Chapter Five

eHealth Architecture (eHA)

and Standards

For 3rd Year HI Students

By
Temesgen Dileba (MSc HI)
 Chapter Objectives
At the completion of this chapter the students
will be able to:
 Explain concepts of eHealth architecture
 Define standards and interoperability
 Describe the type of standards
 Explain the type of interoperability
 Introduce Terminology Management System
 Describe Ethiopian TMS /NHDD
 Concepts of eHealth Architecture

• Definition of common terminologies

• Architecture
– is the art of designing that enhances easy
understanding of work or task, procedure, step,
picture, communication, concept, etc.
• eHealth Architecture
– is a concept that provides a foundational plan to
support the acquisition, exchange, sharing, and use
of health data.
 Concepts of eHealth Architecture …..
• Definition of common terminologies...
• Ethiopian eHealth Architecture
– is a conceptual model that depicts the information
systems, data sources, and integrations that the
FMoH proposes to implement, maintain and
achieve its strategic goals.
• Standard
– is a uniformity, in measure, norm, or model in
comparative evaluations
– help to maximize compatibility, interoperability,
safety, repeatability, or quality.
 Concepts of eHealth Architecture …..

• Definition of common terminologies...

• Standardization
– is the process of developing technical
standards based on the consensus of different
parties such as users, interest groups, standards
organizations, and governments.
– is concerned with the uniformity of processing,
management, and governance with the provision of
solutions for associated problems in the field of
healthcare 5
 Concepts of eHealth Architecture …..

• Definition of common terminologies...

Interoperability
 is the property that allows for the
unrestricted sharing of resources
between different systems.
 is the ability to share data between
different components or machines, both
via software and hardware
 Concepts of eHealth Architecture …..

Definition of common terminologies...

Interoperability….
 is the exchange of information and
resources between different computers
through local area networks (LANs) or wide
area networks (WANs).
 is the ability of two or more components or
systems to exchange information and to use
the information that has been exchanged
 Concepts of eHealth Architecture …..

 Global Health Access Requires:

 the use of information and communication
technologies for the delivery of healthcare
services.
 a key for improving healthcare services and
health information, particularly in the
developing world.
 Concepts of eHealth Architecture …..

 To deliver such health properly it needs

 Interoperability & Standards
 Overcoming technical infrastructure barriers
 Addressing privacy, and security issues
 Other legal requirements.
 Concepts of eHealth Architecture …..
• Due to an improved eHealth policy in the
country, in recent years Ethiopian MoH
involved in several e-health apps such as:
EMR and EHR
LMIS and FIMS
GIS
Tele-education, telemedicine, & mHealth
HRIS
DHIS2,
 Data warehouse etc.
 Concepts of eHealth Architecture …..
 The Major goals of eHealth:
 Improve the capacity and capability of health professional
 Interoperable electronic health systems for all patient
 Improve health research, knowledge and practice sharing,
and information management
 Access to health services through electronic means
 Efficient system to transfer patients between health
facilities
 Patient health information available to clinicians in all
HCF.
 Concepts of eHealth Architecture …..
• How to achieve these goals: Strategies

• Identifying the main challenges for the health sector

– How to easily and securely share patients’ health

information?
The strategic solution is

• Interoperability- the ability or capability of two or more

systems to exchange information and use the exchanged

information. (Institute of Electrical and Electronic Engineers,

1991)
 Concepts of eHealth Architecture …..

• Connectivity- network capability

• Diagnostics-drug, vaccines, equipment
• Inter-regional collaboration-stakeholders
• Leading change-human resource development
• Governance-policy support
• Leveraging technology-ambulance, mHealth, road
• Interoperability-HIE
 Concepts of eHealth Architecture …..
 Interoperability
 is the ability of information technology systems
and software applications to communicate, to
exchange data, accurately, effectively, and
Consistently

 Use the information that has been exchanged.

 Making healthcare information systems

interoperable will contribute to more effective and
efficient patient care.
 Concepts of eHealth Architecture …..

• Interoperability in the eHealth System:

– able to share lifelong EHRs of patients
among different healthcare providers
– Provide clinical decision support through
the use of clinical guidelines
• Such as Electronic Health Record
Systems (EHRs), laboratory information
systems (LISs) as part of EHRs, and
wireless medical sensor devices.
 Concepts of eHealth Architecture …..
• Interoperability in the eHealth System:
– Different healthcare enterprises share different
structures and format
– Such sharing needs very complex issues of
compatibility and interoperability.
– Of them HL7 is a healthcare standard used to
allow data sharing around the globe.
 Types of Interoperability
• According to the Health Information and
Management System Society (HIMSS) there
are four levels of interoperability in healthcare:
– Foundational – Level I (Technical)

– Structural – Level II (Syntactic)

– Semantic – Level III

– Organizational – Level IV
 Types of Interoperability….

