Converting HL7 CDA Based Nationwide Austrian Medication Data to OMOP CDM.

Austria's national Electronic Health Record (EHR) system holds information on medication prescriptions and dispenses in highly structured HL7 Clinical Document Architecture (CDA) documents. Making these data accessible for research is desirable due to their volume and completeness. This work describes our approach of transforming the HL7 CDA data into Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) and highlights a key challenge, namely mapping the Austrian drug terminology to OMOP standard concepts.

Transforming Documents of the Austrian Nationwide EHR System into the OMOP CDM.

The Austrian nationwide EHR system ELGA can contribute valuable data for research due to its high volume of data and broad population coverage. In order to be applicable in international research projects, transformation to a standardized, research-oriented data model such as the OMOP common data model is essential. In this paper we describe our experience with the corresponding transformation task. Using Python scripts, we implemented a prototypical process that extracts, transforms, maps, and loads fully structured sections of ELGA documents to an OMOP database.

Extending the Austrian National EHR System with Patient-Reported Outcome Data.

The Austrian national Electronic Health Record system ELGA is a population-based infrastructure for health data. However, to date, it does not include patient-reported outcomes. In this paper, we describe on-going work on extending ELGA with patient-reported outcome data. This will be done by linking ELGA with the infrastructure of the Health Outcomes Observatory (H2O) initiative. The focus will be on using ELGA's identifier registry for H2O patients and making H2O outcome data accessible in ELGA via an existing ELGA document type for telemonitoring.

Generation of FHIR-Based International Patient Summaries from ELGA Data.

Patient summaries grant healthcare providers a concise overview of a patient's status. This paper showcases to which degree International Patient Summaries (IPS) represented in HL7 FHIR format can be generated using data from the nationwide Austrian Electronic Health Record system ELGA. A solution is presented which enables the automated software-assembled generation of an IPS using the FHIR Mapping Language. The generated document successfully validates against the IPS profiles. Our results show that all required IPS sections can be supplied from ELGA data.

Semiautomatic Recruitment of Trial Patients Using ELGA Data: Conceptual Design and Implementation of an IT Tool.

Reuse of EHR data can substantially improve the recruitment process of clinical trials. As shown earlier, Shared EHR systems are particularly attractive data sources. The goal of this work was to conceptually design and implement a user-friendly tool for semiautomatic trial recruitment using ELGA data. The tool applies a web-based client (Vue and Electron frameworks) - server (Django-Python and Java server, SQLite database) architecture. Trial eligibility criteria are expressed as XPaths. Access to ELGA documents is simulated using the eHealth Connector library and the IHE XDS Open eHealth Integration Platform framework. Usability was optimized in expert interviews with investigators of two active trials. First feedback based on synthesized ELGA test data indicates suitability for clinical end users. Further insights are expected from applying the tool to real ELGA data.

International Comparison of Six Basic eHealth Indicators Across 14 Countries: An eHealth Benchmarking Study.

BACKGROUND: Many countries adopt eHealth applications to support patient-centered care. Through information exchange, these eHealth applications may overcome institutional data silos and support holistic and ubiquitous (regional or national) information logistics. Available eHealth indicators mostly describe usage and acceptance of eHealth in a country. The eHealth indicators focusing on the cross-institutional availability of patient-related information for health care professionals, patients, and care givers are rare. OBJECTIVES: This study aims to present eHealth indicators on cross-institutional availability of relevant patient data for health care professionals, as well as for patients and their caregivers across 14 countries (Argentina, Australia, Austria, Finland, Germany, Hong Kong as a special administrative region of China, Israel, Japan, Jordan, Kenya, South Korea, Sweden, Turkey, and the United States) to compare our indicators and the resulting data for the examined countries with other eHealth benchmarks and to extend and explore changes to a comparable survey in 2017. We defined "availability of patient data" as the ability to access data in and to add data to the patient record in the respective country. METHODS: The invited experts from each of the 14 countries provided the indicator data for their country to reflect the situation on August 1, 2019, as date of reference. Overall, 60 items were aggregated to six eHealth indicators. RESULTS: Availability of patient-related information varies strongly by country. Health care professionals can access patients' most relevant cross-institutional health record data fully in only four countries. Patients and their caregivers can access their health record data fully in only two countries. Patients are able to fully add relevant data only in one country. Finland showed the best outcome of all eHealth indicators, followed by South Korea, Japan, and Sweden. CONCLUSION: Advancement in eHealth depends on contextual factors such as health care organization, national health politics, privacy laws, and health care financing. Improvements in eHealth indicators are thus often slow. However, our survey shows that some countries were able to improve on at least some indicators between 2017 and 2019. We anticipate further improvements in the future.

