전자건강기록(EHR, Electronic Health Record)

표준 채택과 혁신

2016. 02. 182016. 02. 18

김일곤경북대학교 컴퓨터학부 교수

기술개요

기술연관도

기술동향

시장동향-진료정보교류현황시장동향-진료정보교류현황

표준동향

특허동향

현장적용사례 및 한계

EHR 을 이용한 빅데이타 활용

[원천기술]

ID,MPIID,MPIID,MPIID,MPI

④④④④

ID,MPIID,MPIID,MPIID,MPI⑫

CDSS

㉠ 영상·기능

검사

㉠ 영상·기능

검사

㉡ 진단 ·병리검

사

㉡ 진단 ·병리검

사

㉢ 진단

폼

⑨FHIR 플랫

폼

⑩보안프레임⑤⑤⑤⑤⑤⑤⑤⑤

HIEHIEHIEHIE

②②②②

HIEHIEHIEHIE

③③③③데이터입데이터입데이터입데이터입③③③③데이터입데이터입데이터입데이터입

력력력력

①①①①용용용용①①①①용용용용

어어어어

ⓐ개인건강정보서

비스

ⓐ개인건강정보서

비스

ⓑ개인영상정보

교류

ⓑ개인영상정보

교류ⓒReal Time

Service

ⓒReal Time

Service

ⓓ 전자처방전

ⓔ 인체자원은ⓔ 인체자원은

ⓕ 질·정도관

리

ⓕ 질·정도관

리ⓖ 보험청구·

심사

ⓖ 보험청구·

심사ⓗ진료협력서비

스

ⓗ진료협력서비

스ⓘEmergency

service

ⓘEmergency

service ⓙ위험·위기ⓙ위험·위기

[플랫폼] [진료] [활용]

CDSS

㉣ 처방

워크워크

⑪질·정도관

프레임워크

⑪질·정도관리

프레임워크

Set/UnitSet/UnitSet/UnitSet/Unit

⑤⑤⑤⑤

Common Common Common Common

Data Data Data Data

Set/UnitSet/UnitSet/UnitSet/Unit

력력력력

행

ⓔ 인체자원은

행

⑧⑧⑧⑧IHE IHE IHE IHE

ProfilesProfilesProfilesProfiles

⑧⑧⑧⑧IHE IHE IHE IHE

ProfilesProfilesProfilesProfiles

인증/테스트( INFRA structure)

관리

ⓙ위험·위기

관리

㉤ CP&CPG

⑥⑥⑥⑥

DeviceDeviceDeviceDevice

⑥⑥⑥⑥

DeviceDeviceDeviceDevice

⑦⑦⑦⑦

CCM/CIMICCM/CIMICCM/CIMICCM/CIMI

⑦⑦⑦⑦

CCM/CIMICCM/CIMICCM/CIMICCM/CIMI

ⓚ 원격의료서

비스

ⓚ 원격의료서

비스ⓛSHP 서비스

ⓜ Public

Health

ⓜ Public

Health

ⓝ보건·복지연계

서비스

ⓝ보건·복지연계

서비스

ⓞ 민간보험보상

서비스

ⓞ 민간보험보상

서비스

ⓟ임상연구 지

원

ⓟ임상연구 지

원

CCD for

Rehabilitation

And CRS

CDA including

Standard term

Worker’s Worker’s

Compensation Hospital Compensation Hospital

Healthcare

service

payment

providerprovider

…

Information Information

exchange serviceexchange service

Meta

data

Metadata

patient info

CDA(referral/reply/CRS)

Document of

referral/reply/CRS

Fund

Project Administrator

Subproject Administrator

Request

smart care

service

content

smart

activity

tracking

Recognize

Multi-Sensor

Industrial Industrial Accident Accident

Special HospitalsSpecial Hospitals

patientpatient

SmartCareSmartCare ServiceServiceActivity sensor

Response

Interactive

Content

Subproject Administrator

Consulting Group

Ref. Ref. ezCareTechezCareTech, Korea, Korea미래부,근로복지공단 k-Health 3.0

“지역 내 거점 대형병원을 중심으로 환자 정보 네트워크를 형성하여,

개별 의료기관에서 생성된 진료정보 및 영상정보를 하나의 커뮤니티

혹은 지역 단위 내에서 전자적으로 공유하는 시스템”