• Foundational interoperability
• is the most basic level.
• opens up a direct data exchange channel
between two health systems.
• systems at this level can’t process the data
being exchanged yet.
• one system or application securely
communicates data to and receives data
from another
 Types of Interoperability….

• Structural interoperability
• Covers data formats.
• defines the format, syntax, and organization of
data exchange including at the data field level
for interpretation
• With this level, systems can now dig deeper
into what exactly they send each other.
• Think of a pharmacy system that uses the
same information exchange format as a
provider so that it can process medication
lists.
 Types of Interoperability….

• Semantic interoperability
• Covers data handling and usage among two or more
systems.
• It Leverages data in a standardized way and shares
information and understands the information that can be
exchanged.
• For example, two systems can now recognize
terminology, medication symbols, and others while
exchanging data automatically, without human
intervention.
• Takes both structure and codification data including
vocabulary, so that receiving information technology
systems interpret the data
 Types of Interoperability….
• Organizational interoperability
– is about what it takes for semantic
interoperability to become a feasible system
in health facilities.
– Includes governance, policy, social, legal,
and organizational considerations to
facilitate the secure, seamless and timely
communication and use of data both within
and between organizations, entities, and
individuals.
Types of Interoperability….
 Why eHealth Architecture?

• The aims of designing eHealth

Architecture are:
– Maximizing ICT resource utilization
through curation, publication, and
dissemination of the eHealth Architecture
diagram.
– Creating and maintaining a detailed eHealth
architecture Roadmap Advising project
teams on integration paths and the use of
standards.
 Why eHealth Architecture?....
 The aims of designing eHealth….
 Creating and maintaining an inventory
of existing eHealth and mHealth
applications (Projects and Products)

 Maximizes IT investments by creating

reusable components, standardized
data, and a plan for integration
 Components of eHealth Architecture
• Shared services
– Provides access to common functions and data
sources
• Institution-based HIS and data sources
– administered centrally and support institutional
capabilities of the FMOH.
• Population-based HIS and data sources
– Allows collecting data directly from the
population.
• Point of service HIS
– used by health workers to facilitate service
delivery
Components of eHealth Architecture….
• Interoperability services
– Mediates the exchange of health information
between information systems in the eHA.
– It enables transaction scheduling, message routing
and encryption, transaction tracking, and error
management.

• Analytics and business intelligence

– A technology-driven approach to enhance strategic
and operational decision-making by consolidating
and analyzing data across organizational units.
Components of eHealth Architecture….

• External system
– provide important capabilities or data to the
FMOH, but fall outside of FMOH
governance.
• Governance
– The design of the HIS governance supports
the inclusion of decisions around strategy,
standards, guidelines, capacity building as
well as HIS policies and procedures
 The central point to achieve
interoperability
 Establish an interoperability framework
 Contains the set of policies, guidelines,
standards, rules

 Promote the development of information

systems and their integration
 This involves adopting open-ended
solutions and providing tools or services
that facilitate the implementation
 The central point to achieve
interoperability.....
 Resolve legal and regulatory concerns
 Digital signatures, information integrity, security
policies, and data modification processes.
 Empower the patient
 to give them the power to decide how their
data is used.
 Human capital development
 All health system users should be trained on the
validity of the new scheme as well as on topics
such as its challenges and changes
 Benefits of Interoperability

Improve the patient care experience (including

quality and satisfaction), for a better patient
experience
Improve the health of the population served,
for better population health
Reduce the per capita cost of health care, for a
lower cost of care
Improve the working lives of healthcare
providers, including doctors and staff, for
better provider well-being
 Challenges of Interoperability

 Inconsistency of terminology
 Too much data to handle
 Data security and privacy concerns
 Lack of trained staff and skill
• Lack of government coordination
• Irrelevant standards exist
 Standards

 Standard
USB cable
 is an agreed way of doing something.
Shoes, clothes
Paper sizes
Switches etc.
 is uniformity in making a product, managing a
process, delivering a service, or supplying
materials
 is not good or bad, but provides a basis to measure
and assess activities and things.
 Standards….
• Standards take the form of a reference
document:
– Specifications or guidelines
– Conditions or requirements for products
– Operations, services, methods, and systems on
how to design, operate, manufacture or manage
something.
• used consistently and properly to ensure
quality, safety, and efficiency
 Healthcare standards
• According to ISO a standard is a document,
established by consensus and approved by a
recognized body, that provides, for common
and repeated use, rules, guidelines or
characteristics for activities or their results,
aimed at the achievement of the optimum
degree of order in a given context.