Reusing Data of an EU-Wide EHR System for Clinical Trials: A Capabilities Analysis.

Conduction of clinical trials may benefit from the reuse of EHR data. The upcoming EHR system eHDSI provides data exchange between European countries and thus represents an attractive data source for multinational trials. In this paper we analyze to what extent eHDSI could provide data relevant for trials with a focus on patient recruitment. Data elements identified in the EHR4CR project to be frequently used in trials were mapped to the HL7 templates of the eHDSI document types using the open source tool ART-DECOR. From the 149 EHR4CR data elements, 44 (30%) could be mapped to eHDSI document components. Despite this moderate coverage, eHDSI could still provide a substantial contribution for recruitment by an automatic pre-filtering process of large groups of potential trial candidates.

Telemonitoring readiness among Austrian diabetic patients: A cross-sectional validation study.

Digitalized healthcare services offer remote and cost-effective treatment of diabetes patients. Thus, the present online study analyzed the readiness to use telemonitoring among Austrian diabetes patients. We developed and validated a German version of the patient telehealth readiness assessment tool and performed quantitative context analysis of free-text comments on perceived barriers and benefits of telemonitoring. Participants (n = 41, 42.6% females) achieved a medium average readiness level for telemonitoring. The three top benefits were intensified care, shorter travel and waiting times, and better therapy adjustment. The top three barriers were data privacy issues, loss of personal communication and focus on blood sugar, and teledoctor competence. Diabetes patients represent a suitable target group for remote treatment opportunities. However, a shift from traditional face-to-face medical care to exclusive telemonitoring treatment from diagnosis to consultation and treatment requires fundamental new legal framework conditions.

Quantification of the resilience of primary care networks by stress testing the health care system.

There are practically no quantitative tools for understanding how much stress a health care system can absorb before it loses its ability to provide care. We propose to measure the resilience of health care systems with respect to changes in the density of primary care providers. We develop a computational model on a 1-to-1 scale for a countrywide primary care sector based on patient-sharing networks. Nodes represent all primary care providers in a country; links indicate patient flows between them. The removal of providers could cause a cascade of patient displacements, as patients have to find alternative providers. The model is calibrated with nationwide data from Austria that includes almost all primary care contacts over 2 y. We assign 2 properties to every provider: the "CareRank" measures the average number of displacements caused by a provider's removal (systemic risk) as well as the fraction of patients a provider can absorb when others default (systemic benefit). Below a critical number of providers, large-scale cascades of patient displacements occur, and no more providers can be found in a given region. We quantify regional resilience as the maximum fraction of providers that can be removed before cascading events prevent coverage for all patients within a district. We find considerable regional heterogeneity in the critical transition point from resilient to nonresilient behavior. We demonstrate that health care resilience cannot be quantified by physician density alone but must take into account how networked systems respond and restructure in response to shocks. The approach can identify systemically relevant providers.

Expressing Patient Selection Criteria Based on HL7 V3 Templates Within the Open-Source Tool ART-DECOR.

BACKGROUND: Reuse of EHR data for selecting patients who are eligible for clinical research can substantially improve the recruitment process. ART-DECOR is an open-source tool that is commonly used to design and publish HL7 V3 templates of national (e.g. ELGA) and international EHR initiatives. OBJECTIVES: Extend ART-DECOR to allow the definition of criteria that may be used for patient selection. METHODS: Using the native ART-DECOR development framework we extended existing ART-DECOR template associations by allowing conditions to be formulated. RESULTS: An editor for the specification of conditions was implemented. The resulting criteria are internally translated to XPath expressions and can be immediately applied to CDA documents. As a prototypical application of our approach we implemented a "Trial Criteria Evaluator" tool that allows trial eligibility criteria to be composed of our ART-DECOR criteria and have them checked against a patient's CDA documents. CONCLUSION: Referring to HL7 templates, our criteria can be applied to documents of national EHR systems such as ELGA and hereby reach a broad patient cohort. Implementing our approach within ART-DECOR alleviates its reuse and enhancement by other researchers.

