China National EHR How Far We Are?

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China National EHRHow Far We Are?

• Huilong Duan, Ph.D.
• School of Biomedical Engineering Instrument
  Science
• Zhejiang University
• Email duanhl_at_zju.edu.cn

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Global Challenges in Health Care

• Cost-containment and affordability
• Expanded access
• High quality of health care
• Chronic disease management (e.g. Cardiovascular
  diseases, diabetes)
• Infectious disease prevention and management
  (e.g. H1N1 Flu, AIDS, SARS, TB)

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Current Health Care in China
57 population in rural areas 80
hospitals in cities

• Uneven distributed limited health care
  resources
• Limited medical insurance coverage
• Increasing costs

Large amount of migrant people (0.147 billion)
Limited health Infrastructure (2.75 bed/1000)
Aging population (0.144 billion)
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Medical Expenses in China
government
32 gt 17 government 48 gt 29 society 20 gt
54 private
society
private
Difficulty and high cost in seeking medical
service is the TOP ONE concern! -- Society of
China Analysis and Forecast Blue Book, 2007
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Reform to Provide Better Health Care
Establish national essential drug system 
medical insurance systems that will cover all
urban and rural residents.
medical insurance systems that will cover all
urban and rural residents.
Rural health
Rural health
Public health
Public health
Community health
Community health
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Health Care Reform in China
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HIT Supports in the Reform
e-Health
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EHR is Critical in e-Health
Personalization
Healthcare Face-To-Face

• Passive treatment to proactive prevention
• Seamless access to health services

Heal th service
City hospital
Regionalization

• Isolation of the medical resources to
  subdivision, share, synergy regionalization

Government agencies
Data center
County or city level hospital
Citizen
Informationization

• Medical and health technology
• based on modern electronics, engineering,
  information and bio-engineering  

Related medical and health institutions
Urban and rural community health service agencies
Electronic health record as the core Resources
sharing as the basic
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Case 1 Community health service in
Dongcheng district of Beijing
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Case 2 Health Information System in Xiamen City
Civil Affairs
Insurance
Bank
Price Control
Supply
Drug administration
e-Hospital
e-Health Administration
e-Community Healthcare
Regional Health Data Center
e-CDC
e-Health Supervision
e-family healthcare
Up level health data center
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Case 3 Regional health information network
(????) of Shanghai

• Goal
• Connect hospitals and share medical information
• Improve HIT adoption in hospitals
• Provide economical and convenient healthcare
• First phase 
• Share information among hospitals patients
  basic information, medical record, laboratory
  result, medical image and report
• Web port query, consult, appointment
• Public Health statistics, monitoring

Avoid unnecessary repeated lab test and
medical imaging examination
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Case 4 National e-Health Key Technology and
Regional Trial Implementation in Zhejiang
Province

• Supported by Ministry of Health, Ministry of
  Science and Technology, and Zhejiang Province
• 7 tasks to evaluate key technologies and the
  applications in e-health

Zhejiang Province 22 regions Covering 8 million
population
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Task 1EHR modeling

• Define health meta data and data sets from
  fetus to death
• Model EHR to cover all the key health points of
  entire life
• Define the services to integrate all the health
  information together

death
birth
Health care service cover the entire life
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Task 2Standards and specifications development
Cooperation with organizations such as Ministry
of Health, Chinese Association of Health
Information, Standardization Administration of
China, to develop and integrate standards that
will meet the needs of e-health

• Data classification and coding specification

• Data collection and exchange norms

• Standardize business processes

Health Record basic infrastructure and data
specification(on trial) EMR basic
infrastructure and data specification (Draft)
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Task 3Applications development on EMR

• Advanced clinical information systems
• Data mining and analysis technologies on EMR

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Task 4Regional health information exchange
platform
government
social insurance
business insurance
blood station
pharmacy
antiepidemic organization
supplier
Regional Data Center
maternity and child healthcare
bank
health supervision
emergence center
citizen
hospitals
community health service center
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Task 5EMR based Tele-medicine platform
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Task 6Prompt clinical pathway and other CDSS
adoption in hospitals
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Task 7Regional implementation and evaluation

• Every 1,500 residents has a family doctor
• Health examinations for EHR (free of charge)
  every 2 years
• Depends on the adoption of HIT

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EHR related Actions in China

• Starting in 2009, a unified health record for all
  residents will be established throughout the
  country, promoting equality in right to basic
  health service
• -- National Human Rights Action Plan of China
  (2009-2010)
• Focus on developing regional health information
  platform upon resident electronic health record,
  and hospital information platform upon EMR
• -- major work plan of Ministry of Health in
  the year 2009

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Establish a National EHR in China

• Interoperability
• Health policy level
• Health services level
• Semantic level
• Technical and functional level
• Security and privacy
• Laws, regulations, and standards
• Security and privacy education
• Technical practices
• The cost
• Government role in investment

• Three major challenges

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Semantic Interoperable EHR

• Generic reference models for representing
  clinical (EHR) data
• e.g. EN 13606, HL7 CDA, openEHR Reference
  Model
• Agreed clinical data structure definitions
• e.g. openEHR archetypes, HL7 templates,
  generic templates and data sets
• Clinical terminology systems
• e.g. LOINC, SNOMED-CT

StandardizedArchitecture
StandardizedInterfaces
StandardizedData Structures
StandardizedData Vocabularies
StandardizedFunctional Behaviour
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Major difficulties to achieve interoperability