• Two of the key terms are consensus and

recognized body
 Healthcare standards…..

• Consensus:
– is general agreement, characterized by the
absence of sustained opposition to
substantial issues by any important part of
the concerned interests and by a process that
involves seeking to take into account the
views of all parties concerned and to
reconcile any conflicting arguments.

– Consensus need not imply unanimity.

 Healthcare standards…..
• A recognized body
– is an internationally recognized standards
development organization such as ISO, CEN, BSI,
ANSI and its accredited SDOs including HL7.
• The activity of standardization
– consists of the processes of formulating, issuing
and implementing standards.
• Important benefits of standardization
– improvement of the suitability of products,
processes and services for their intended purposes
– prevention of barriers to trade and facilitation of
technological cooperation.
 Healthcare standards…..
• Two main considerations of standard are:
– Exact specifications, which enable interworking of
nuts and bolts, paint colors and computers
– Minimum thresholds to ensure the safety and
quality of processes, materials and the
environment.
– For healthcare interoperability we mainly need
• stringent specifications at the technical and data
layers
• minimum thresholds may be needed to ensure
safety and security at the human and
institutional levels.
 Why standards for interoperability?

• Connect and communicate computer

and software systems with one
another
• Help fosters better communication
between disparate systems
• It is easier for medical service
providers to share patient information
with one another.
Why standards for interoperability?....

• Makes healthcare more efficient, by

avoiding orders from redundant patient
tests
• Helps specialists to communicate quickly
with referring doctors.
• Bring safety and protection of
confidential patient data
• Lowered costs are given improved
efficiency in data sharing
 Types of Standards
Proprietary
developed for private use by profit-driven
industry organization
Open standard
used by interested stakeholders developed
by for-profit and nonprofit organization
Regulatory standards
Established or adopted by government or
regulatory agencies by utilizing a previous
standard and making it a requirement
 Standards in eHealth systems
 One of the challenges and opportunities
of e-health standardization is the increase
of infinite e-health standards developed
by numerous standards-setting
institutions.
 One historical challenge is that many of
these e-health standards are not
interoperable with each other or directly
coordinated with each other at an
institutional level
 Standards in eHealth systems….
• What is the International Organization for
Standardization (ISO)?
– is an independent, non-governmental international
organization with a membership of 165 national
standards bodies.
– Founded in 1947 and based in Geneva,
Switzerland,
– ISO brings together experts to share knowledge
and develop voluntary, consensus-based, market-
relevant International Standards that support
innovation and provide solutions to global
challenges.
 Standards in eHealth systems….
• About ISO:
– More than 22500 International Standards

– Develop 100 new standards each month

–
– 249 technical committees involved

– The are 165 members countries

How standard body works?
Key aspects of standards
Healthcare Standard development
organizations
Healthcare standards
 Health Informatics Standard

• In 1990, European Committee for

standardization (CEN) set up the first formal
international standards organization in health
informatics, CEN/TC 251.
• Its scope is:
– Standardization in the field of Health Information
and Communications Technology (ICT) to achieve
compatibility and interoperability between
independent systems and to enable modularity.
 Health Informatics Standard…..
• Standardization in the field of Health
Information and Communications Technology
(ICT) includes:
• requirements on health information
structure to:
– support clinical and administrative procedures,
technical methods
– support interoperable systems as well as
requirements regarding safety, security and
quality.
 Health Informatics Standard…..
• CEN/TC 251 is organized into four working
groups (WGs):
– information models

– terminology and knowledge representation

– Security, safety and quality

– technology for interoperability

 Health Level Seven (HL7)

