Electronic Health Record Interoperability as Realized in the Turkish Health Information System

Summary

Objectives: The objective of this paper is to describe the techniques used in developing the National Health Information System of Turkey (NHIS-T), a nation-wide infrastructure for sharing electronic health records (EHRs).

Methods: The UN/CEFACT Core Components Technical Specification (CCTS) methodology was applied to design the logical EHR structure and to increase the reuse of common information blocks in EHRs.

Results: The NHIS-T became operational on January 15, 2009. By June 2010, 99% of the public hospitals and 71% of the private and university hospitals were connected to NHIS-T with daily feeds of their patients’ EHRs. Out of the 72 million citizens of Turkey, electronic healthcare records of 43 million citizens have already been created in NHIS-T. Currently, only the general practitioners can access the EHRs of their patients. In the second phase of the implementation and once the legal framework is completed, the proper patient consent mechanisms will be available through the personal health record system that is under development. At this time authorized health-care professionals in secondary and tertiary healthcare systems can access the patients’ EHRs.

Conclusions: A number of factors affected the successful implementation of NHIS-T. First, all stakeholders have to adopt the specified standards. Second, the UN /CEFACT CCTS approach was applied which facilitated the development and understanding of rather complex EHR schemas. Finally, the comprehensive testing of vendor-based hospital information systems for their conformance to and interoperability with NHIS-T through an automated testing platform enhanced substantially the fast integration of vendor-based solutions with the NHIS-T.

Keywords

Electronic healthcare records - interoperability - health information exchange - standards - UN/ CEFACT CCTS - HL7 CDA - eHealth conformance and interoperability testing