Patient-Sharing Relations in the Treatment of Diabetes and Their Implications for Health Information Exchange: Claims-Based Analysis.

BACKGROUND: Health information exchange (HIE) among care providers who cooperate in the treatment of patients with diabetes mellitus (DM) has been rated as an important aspect of successful care. Patient-sharing relations among care providers permit inferences about corresponding information-sharing relations. OBJECTIVES: This study aimed to obtain information for an effective HIE platform design to be used in DM care by analyzing patient-sharing relations among various types of care providers (ToCPs), such as hospitals, pharmacies, and different outpatient specialists, within a nationwide claims dataset of Austrian DM patients. We focus on 2 parameters derived from patient-sharing networks: (1) the principal HIE partners of the different ToCPs involved in the treatment of DM and (2) the required participation rate of ToCPs in HIE platforms for the purpose of effective communication. METHODS: The claims data of 7.9 million Austrian patients from 2006 to 2007 served as our data source. DM patients were identified by their medication. We established metrics for the quantification of our 2 parameters of interest. The principal HIE partners were derived from the portions of a care provider's patient-sharing relations with different ToCPs. For the required participation rate of ToCPs in an HIE platform, we determine the concentration of patient-sharing relations among ToCPs. Our corresponding metrics are derived in analogy from existing work for the quantification of the continuity of care. RESULTS: We identified 324,703 DM patients treated by 12,226 care providers; the latter were members of 16 ToCPs. On the basis of their score for 2 of our parameters, we categorized the ToCPs into low, medium, and high. For the most important HIE partner parameter, pharmacies, general practitioners (GPs), and laboratories were the representatives of the top group, that is, our care providers shared the highest numbers of DM patients with these ToCPs. For the required participation rate of type of care provide (ToCP) in HIE platform parameter, the concentration of DM patient-sharing relations with a ToCP tended to be inversely related to the ToCPs member count. CONCLUSIONS: We conclude that GPs, pharmacies, and laboratories should be core members of any HIE platform that supports DM care, as they are the most important DM patient-sharing partners. We further conclude that, for implementing HIE with ToCPs who have many members (in Austria, particularly GPs and pharmacies), an HIE solution with high participation rates from these ToCPs (ideally a nationwide HIE platform with obligatory participation of the concerned ToCPs) seems essential. This will raise the probability of HIE being achieved with any care provider of these ToCPs. As chronic diseases are rising because of aging societies, we believe that our quantification of HIE requirements in the treatment of DM can provide valuable insights for many industrial countries.

Can the Austrian Nation-Wide EHR System Support the Recruitment of Trial Patients?

Automatic comparison of routinely collected EHR data with trial eligibility criteria can speed up patient recruitment. The present work aims to analyze to what extent the Austrian nation-wide EHR system ELGA could support this task. Using the open source tool ART-DECOR we tried to map a reference list of 150 common eligibility criteria specified in the EHR4CR project to the HL7 CDA templates that describe the structure of ELGA document types. For 61% of the criteria mappings could be made to ELGA template elements holding structured data. Comparing our results with similar work, we conclude that ELGA could be a useful component for the automatic identification of trial patients.

Readiness to use telemonitoring in diabetes care: a cross-sectional study among Austrian practitioners.

BACKGROUND: Telemonitoring services could dramatically improve the care of diabetes patients by enhancing their quality of life while decreasing healthcare expenditures. However, the potential for implementing innovative treatment options in the Austrian public and private health system is not known yet. Thus, we analyzed the readiness to use telemonitoring in diabetes care among Austrian practitioners. METHODS: We conducted an online survey among a purposive sample of Austrian practitioners (n = 41) using an adapted German version of the practitioner telehealth readiness assessment tool. We assessed three readiness domains for telemonitoring in the context of diabetes care, i.e. core readiness, engagement readiness, and structural readiness, and validated the German tool using principal components analysis. RESULTS: Study subjects perceived themselves as open to innovations and also expressed optimistic attitudes towards telemonitoring in general and offering telemonitoring-based services for their patients. Participants achieved a medium average readiness level for telemonitoring (58.2, 95% CI 53.9-62.5) and were thus in a good position to use telemonitoring, although some arguments may adversely affected its use. The top three perceived benefits of telemonitoring were enhanced quality of treatment, better therapy adjustment, and reduced travel and waiting times for patients. The top three barriers were reduced personal communication, practitioner time expenditure and equally placed poor financial compensation as well as data security and privacy issues. CONCLUSION: Our data revealed that Austrian practitioners showed a quite moderate readiness to use telemonitoring in diabetes care. To further advance telemonitoring readiness among all pillars of diabetes care in Austria, joint efforts among healthcare stakeholders are required to overcome existing financial, organizational, and technical obstacles.