Ref: 메디시티 대구 & GE-KTC

• 핵심 SW(XDS.b:Cross-Enterprise Document Sharing) IHE인증(Validation) 여부– GE Global은 인증 획득 -> GE KTC (14년도 설치)– 이지케어텍 SW는 인증 획득– Tplus 자체 개발중 -> 빨리 인증 받아야

• 경북대 IHIS 연구소, IHE Korea 도움 필요

• XCA(Cross Community Access) SW 존재 여부– 이지케어텍 개발 해야 함– GE KTC 솔루션 있지만 개선 필요– 추후 협력 공동 개발

14

– 추후 협력 공동 개발

• 의뢰서, 회신서 CDA IG(Clinical Document Archictecture Implementation Guideline) 작성 위치, 보관 장소

– 대구시: 경대병원, 의료원 거점 병원– 분당서울대, 근로복지공단: 개별 병원– 아키텍처(분당서울대,근로복지공단): Registry(거점), Repository(각 의료기관)– 아키텍처(대구시): Registry(거점), Repository(거점)

• 참여 기관 차별성– 분당서울대, 근로복지공단: 의원 중심 (3차 종합병원 참여 확대 예정)– 대구시: 병원급(중소병원, 전문센터, 종합병원) 다수 참여

국내 진료정보교류 확산과 수가 반영

• 분당서울대병원, 신촌세브란스병원, 근로복지공단, 대구시 진료정보교류 시범사업 연결, 확산

• 의뢰, 회송 수가 반영 시범사업

• “Resources” are:– Small logically discrete units of exchange– Defined behaviour and meaning– Known identity / location– Known identity / location– Smallest unit of transaction– “of interest” to healthcare

– V2: Sort of like Segments– V3: Sort of like CMETs

• Instances shared using XML & JSON• Collections represented using ATOM

– Same technology that gives you your daily news summarysummary

– Out-of-the-box publish/subscribe

• Web calls work the same way they do for Facebook & Twitter

• Rely on HTTPS, OAuth2, etc. for security functions

• FHIR and CIMI are very different things (scope, paradigm)

• Multiple ways to relate:– FHIR could use CIMI definition framework in the backg

round– FHIR could use CIMI definition framework in the backg

round– FHIR could produce CIMI definitions as part of it’s produ

cts– CIMI could define clinical models as FHIR resource pro

files (FHIR the way to deliver things)– Pursue independent paths (for now…) and see what work

s

Ref: Grahame Grieve

• MHD–Mobile access to Health Documents

• DocumentReference, DocumentManifest

• PDQmPatient Demographic Query for mobile

• PDQm–Patient Demographic Query for mobile

• Patient

• PCD–Patient Care Device

• Observation, ObservationReport–white paper was published

• adding travel history to EHR system–based on SMART project

• Reference– http://jama.jamanetwork.com/article.aspx?articleid=1919175– http://jama.jamanetwork.com/article.aspx?articleid=1919175

• Patient application that is configured to securely connect to a PHR(Personal Health Record) in order to submit a medical history document. (For example BlueButton+)– 대학병원(Tersiary Hospital)에서 진료받은 내역, Care – 대학병원(Tersiary Hospital)에서 진료받은 내역, Care

Record Summary, Imaging Documents를 Download 받아, 지역 병원(Community Hospital/Clinic)에 Upload 한다.

– 지역 병원(Community Hospital/Clinic)에서 진료받은 내역, Care Record Summary, Imaging Documents를Download 받아, 대학병원(Tersiary Hospital)에 Upload 한다.