• References

• 1 Kose I, Akpinar N, Gurel M. et al. Turkey’s National Health Information System (NHIS). In: Proc of the eChallenges Conference, Stockholm, Oct 2008. pp 170-177.
• 2 ISO/TR 20514:2005. Health informatics – Electronic health record – Definition, scope and context
• 3 Clinical Document Architecture, Release (cited June 18, 2010). Available from: http://www.hl7.org/v3ballot/html/infrastructure/cda/cda.htm
• 4 UN/CEFACT Core Components Technical Specification (cited June 18, 2010). Available from: http://www.unece.org/cefact/ebxml/CCTS_V2-01_Final.pdf
• 5 The Central Civil Registration System (MERNIS).. Turkish Ministry of the Interior, General Directorate of Civil Registration and Nationality (cited June 18, 2010). Available from: http://www.nvi.gov. tr/English/Mernis_EN, Mernis_En.html
• 6 Doctor Data Bank.. The Ministry of Health, Turkey (cited June 18, 2010). Available from: http://sbu.saglik.gov.tr/drbank/drbilgis.aspx
• 7 The Systematized Nomenclature of Medicine (SNOMED) (cited June 18, 2010). Available from: http://www.ihtsdo.org/snomed-ct
• 8 Logical Observation Identifiers Names and Codes (LOINC) (cited June 18, 2010). Available from: http://www.regenstrief.org/loinc
• 9 READ Codes (cited June 18, 2010). Available from: http://www.connectingforhealth.nhs.uk/systemsandservices/data/readcodes/
• 10 Medical Subject Headings (MeSH) (cited June 18, 2010). Available from: http://www.nlm.nih.gov/mesh/2010/mesh_browser/MBrowser.html
• 11 International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) (cited June 18, 2010). Available from: http://apps.who.int/classifications/apps/icd/icd10online/
• 12 The Health Coding Reference Server (HCRS).. The Ministry of Health (cited June 18, 2010). Available from: http://sbu.saglik.gov.tr/SKRS2_Listesi
• 13 HL7 Version 3 Standard: Transport Specifications Overview (cited June 18, 2010). Available from: http://www.hl7.org/v3ballot/html/infrastructure/transport/transport-intro.htm
• 14 HL7 version 3 standard: Transport specification – web services profile, release 2 (cited June 18, 2010). Available from: http://www.hl7.org/v3ballot/html/infrastructure/transport/transport-wsprofiles.htm
• 15 Web Services Security UsernameToken Profile 1.1, OASIS Standard Specification, February 1, 2006 (cited June 18, 2010). Available from: http:/www.oasis-open.org/committees/download.php/16782/wss-v1.1-spec-os-UsernameTokenProfile.pdf
• 16 Transport Layer Security (TLS) and Secure Socket Layer (SSL) (cited June 18, 2010). Available from: http://en.wikipedia.org/wiki/Transport_Layer_Security
• 17 The National Health Data Dictionary (NHDD) of Turkey (cited June 18, 2010). Available from: http://www.sagliknet.saglik.gov.tr/portal_pages/notlogin/bilisimciler/docs/usvs_sozluk_1.1.rar
• 18 The Family Medicine Model of Turkey (cited June 18, 2010). Available from: http://www.ailehekimligi.gov.tr
• 19 The Centralized Hospital Appointment System (CHAS) (cited June 18, 2010). Available from (in Turkish): http://www.e-saglik.gov.tr/merkezi/hastane-randevu-sistemi-mhrs-id25-18.html
• 20 HL7 Clinical Document Architecture Release 1 (cited June 18, 2010). Available from: http://www.hl7.org/implement/standards/cda.cfm
• 21 HL7 Reference Information Model (cited June 18, 2010). Available from: http://www.hl7.org/v3ballot/html/infrastructure/rim/rim.htm
• 22 CEN EN 13606-1.. Health informatics – Electronic health record communication – Part 1: Reference model. European Committee for Standardization, Brussels, Belgium, EN 13606-1; 2007
• 23 ISO/IEC 11179-4:2004 (Information technology – Metadata registries (MDR) – Part 4: Formulation of data definitions) (cited June 18, 2010). Available from: http://www.iso.org/iso/catalogue_detail.htm?csnumber=35346
• 24 Yuksel M, Dogac A, Akdag R. et al. Automatic Transformation of Local EHRs to the International Stand ards: Application in Turkey’s NHIS. eChallenges Conference, Istanbul; Turkey, Oct: 2009
• 25 Kabak Y, Dogac A, Kose I. et al. The Use of HL7 CDA in the National Health Information System (NHIS) of Turkey. 9th International HL7 Interoper-ability Conference (IHIC), Crete, Greece, Oct 2008 pp 49-55.
• 26 The Anatomical Therapeutic Chemical (ATC) Classification System.. WHO Collaborating Centre for Drug Statistics Methodology (cited June 18, 2010). Available from: http://www.whocc.no/atc/structure_and_principles/
• 27 Namli T, Aluc G, Dogac A. An Interoperability Test Framework for HL7-based Systems. IEEE Trans Inf Technol Biomed 2009; 13 (03) 389-399.
• 28 Namli T, Dogac A. Testing Conformance and Inter-operability of eHealth Applications. Methods Inf Med 2010; 49 (03) 281-289.
• 29 Namli T, Aluc G, Sinaci A. et al. Testing the Conformance and Interoperability of NHIS to Turkey’s HL7 Profile. 9th International HL7 Interoperability Conference (IHIC), Crete. Greece: Oct 2008 pp 63-68.
• 30 RIDE – A Roadmap for Interoperability of e-Health Systems in Support of COM 356 with Special Emphasis on Semantic Interoperability.. Deliverable D2.1.4 – European Good Practices (cited August 9, 2010). Available from: http://www.srdc.metu.edu.tr/webpage/projects/ride/deliverables/RIDE_D2.1.4_EuropanGoodPractices_v1.2.doc
• 31 Smart Open Services for European Patients (epSOS) (cited August 9, 2010). Available from: http://www.epsos.eu
• 32 FP6 IST 027065 RIDE: A Roadmap for Interoper-ability of eHealth Systems in Support of COM 356 with Special Emphasis on Semantic Interoperability (cited October 25, 2010). Available from: http://www.srdc.metu.edu.tr/webpage/projects/ride