then my region does a full record update from the current home >region? or just try to display his tetanus vaccination history? > in teh above example, only the vacc history. But even if you wanted more, here's how it could work. THe consent settings are already in place for categories of carer like 'treating physician', 'any physician', etc. So all the patient might have to do is add this doctor to one of these categories, _on a time-limited basis_, and this doctor can have a normal view of the patient's EHR for that period, ensuring that that doctor can perform care without worrying that half the view is hidden from them. All this is quite dependent on patient consent settings, so it may vary significantly. >One of the problems alluded to is that different regions might be using >very different EHR structures. Thus a simple "record refresh" in region >B from the information stored in Region A is not so simple. It would >involve mappings at least, and possibly even data transformation. The >inability to assume an overarching authority seems to be the Achilles >heel. After a dozen record "movements" from one region to the next, >many little mapping and transformation errors may have accumulated to >thoroughly hose up the medical information in the patient's "master" >record. > this is why shared EHRs need to obey a standard, at least for communication. It is up to the builders of the systems to ensure lossless communication. Consider the case of Europe. The CEN 13606 EHR standard, currently being revised to include archetypes, various HL7isms and so on, defines a means of communication between EHR systems. If European EHR systems obey this standard (starting from about end 2004) then widespread EHR, reliable communication will start happening. If the systems builders use openEHR 'on the inside' then they will have almost no work to do in talking CEN 13606; they will also be able to share archtectural components via the software or open source market places. I don't think it's impossible at all. >One way around the central record managing authority would be to have >VERY FEW regions... each with a well organized regional authority... who >come together under a global organization and work out a very tight >choreography for these refresh/hand-off operations. But this sounds >harder and no more likely to be created as one single authority such as >the UN imposing the requirements on all regions. > the UK NHS is taking this route, and has divided the UK into five regions, and is mandating certain rules for health information provision for each. Only big information managers can deal with such a large challenge, which is why we have already seen teh merger of iSoft and Torex in the UK. >I believe that the most critical point for global standardization and >what we must aim for (first) is the information in the record. When the >world has settled into that (something that will ALSO require a central >authority, but just for standardizing what the information elements >mean, not for choreographing complex record-merge operations), people >will gradually come around to the idea of moving to the next level of >system interoperability, with standard record structures. > agree. >With only the information standardized globally, two large and >cooperative regions (say, US and Australia) could still choose to create >a US-Aus. information authority and orchestrate a high level of >interoperability for patients and providers floating anywhere within our >two countries. > I would guess more like a contaractual agreement, or even a kind of information 'treaty'... > If the "functional regions" initially were more along >the sizes of counties and states, then we'd have a lot more hassle and >negotiating. So I would suggest the world start with the largest sized >regions that could be reasonably managed with the same EHR structure. > Personally I envisage a more hierarchical structure, with a few levels of EHR, starting at e.g. counties or similar. Above that all EHRs are summarized, and contain pregressively less detail, but do not lose the important data such as allergies and vaccinations. >The critical issue for all regional participants would be a strong, >competent regional authority... that operated in conformance to a set of >well defined "regional authority rules"... maintained by the UN?? > maybe WHO, if he US doesn't drop out due to the idiotic stance of daily sugar intakes...;-) - thomas - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
