1. Welcome to Aalborg University No. 1 of 31 Balancing centralised and decentralised EHR approaces to manage standardisation Department of Health Science and Technology, Aalborg University Kirstine Hjære Rosenbeck, Anne Randorff Rasmussen, Pia Britt Elberg, Stig Kjær Andersen

2. Welcome to Aalborg University No. 2 of 31 Agenda Clinical content of EHR systems The complexity of clinical content modelling Aim – Bridging the gab between current decentralised practise and centralised standardised approaches The clinical content format Method and results Achievements and Limitations Future methodologies Focusing on content before structure and proving the benefits of standardisation. Example: Regional clinical content-SNOMED CT project Take home messages

3. Welcome to Aalborg University No. 3 of 31 Clinical content in a Danish context In short clinical content is the reformulation of clinical domain knowledge into a form suited for implementation in e-health systems. Clinical domain knowledge originates from Health Care Professionals, established medical knowledge or analysis of the clinical workspace. Challenges in clinical content modelling No common format which creates local variations, vendor specific modelling and hereby difficulties in sharing and reusing clinical content Clinical content compared to openEHR archetypes and templates All aspects of clinical content modelling are not included in openEHR archetypes and templates. When working with interoperability, the goal is standardised data management. Therefore clinical IT system requirements related to i.e. user interface design, supporting workflows and presenting patient information is typically not included in these frameworks. [Fabricius, 2008] Data definition not delimited from the other goals when customizing EHR-systems

4. Welcome to Aalborg University No. 4 of 31 [Stroetmann et.al, 2007] Infrastructure, connectivity, interoperability – inventory of key relevant Member States and international experience. “Due to the complexity of the system, only limited progress in full semantic interoperability has been made over the last years in any of the countries.” [Stroetmann et.al, 2007] Complexity of clinical content modelling

5. Welcome to Aalborg University No. 5 of 31 Aim of study Development of a clinical content format Problems Sharing and reusing clinical content is not possible since the models are proprietary A domain of unique complexity. One consequence is the difficulty of bridging the gabs between local goals and national/international goals Aim of the clinical content format Motivate sharing and reusing of clinical content Motivate implementation of national standards in regional projects

6. Welcome to Aalborg University No. 6 of 31 Method Point of departure [Hevner et al, 2004]: Innovative, need-driven, including knowledge base, iterative Analysis of regional and national and international work related to clinical content modeling Information retrieval: Interviews and material retrieval in existing clinical content projects (2/5 regions in Denmark), browsing EHR standards and clinical terminologies in medline, google and others Analysing granulation and standardisation Project duration (Febuary-May 2009) [Hevner, et al 2004] Design science in information systems research.

7. Welcome to Aalborg University No. 7 of 31 Result - clinical content format Result of analysis The documentation developed by the two studied organisations was comparable Complex functionality or technical standardisation was not introduced in any sites In Denmark no decisions regarding EHR models are taken, however SNOMED CT are chosen as general terminology Characteristics Emphasis on GUI structure and terminology Both input and output GUIs and simple data definitions SNOMED CT, but no EHR models No decision support or clinical pathways supported

8. Welcome to Aalborg University No. 8 of 31 Possible achievements and limitations Focus on developing a format that meets current business needs Focus on making SNOMED CT part of the format The limitations show that merely focusing on the structural issues, does not necessarily lead to clear results in terms of Sharing and reuse of clinical content Standardisation - More manageable to introduce than other models -Still workload associated with introduction -The classical groupware problems [Grundin, 1994] - SNOMED CT becomes a key part of clinical content modelling - It is unproven that SNOMED CT makes a difference in clinical content modelling [Grundin, 1994] Groupware and social dynamics

9. Welcome to Aalborg University No. 9 of 31 Future studies

10. Welcome to Aalborg University No. 10 of 31 Future studies Examples of what it means to put content before structures, and build bridges in stead of towers SNOMED CT and clinical content Introducing SNOMED CT, while implementing a configurable EHR system on multiple sites in Northern Denmark Goal: Labels and drop-down menu-terms should be SNOMED CT coded, unless it makes no sense at all Regional motivation Common terminology across the Region – more understandable Avoid redundant terminology, by using the SNOMED CT hierarchy to structure the local terms into trees in stead of lists Use of the same terminology on multiple sites, making information comparable. Comparable information is a prerequisite for data sharing and secondary use.

11. Welcome to Aalborg University No. 11 of 31 Take home messages Regional, national and international goals of introducing EHR systems are conflicting. Often vendors and local buyers have no interest in standardisation – there is no business case Analysing existing modelling of clinical content showed that it was possible to form a simple common formalism, closer to current business-needs than standardised models. Introducing a common format might require work beyond formalism, since the workload associated with introduction should be weight against the actual local benefits Thank you for listening Correspondence: kirse@hst.aau.dk