Is Austria Ready for Telemonitoring? A Readiness Assessment Among Doctors and Patients in the Field of Diabetes.

BACKGROUND: Telemonitoring offers new opportunities in the treatment of chronically ill patients and could help to improve their quality of life while reducing healthcare costs. OBJECTIVES: The willingness to use telemonitoring is examined for both physicians and patients. From the perspective of the most important stakeholders, advantages and disadvantages as well as barriers for telemonitoring are analysed. METHODS: A Telehealth Readiness Assessment was carried out with physicians (n = 41) and patients (n = 47) in a cross-sectional study. A stakeholder survey was conducted by use of interviews (n = 28). RESULTS: Average readiness for telemonitoring is 58% for physicians, and 65% for patients. Both are thus in a position where there are several arguments which adversely affect the success of telemonitoring. The most important advantage is the intensified care, while the biggest concerns are data protection as well as the loss of personal communication. The greatest barriers are the lack of funding, the weak clinical and economic evidence and the organisation of the Austrian healthcare system. CONCLUSION: There are still some barriers to overcome, especially financial, political and organisational.

Mortality and continuity of care - Definitions matter! A cohort study in diabetics.

OBJECTIVE: To demonstrate that when investigating the relevance of continuity of care for patient outcomes, different definitions can lead to contradicting results. METHODS: We used claims data from the regional public health insurer of Lower Austria covering the period from 2008 to 2011. The study sample included subjects with repeated dispensings of anti-diabetic drugs. The continuity of care index was calculated firstly based on a patient's contacts with general practitioners (primary COCI) and secondly based on contacts at all medical disciplines (total COCI). The association of the two continuity of care measures with mortality was assessed in separate univariable and multivariable Cox regression models. RESULTS: Our study sample consisted of 51,717 patients with a median observation time of 3.65 years. The data showed that a high total COCI was associated with increased mortality, while there was no association between primary COCI and mortality. CONCLUSIONS: Measures of continuity of care are highly sensitive to the type of medical disciplines taken into account. The continuity of care index calculated from contacts at all medical disciplines might measure diversity rather than continuity of care.

A Web-Based Tool to Evaluate Data Quality of Reused Health Data Assets.

BACKGROUND: Data from the health care domain is often reused to create and parameterize simulation models for example to support life science business in the evaluation of new products. Data quality assessments play an important part to help model users in interpreting simulation results by showing deficiencies in the raw data used in the model building and offers model builders a comparison of data quality amongst the used data assets. OBJECTIVES: Assess data quality in raw data prior to creating simulation models and prepare results for model users. METHODS: Using a literature review and documentation of previous models created, we searched data quality criteria. For eligible criteria we formulated questions and viable answers to be used in a questionnaire to assess data quality of a data asset. RESULTS: We developed a web tool to evaluate data assets using a generic data model. Percentage results are visualized using a radar chart. CONCLUSION: Data quality assessment with questionnaires offers model builders a framework to critically analyse raw data and to detect deficiencies early in the modelling process. The summarized results can help model users to better interpret simulation results.

Disease Monitoring Related Adherence and Its Association with Mortality in Lower Austrian Diabetes Patients.

BACKGROUND: Patient adherence is an important component of an efficient therapy. For diabetes patients it may contribute to controlled glucose values and reduction of adverse outcomes. OBJECTIVES: We aim to examine a potential association of Lower Austrian diabetes patients' adherence concerning their disease monitoring and mortality. METHODS: Using a retrospective cohort study design, claims data of 55,873 diabetes patients were examined for regular HbA1c lab tests that served as a proxy for monitoring related adherence. The cumulative incidence of mortality was estimated in the total study population and separately for different levels of adherence using the product-limit method. Mortality was compared between the different levels of adherence by the log-rank test. RESULTS: The cumulative incidence of mortality after one and two years was 4.2% and 8.7%. Patients with low adherence had a significantly higher risk of mortality than patients with high adherence (p < 0.001). Further results of a multivariable analysis will be presented at the conference. CONCLUSION: According to our preliminary univariate analysis, monitoring related adherence seems to be substantially beneficial for diabetes patients in Lower Austria.