 A non-profit organization dedicated to

providing a frame-work and standards for the
exchange
 2300 members, 500 which are corporation
 Most widely used standards for data
communication between health information
systems
 E.g. Clinical Document Architecture (CDA)
Fast Healthcare Interoperability
Resources (FHIR)
 Health Level Seven (HL7)….
• Affiliates in 31 countries.
• Produces the world’s most widely used
standards for healthcare interoperability.
• Most of the leading suppliers use and support
the development of HL7 standards across six
continents
• empowers global health data interoperability
by developing standards and enabling their
adoption and implementation.
 Health Level Seven (HL7)….
• Health Level 7
– is derived from the 7th level of the ISO’s
Open Systems Interconnect (OSI) model.
• The OSI model:
– has seven layers
• the top three layers are concerned with
applications (interworking)
• the lower four layers are concerned with
the transmission of data (interconnection)
 Health Level Seven (HL7)….
• Layer 7 – Application:
– addresses definition of the data to be exchanged,
the timing of the interchange, and the
communication of certain errors to the application.
• Layer 6 – Presentation:
– concerned with the syntax of information transfer
between end systems.
• Layer 5 – Session:
– provides mapping between physical and logical
sessions, including checkpoint recovery and
restart.
 Health Level Seven (HL7)….
• Layer 4 – Transport:
– provides end-to-end transmission of data to the required
quality of service (e.g. error-free).
• Layer 3 – Network:
– concerned with routing and relaying between multiple sub-
networks
• Layer 2 – Data-link:
– transmit a stream of bits from one network node to another
with indication of errors and limited error correction.
• Layer 1 – Physical:
– provide the interface to the physical communications
medium
Health Level Seven (HL7)….
E-health standard organizations
 Ten commandments for effective standards
• Cooperate on standards, compete on products
– This is the Golden Rule of technical standards.
– The essence of standardization is to provide
interfaces for multiple products to work together
well, while encouraging suppliers to develop the
best products possible.
• Use caution when mixing patents and
standards
– Perhaps the biggest challenge faced in creating
technical standards is making them available for
everyone to use without restrictions while
protecting the intellectual property of invention.
Ten commandments for effective standards…..
• Know when to stop
– Not every standards project should be completed.
– Not every standards project should be started.
– Not everyone wants to join.
– Timing is important, as is having the right
participants.
• Be truly open
– The word “open” has many definitions. When it
comes to standards, open means available to
everyone, without discrimination or conditions.
Ten commandments for effective standards…..

• Realize that there is no neutral party

– Everyone participating in a standards project has a
reason for being there, whether it is obvious or not.
– Technical standards can be political.
• Leverage existing organizations and proven
processes
– Reinventing the wheel isn’t necessary.
– It is more effective to work within experienced
standards development organizations.
Ten commandments for effective standards ……

• Think relevance
– Technical standards can be expensive to produce,
so it’s important that they address a real need or
solve a real problem.
• Recognize that there is more than one way to
create a standard
– Formal standards committees are just one way to
create technical standards for an industry.
– Different methods have pros and cons.
Ten commandments for effective standards …..

• Start with contributions, not from scratch

– Producing standards from technology that has
already been developed can speed up the
standardization process and increase the quality of
the resulting standard.
• Know that standards have technical and
business aspects
– Getting the technical details right for a standard is
necessary, and so is understanding the commercial
 Terminology management System

• TMS:
– is a software tool specifically designed to collect,
maintain, and access terminological data.
– is used by translators, terminologists, technical
writers, and various other users.
– is used to code and classify the entire healthcare
domain data from procedure to diagnosis.
 Why TMS?

• Allows all medical professionals to:

– understand each other and communicate
effectively
– understands what a condition, medicine, or
procedure is
– fulfill their roles accordingly, whether that is
delivering medicine or billing for a
medicine
– fully understand staff communications and
training
 Why TMS?......
• Allows all medical professionals to:……
– Speaking the standardized “Language of
Medicine”
– Improve patient safety through quality
communication
– Improve patient experiences through patient
education - helps patients become a more active
part of their care team, leading to improved
satisfaction
– provide more efficient care, where physicians or
nurses may write quickly and scribble common
abbreviations
Terminology management System……
 evoTerm: Centrally-stored terminology, available via
the Internet. Demo available to test the platform
 flashterm - terminology management and knowledge
management
 qTerm™: web-based terminology management
software.
 i-Term:, Acrolinx: , Anylexic: etc...
 In our country
National Health Data Dictionary (NHDD)
 In summary
• Definition of terms:
– eHealth Architecture - is a concept that provides a
foundational plan to support the acquisition,
exchange, sharing, and use of health data.
• Interoperability - is the ability of information
technology systems and software applications to
communicate, to exchange data, accurately,
effectively, and Consistently
• Four levels of interoperability in healthcare:
Foundational – Level I (Technical), Structural – Level
II (Syntactic), Semantic – Level III and
Organizational – Level IV
 In summary....
• The Components of eHealth Architecture are: shared
services, institution-based HIS and data sources,
population-based HIS and data sources, point of
service HIS, interoperability services, analytics and
business intelligence, external system and
governance.
• Objectives of designing eHealth architecture, its
benefits and challenges of its implementation.
• Standards, healthcare standards, why standards,
health informatics standards and standard
organizations and TMS
 Self Assessment Questions

 Explain about the concepts of eHealth

architecture?
 Explain about standards and interoperability
including how to this interrelated?

 Describe the type of standards, and health

standard development organizations?
 Self Assessment Questions....

 Explain the types and levels of interoperability?

 What is Terminology Management System its

importance in healthcare service?

 Describe about Ethiopian TMS /NHDD and its

importance?