11

Integrated Architecture – Public Health Perspective

Cecil O. Lynch, MD, MS

Chief, Office of Informatics & Surveillance, DCDC, California Department of Health Services

Chair, Graduate Group Medical Informatics, Assistant Professor, Medical Informatics,University of California - Davis

22

InfrastructureInfrastructure

Entry: in·fra·struc·ture

Function: noun1 : the underlying foundation or basic framework (as of a system or organization)2 : the permanent installations required for military purposes3 : the system of public works of a country, state, or region; also : the resources (as personnel, buildings, or equipment) required for an activity

Merriam-Webster Online Dictionary

33

The ProblemThe Problem

PPPricePrice

PiecesPieces

PartitionsPartitions

PrivacyPrivacy

PoliticsPolitics

44

PricePrice

Technology is expensiveTechnology is expensive

Funding has been inadequate compared Funding has been inadequate compared to expectationsto expectations

Budget constraints at the State levelBudget constraints at the State level

Funding mechanism has restrictionsFunding mechanism has restrictions

High cost of bureaucracyHigh cost of bureaucracy

55

PiecesPieces

Multiple vendors Multiple vendors

Disparate technologies Disparate technologies

Legacy systems and legacy development Legacy systems and legacy development of new systems of new systems

Focus on function not on integration Focus on function not on integration

66

PartitionsPartitions

Department level development Department level development

Reproduction of infrastructure Reproduction of infrastructure

Persistent stovepipe approach Persistent stovepipe approach

““My needs are special” mentality My needs are special” mentality

No “big picture” approach No “big picture” approach

77

PrivacyPrivacy

HIPAA concerns HIPAA concerns

State legislative barriers State legislative barriers

Learned behavior Learned behavior

Inadequate security Inadequate security

I. T. isolation I. T. isolation

88

Politics Politics

Maintenance of control Maintenance of control

Fear of change Fear of change

Out of touch decision makers Out of touch decision makers

Publication worries Publication worries

Unaligned priorities Unaligned priorities

99

Separate Silos Separate Silos STD Food borne Disease

LIMS HIVVector-Borne

DiseasesTB

Childhood Lead Chronic Disease

CancerVital Records

Immunization Environmental

1010

Common ComponentsCommon Components

Demographic Data

Analysis & Reporting

Provider Information

MappingSecurity

Privacy

Codedterms

Messaging

1111

Common ComponentsCommon Components

PatientRegistry

AnalysisEngine

Clinician Registry

GISEngine

Two FactorAuthentication

Public HealthDirectory

CentralTerminology

Server

IntegrationHub

1212

Active DirectoryActive Directory

Group

Domain

Group

Policy

User

User

User User User

User User

Certificate Template

Policy

Certifate Sever

Clinician Registry

PatientRegistry

Two FactorAuthentication

Public HealthDirectory

HAN

1313

Interoperability RequirementsInteroperability Requirements

Equivalent data typesEquivalent data types– Preferably derived from the data modelPreferably derived from the data model

Common terminologyCommon terminology– Unambiguous codingUnambiguous coding

Agreed upon formatAgreed upon format– Must be readableMust be readable

Appropriate connectionAppropriate connection– Message must be routed appropriatelyMessage must be routed appropriately

1414

Interoperability LayersInteroperability Layers

1 Physical

2 Data Link

7 Application

8 Semantic

6 Presentation

5 Session

4 Transport

3 Network

VocabularySemantic model

Data exchange

Data encoding

Security

Communication

Medical Informatics

}}

Information

Technology

OSI Network Model

{Concept for slide from Ted Klein and Tim Morris

1515

Why Code Data?Why Code Data?

ColdCold

–February is a February is a coldcold month. month.

–She met his gaze with a She met his gaze with a coldcold stare.stare.

–Julia is in bed with a Julia is in bed with a coldcold..

February is a 45893009 month.She met his gaze with a 285846001 stare.

Julia is in bed with a 82272006.

1616

Why Code Data?Why Code Data?

myocardial infarctionmyocardial infarction

cardiac infarctioncardiac infarction

heart attackheart attack

infarction of heartinfarction of heart

MI - Myocardial infarctionMI - Myocardial infarction

myocardial infarctmyocardial infarct

2229800622298006

2229800622298006

2229800622298006

2229800622298006

2229800622298006

2229800622298006

Term Concept IDDescription IDDescription ID3743601437436014

3744201337442013

3744301537443015

3744101837441018

17848720191784872019

17848730121784873012

1717

VocabularyVocabulary

HL7 V3 messaging is complex HL7 V3 messaging is complex Byproduct of semantic necessity Byproduct of semantic necessity A library of post coordinated terms is essential A library of post coordinated terms is essential CDC vocabulary mapping has not reached CDC vocabulary mapping has not reached this level of detail yet this level of detail yet