• Chinese version medical terminology standard,
  code systems and message exchange standard
• Management and regulation lag behind the
  requirement of HIT
• Agreed EHR/EMR conception and recognition
• Standard-based HIT systems and products
• Clinical informatics research and knowledge base
  support

• Difficult to share data between information
  islands
• Clinical information system adoption is low,
  clinician get insufficient benefits from HIT
• Repeated low-level HIT applications exhausted
  most of the investment

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Security and Privacy

• MOH Measures for the Administration of
  Electronic Certification Services in Healthcare
  (on trial) begin trial implementation at Jan. 1,
  2010
• Privacy Security standard and implementation
  specifications like HIPAA in the US are not
  available
• Should coordinate with interoperable architecture
  design work and general privacy legislation
  procedure
• Electronic certification service provider is
  needed to support the future national EHR
• Both clinicians and patients lack security and
  privacy consciousness

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Governments role

• Many roles for the government to choose in
  e-health. Different role has different cost and
  risk
• Planner and investor

Strategic investor
System developer
Standard maker
Construction supervisor
Policy maker
Industry supporter
Strategy Planner
Infrastructure constructor
Best practice promoter
System operator
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HIT standards break out in China
Ministry of Health of China published several HIT
standards since 2009

• Health Record basic infrastructure and data
  specification (on trial) at May 19, 2009.
• EMR basic infrastructure and data specification
  (Draft) at August 4, 2009.
• Technical Solution for Regional Health
  Information Platform based-on EHR (on trial) at
  December, 2009
• National Health Data Dictionary and Meta Data
  Management System at December, 2009
• Measures for the Administration of Electronic
  Certification Services in Healthcare (on trial)
  at December, 2009
• Electronic Medical Record basic specification (on
  trial) at March, 2010

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A Study on Information Infrastructure of A
nationwide EHR

• Jointly funded by China NSF and Chinese Academy
  of Engineering
• Part of the study on national long term
  development strategy of engineering science and
  technology of China

Project Director Huilong Duan
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National EHR Roadmap
Operation Refinement (2025-2030)
Preparation Trial (2010-2016)
Construction Development (2017-2025)
2010
2020
2030
2015 50 3-level hospital 30 urban community
health center 20 rural hospital or
clinic Adoption interoperable EMR/EHR Demonstratio
n regional EHR
2025 100 3-level hospital 90 urban community
health center 80 rural hospital or
clinic Adoption interoperability EMR/EHR A
nationwide interoperable health information
network formed
2020 80 3-level hospital 50 urban community
health center 50 rural hospital or
clinic Adoption interoperable EMR/EHR Establish
above 10 province level EHR systems.
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Preparation and Trial (2010-2016)

• Tasks
• Medical informatics basic construction
• Enterprise information construction
• Regional EHR demonstration
• Plans in detail
• Establish a national organization to lead and
  coordinate the national wide Health IT efforts
  and responsible for drawing the detail blue
  print of National EHR
• Establish professional standard organizations
• Modify and new law and regulation adjusting to
  e-health
• Healthcare information security and privacy act
• EMR regulation
• Launch finance and policy to accelerate
  standard-based interoperability EMR adoption in
  hospitals

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Construction and development (2017-2025)

• Tasks
• Widespread standard-based interoperability EMR in
  hospitals
• National EHR infrastructure construction
• Plans in detail
• Nationwide high speed networks for health
  information exchange
• Construct national standard EHR information
  infrastructure, such as Identity, Service,
  Auditing Service, Encryption Service, User
  Authentication Service, et al.
• Promote knowledge systems and applications such
  as clinical decision support system, digital
  clinical guideline, clinical pathway
• Promote self-care and household medical systems
  and devices integrated in the EHR
• Online billing in the new medical security
  systems, develop funding monitoring tools

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Operation and refinement (2025-2030)

• Tasks
• Refine the operation mode and regulation system
• A complete e-health system based on national EHR
• Plans in detail
• Establish professional national EHR operator,
  gradually operates in market mode
• Study the deep utilization of national EHR data
  resource and add value for enterprise connect in
  national EHR networks
• Popularize the self-care and family-care health
  service supported by professional systems and
  applications
• Accelerate the new healthcare service mode
• Community health deal with most of the health
  problems
• 3rd level hospital only accept transfer patient
  from GP

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EHR in translational medicine
Standard semantic interoperable EHR provide the
possibility to reuse the data for research
purposes

• Integration of genomic information in EHR may
  lead to genotype-to-phenotype correlation
  analysis
• China national EHR, on 1.3 billion persons
  health and medical data and information, will
  have a significant impact on translational
  research

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Colorectal Cancer Translational Research Center
at ZJU

• Participating institutions
• -- School of Medicine
• -- Sir Shaw Run Run Hospital
• -- School of Biomedical Engineering Instrument
  Science
• Provide efficient communications and resource
  sharing between biomedical and clinical
  researches in colorectal cancer
• Benefit patients with medical discoveries

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Information infrastructure to enable
translational research
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Translational EHR in future
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China National EHR long way ahead

• Most of the hospitals still use paper-based
  medical records
• Currently available standards are far from enough
  for e-health
• a common problem in most countries, especially in
  China
• Lack of professional talents in both research and
  industry
• medical informatics education just began
• Short of products and systems in the market
• Some social obstacle will exist for a long time
• hospitals unwilling to share their data
• clinician unwilling to change their workflow
• people unwilling their privacy under risk

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Thank you!