• 실손 보험 청구에 필요한 문서• Care Record Summary• 수술기록지, 병리/진단검사결과/영상의학보고

서, 의뢰/회신서, 투약 히스토리/상황서, 의뢰/회신서, 투약 히스토리/상황• 건강검진결과지

• RF(BLE+ZigBee) 내장 스마트 게이트웨이의 3가지 역할• 위치의 기준 • Access Point • 노드 간의 거리 기반 이웃 연결 (문, 복도)

R

R R R0

RR R

RRRR

R

스마트 단말 SLiM HubResourceDevice

RRR R

RR R R

4

R R R

R2

R

R

1

R3

RR

R

스마트 조명

IT Infrastructure (ITI) domain– Patient Demographics Query for Mobile (PDQm) a profile of the FHIR Patient

resource for simple lookup and reference. Following the functionality requirements profiled in PDQ (HL7 v2), and PDQv3 (HL7 v3)

– Patient Identifier Cross-reference for Mobile (PIXm) an operation profile for retrieving just cross-referenced identifiers for a given patient - Published 2015-08-07

– Mobile access to Health Documents (MHD) a profile on DocumentReference and DocumentManifest to provide a HTTP REST and Mobile application friendly API for the usecases profiled in XDS, XDR, and XCA. The MHD profile and DocumentManifest to provide a HTTP REST and Mobile application friendly API for the usecases profiled in XDS, XDR, and XCA. The MHD profile may be used as an API to these Document Sharing infrastructures, or may be used alone.

– RESTful Query to ATNA a profile on AuditEvent for query and reporting. -First Published 2015-08-07

– Mobile Alert Communication Management (mACM) a profile on Communication for alert notifications - Published 2015-08-07

– Companion– Internet User Authorization (IUA) a profile of OAuth for use with HTTP REST

access - Published 2013-09-20

• http://fhir.healthintersections.com.au/ - Grahame's test server.– Supports all resource types, all operations, xml + json– implementation details: open source - see [[1]]– also available using SSL at https://fhir.healthintersections.com.au/ (not

operational right now)– see Health Intersections FHIR Server login documentation for Oauth

• http://spark.furore.com - Ewout's test server (previously fhir.furore.com). The actual service endpoint is at http://spark.furore.com/fhir.actual service endpoint is at http://spark.furore.com/fhir.– Supports all resource types, all operations, xml + json– implementation details: C# reference implementation, WebApi 2.0 library, Mongo

DB for storage and search.– Server is running on AppHarbor, Mongo at MongoLab, and storage of binary is

done on Amazon S3– Available in the open source - see [[2]]

• http://nprogram.azurewebsites.net/ - Rik Smithies/NProgram test server– person and patient resources, read only (C#)

• http://fhir.oridashi.com.au - Brett Esler/Oridashi demo servers overview– read-only implementation, .NET 2.0, C#, self-host web server, SQL Server DB - legacy CIS– DSTU1: 'Best Practice CIS' http://demo.oridashi.com.au:8190– DSTU2: 'Best Practice CIS' http://demo.oridashi.com.au:8290 and http://bp.oridashi.com.au– DSTU1: 'Medical Director CIS' http://demo.oridashi.com.au:8191– DSTU2: 'Medical Director CIS' http://demo.oridashi.com.au:8291 and http://md.oridashi.com.au– DSTU1: 'Zedmed CIS' http://demo.oridashi.com.au:8192/– DSTU2: 'Zedmed CIS' http://demo.oridashi.com.au:8292/ and http://zm.oridashi.com.au

• https://fhir.smartplatforms.org - Josh Mandel / SMART Platforms– Open-source server in Grails (Java/Groovy) + MongoDB– "SMART on FHIR" Server: https://fhir-api.smartplatforms.org | https://fhir-open-api.smartplatforms.org | Source– "FHIR Starter" App Launcher https://fhir.smartplatforms.org | Source

• http://worden.globalgold.co.uk:8080/FHIR_a/hosted_demo.html Robert Worden / Open Mapping Software– Patient resource, read-only– Patient resource, read-only– Illustrates building a FHIR server on any existing application, any resource, by mapping to the application database– Tools to do this now available free, evolving

• https://fhir.orionhealth.com/blaze/fhir/metadata (actual endpoint is https://fhir.orionhealth.com/blaze/fhir/)– Supports all resource types, all operations, xml + json and gzip– All resources (including bundles) are validated with the DSTU XSD files, schematrons and Ewout's validation engine.– implementation details: C# reference implementation, WebApi 2.0 library, SQLserver for storage and search