Example: Example: – Bilateral symmetrical muscle weakness Bilateral symmetrical muscle weakness – A prominent symptom of botulism A prominent symptom of botulism

CentralTerminology

Server

1818

VocabularyVocabulary

- <Observation>  <id root="10.23.4573.90009" />   <code code="39154008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="clinical diagnosis" /> - <value xsi:type="CD" code="26544005" codeSystem="2.16.840.1.113883.6.5" codeSystemName="SNOMED" displayName="muscle weakness">- <originalText>bilateral symmetrical muscle weakness: Present</originalText>- <qualifier>  <name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="with laterality" />   <value code="51440002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="bilateral" />   </qualifier>- <qualifier>  <name code="103372001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="with pattern" />   <value code="255473004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="Symmetrical" />   </qualifier>- <qualifier>- </Observation>

1919

VocabularyVocabulary

- <Observation>  <id root="10.23.4573.90009" />   <code code="39154008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="clinical diagnosis" /> - <value xsi:type="CD" code="26544005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="muscle weakness">- <originalText>bilateral symmetrical muscle weakness: Present</originalText>

2020

VocabularyVocabulary

- <qualifier>  <name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="with laterality" />   <value code="51440002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="bilateral" />   </qualifier>

2121

VocabularyVocabulary

- <qualifier>  <name code="103372001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="with pattern" />   <value code="255473004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="0307core" displayName="Symmetrical" />   </qualifier>- - </Observation>

2222

MessagingMessaging

Is not Is not – Shared databaseShared database– Exchange of data on mediaExchange of data on media– FTP of a data fileFTP of a data file– Submitting a web formSubmitting a web form

IsIs– High speed asynchronous program to High speed asynchronous program to

program communication with reliable deliveryprogram communication with reliable delivery11

1. G.Hohpe,B. Woolf Enterprise Integration Patterns

2323

Simple MessagingSimple Messaging

S

D

R

SendingApplication

ReceivingApplication

Message Gateway

Document Message

Message Channel

Message Router

Message Translator

Message Endpoint

2424

Example Application

2525

System Message ExcerptSystem Message Excerpt

2626

Real life messagingReal life messaging

D

LCS

MDLVARDIS

Message Gateway

Message Document

MessageWrapper

Message Channel

Message Router

Message Splitter

MessageBus

Message Processor

MessageTranslator

MessageGateway

MessageStore

IntegrationHub

2727

STV ExampleSTV Example

GISEngine

2828

SaTScan & RNNH Clusters

AnalysisEngine

2929

CHI NCVHS Data StandardsCHI NCVHS Data Standards

DrugsDrugs– Active Ingredients – FDA UNII codesActive Ingredients – FDA UNII codes– Clinical Drugs – RxNORMClinical Drugs – RxNORM– Manufactured Dosage Form – FDA/CDERManufactured Dosage Form – FDA/CDER– Packaged drug product – NCDPackaged drug product – NCD– Medication Package – FDA/CDERMedication Package – FDA/CDER– Labeling Section Headers - LOINCLabeling Section Headers - LOINC– Drug Classifications – NDF-RTDrug Classifications – NDF-RT– Race and ethnicity labeling – HL7 tablesRace and ethnicity labeling – HL7 tables

3030

CHI NCVHS Data StandardsCHI NCVHS Data Standards

HL7 for messaging standard (current HL7 for messaging standard (current version)version)

LOINC for laboratory test orders and test LOINC for laboratory test orders and test resultsresults

SNOMED CT for clinical termsSNOMED CT for clinical terms

Immunizations – HL7 2.4 messaging and Immunizations – HL7 2.4 messaging and CVX and MVX codesCVX and MVX codes

DICOM for imagingDICOM for imaging

3131

ResourcesResources

PHIN Standards http://www.cdc.gov/phin/PHIN Standards http://www.cdc.gov/phin/

PHIN Messaging PHIN Messaging http://www.cdc.gov/phin/messaging/ http://www.cdc.gov/phin/messaging/

NCVHS/CHI Standards NCVHS/CHI Standards http://www.ncvhs.hhs.gov/ http://www.ncvhs.hhs.gov/

LOINC codes and RELMA http://www.loinc.org LOINC codes and RELMA http://www.loinc.org

HL7 Tools and specifications http://www.hl7.org HL7 Tools and specifications http://www.hl7.org

SNOMED and others http://www.nlm.gov SNOMED and others http://www.nlm.gov

Jterm http://informatics.ucdavis.edu/jterm/ Jterm http://informatics.ucdavis.edu/jterm/