Improving the informational continuity of care in diabetes mellitus treatment with a nationwide Shared EHR system: Estimates from Austrian claims data.

PURPOSE: Shared Electronic Health Record (EHR) systems, which provide a health information exchange (HIE) within a community of care, were found to be a key enabler of informational continuity of diabetes mellitus (DM) care. Quantitative analyses of the actual contribution of Shared EHR systems to informational continuity of care are rare. The goal of this study was to quantitatively analyze (i) the degree of fragmentation of DM care in Austria as an indicator for the need for HIE, and (ii) the quantity of information (i.e. number of documents) from Austrian DM patients that would be made available by a nationwide Shared EHR system for HIE. METHODS: Our analyses are based on social security claims data of 7.9 million Austrians from 2006 and 2007. DM patients were identified through medication data and inpatient diagnoses. The degree of fragmentation was determined by the number of different healthcare providers per patient. The amount of information that would be made available by a nationwide Shared EHR system was estimated by the number of documents that would have been available to a healthcare provider if he had access to information on the patient's visits to any of the other healthcare providers. As a reference value we determined the number of locally available documents that would have originated from the patient's visits to the healthcare provider himself. We performed our analysis for two types of systems: (i) a "comprehensive" Shared EHR system (SEHRS), where each visit of a patient results in a single document (progress note), and (ii) the Austrian ELGA system, which allows four specific document types to be shared. RESULTS: 391,630 DM patients were identified, corresponding to 4.7% of the Austrian population. More than 90% of the patients received health services from more than one healthcare provider in one year. Both, the SEHRS as well as ELGA would have multiplied the available information during a patient visit in comparison to an isolated local EHR system; the median ratio of external to local medical documents was between 1:1 for a typical visit at a primary care provider (SEHRS as well as ELGA) and 39:1 (SEHRS) respectively 28:1 (ELGA) for a typical visit at a hospital. CONCLUSIONS: Due to the high degree of care fragmentation, there is an obvious need for HIE for Austrian DM patients. Both, the SEHRS as well as ELGA could provide a substantial contribution to informational continuity of care in Austrian DM treatment. Hospitals and specialists would have gained the most amount of external information, primary care providers and pharmacies would have at least doubled their available information. Despite being the most important potential feeders of a national Shared EHR system according to our analysis, primary care providers will not tap their full corresponding potential under the current implementation scenario of ELGA.

Bridging the Gap between HL7 CDA and HL7 FHIR: A JSON Based Mapping.

The Austrian electronic health record (EHR) system ELGA went live in December 2016. It is a document oriented EHR system and is based on the HL7 Clinical Document Architecture (CDA). The HL7 Fast Healthcare Interoperability Resources (FHIR) is a relatively new standard that combines the advantages of HL7 messages and CDA Documents. In order to offer easier access to information stored in ELGA we present a method based on adapted FHIR resources to map CDA documents to FHIR resources. A proof-of-concept tool using Java, the open-source FHIR framework HAPI-FHIR and publicly available FHIR servers was created to evaluate the presented mapping. In contrast to other approaches the close resemblance of the mapping file to the FHIR specification allows existing FHIR infrastructure to be reused. In order to reduce information overload and facilitate the access to CDA documents, FHIR could offer a standardized way to query CDA data on a fine granular base in Austria.

Secondary Use of Claims Data from the Austrian Health Insurance System with i2b2: A Pilot Study.

BACKGROUND: In conformity with increasing international efforts to reuse routine health data for scientific purposes, the Main Association of Austrian Social Security Organisations provides pseudonymized claims data of the Austrian health care system for clinical research. OBJECTIVES: We aimed to examine, whether an integration of the corresponding database into i2b2 would be possible and provide benefits. METHODS: We applied docker-based software containers and data transformations to set up the system. To assess the benefits of i2b2 we plan to reenact the task of cohort formation of an earlier research project. RESULTS: The claims database was successfully integrated into i2b2. The docker-based installation approach will be published as git repository. The assessment of i2b2's benefits is currently work in progress and will be presented at the conference. CONCLUSIONS: Docker enables a flexible, reproducible, and resource-efficient installation of i2b2 within the restricted environment implied by our highly secured target system. First preliminary tests indicated several potential benefits of i2b2 compared to the methods applied during the earlier research project.