• http://fhirplace.health-samurai.io/– Supports all resource types, all operations, xml + json– Based on fhirbase (https://github.com/fhirbase/fhirbase)– Implementation: postgresql, clojure/FHIR-Java (https://github.com/fhirbase/fhirplace)

• http://fhirtest.uhn.ca/ - HAPI / University Health Network test server– Supports all resource types and operations– Has query builder UI which can be used to facilitate testing– Endpoints:

• DSTU1: http://fhirtest.uhn.ca/baseDstu1• DSTU2: http://fhirtest.uhn.ca/baseDstu2

• http://open.epic.com/Interface/FHIR - Epic's Sandbox– Supports a subset of resource types, read-only– Runs against a functional Epic database– Includes online test harness for quick syntax checking– Contact open@epic.com for more information

• """"CEOs CEOs CEOs CEOs also should consider, if the agreement is terminated, also should consider, if the agreement is terminated, also should consider, if the agreement is terminated, also should consider, if the agreement is terminated,

in in in in what form they will get what form they will get what form they will get what form they will get their patient data? Will it be readily their patient data? Will it be readily their patient data? Will it be readily their patient data? Will it be readily

portable to another EHR portable to another EHR portable to another EHR portable to another EHR solutionsolutionsolutionsolution?“?“?“?“

• Also, covered entities should consider in their Also, covered entities should consider in their Also, covered entities should consider in their Also, covered entities should consider in their overall overall overall overall

contingency planning contingency planning contingency planning contingency planning "how they "how they "how they "how they back up back up back up back up patient data and patient data and patient data and patient data and

how they will how they will how they will how they will restorerestorerestorerestore such data if their EHR software such data if their EHR software such data if their EHR software such data if their EHR software

becomes inaccessible, such as due to a contract dispute,"becomes inaccessible, such as due to a contract dispute,"becomes inaccessible, such as due to a contract dispute,"becomes inaccessible, such as due to a contract dispute,"

� 사용자 편의 우선으로 인한 자료의 활용성 저하

­ 신속한 입력 및 조회, 화면 디자인에 집중되어 상대적으로 체계적인 자료구조 및 관계 분석 미흡

­ Data를 설명하는 meta data의 기록 부족으로 자료의 해석의 모호성 지속

­ 환자상태 정성지표의 표준화 부재로 자료의 식별력 저하

� 존재를 확인할 수 없는 서식 및 기록의 발생으로 인한 정보의

­ 종이환경에 비해 다량다종의 서식과 기록이 존재하나 서식의 파생이력이 관리되지 않음

­ 기록의 Copy&Paste가 난무하나 이력이 관리되지 않아 자료추적 어려움

­­ Meta data부족으로 인한 정확한 자료의 실시간 검색의 난관 봉착(H/W 성능에 의존)

� 공유의 동기부족으로 인한 표준화 부족, 그로 인한 악순환

­ 기록의 공유로 인한 동기부여의 부재로 효율적 공유를 위한 표준화 작업 미비

­ 상용 EHR시스템 개발 및 보급의 어려움(시스템 potting이 아닌 customizing 지속)

­ 업무의 표준화를 통한 기술의 표준화 부족으로 표준개발 연구자료의 현장적용 미흡

� EHR 이전기록과의 통합관리의 부족으로 인한 자료활용의 악순환 지속

­ 기존 Text date까지 이미지로 변환하여 단순열람 목적으로만 활용

­ Data migration에서 부터 data integration까지 자료 통합을 위한 기술의 개발 및 공유 부진

­ 차세대 시스템으로 upgrade시 이전 기록과의 단절 발생 우려

­ 이전기록과의 단절 또는 연결 부족으로 인한 지속적인 관리비용 증가 예상

• FHIR 기반 국민건강검진 시스템 Globalization

• FHIR 서버, 서비스 개발 위한 Open Source 커뮤니티 구성

• “내건강기록은 내손안에”를 실현할 수 있는 솔루션 구축– 영상기록은 HESEL.org 활용– 영상기록은 HESEL.org 활용– 웹, XDR, XDM, XDS.b 기반 진료정보교류 프레임워크 구축

• 주민번호 키값 사용 제한에 따른 MPI(Master Person Index) 시스템 구축

• Precision Medicine– Voluteer 모집, 지원