HL7 Work Group Report September 20 - 25, 2009 - Atlanta, GA USA HL7 Project Prototype: EHR System Design Reference Model (EHR-SD RM) Immunization and Adverse Event Reporting Nancy Orvis, HL7 Project Co-Chair Stephen Hufnagel PhD, HL7 Project Facilitator September 22, 2009-D

Contents EHR System Design Reference Model (EHR-SD RM) Background 2008 Project Results 2009 HL7 EHR SD RM Project plan What Changed in 2009 ARRA (American Reinvestment and Recovery Act) HITSP Harmonization Framework for reuse HITSP Capabilities Information Exchanges  Interface Standards Specifications HITSP Service Collaborations EHR SD RM Model Jan 2009 baseline project Sep 2009 Information Model (IM) additions 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA Vaccination and Adverse Event Reporting Prototype AHIC Use Cases EHR-S FM Next Steps

Introduction In 2004, Executive Orders 13335 set the objective for National Electronic Healthcare Record (EHR) Interoperability by 2014 In 2006, Executive Order 13410 mandated Federal agencies to begin transformation to Healthcare Information Technology Standards Panel (HITSP) conformant EHR interoperable systems by 2007 We present a standards-based strategic approach for interoperability at the service level to construct semantically consistent interoperable Enterprise Architectures (EAs) It builds upon the functional foundation of the HL7 EHR System Functional Model (EHR-S) and the technical foundation of Thomas Erl’s Service Oriented Architecture (SOA) model to specify a standard Healthcare SOA Reference Architecture (H-SOA-RA) Information Exchange Requirements (IERs) are used to identify services and as the key to traceability from requirements to implementation, test and certification

HL7 Project Intent Implement a step in HL7 roadmap Identify gaps and overlaps in HL7’s portfolio Identify gaps in the EHR-S FM Pilot HL7 ARB SAEAF methodology Create H-SOA-RA Version 2 Create Healthcare SOA EHR-SD Reference Model based on EHR System Functional Model (EHR-S FM) Create prototype architectural case study using HL7 HSSP Practical Guide for SOA in Healthcare “sample health” and service specifications, EHR-S FM, EHR-SD RM, AHIC Use Cases, HITSP Interoperability Specifications and NHIN services Demonstrate standards-based Model Driven Architecture (MDA) approach

HL7 Project Scope This project will mature the April 2008 H-SOA-RA version 1.0 into H-SOA-RA Version 2.0 and integrate it into an EHR-SD RM using HL7 (SAEAF, HITSP MEANS, and EHR System Functional Model (EHR-S FM) Emphasis will be placed on maintaining AHIC, HITSP, NHIN and CCHIT conformance by maintaining IERs and Data Requirements (DRs) traceability Mapping and analysis of the HL7 product portfolio against the EHR-S FM will be used to integrate the reference architecture with HL7 product lines and initially mature the resulting model as a technical white papers, then an informative reference model and finally a standard reference model An HSSP based prototype case study architectural specification will be built to validate the effort using the AHIC-HITSP Immunization and Response Management and Public Health Case Reporting use cases

HL7 Project Schedule Sep 2008 – Healthcare SOA Reference Architecture (H-SOA-RA) Jan 2009 – harmonize and catalogue priority IERs, DRs and candidate services Mar 2009 – map priority IERs, DRs and candidate services to EHR-S FM Jun 2009 - Mappings of V2.5, V3 products to EHR-S FM Jun 2009 - Present at HL7 SOA Conference (for peer feedback) Sep 2009 – Report on Vaccination and Adverse Event Prototype Oct 2009 – Healthcare SOA Reference Architecture (H-SOA-RA) version 2.0 Nov 2009 - HSSP Practical Guide for SOA in Health Care, Part II: Case Study Jan 2010 - EHR-SD RM white paper for HL7 committee comments, to socialize the project. Sep 2010 - EHR-SD RM Balloted as informative document Sep 2011 - EHR-SD RM Balloted as a standard

2008 Project Goal Healthcare SOA Reference Architecture (H-SOA-RA) Identifying Opportunities to Leverage Technology and Alleviate Redundancy or Agency IT Overlap Key Business Driver Patient Centric Processes Key Architectural Objective Standardized Technical Solutions aligned with Core Business Processes. Healthcare Industry INTEGRATION COLLABORATION VA/ DoD Interagency DoD TMA Military Services INTER-AGENCY Joining Forces to Improve Effectiveness, Efficiency, and Service delivery

2008 Health SOA Reference Model Glossary (example) MHS/VA PROPOSED SERVICES SOA SERVICE DEFINITIONS Access to Care Functions IDENTITY Identify and/or lookup subjects-of-care, providers, payers, employers, material resources, and references to various parts of the EHR (hosted locally and/or remotely). Patient Maintain current directory of patient information in accordance with relevant privacy and other applicable laws, regulations, and conventions, including, when available, full name, address or  physical location, alternate contact person, primary phone number, and relevant health status. Provide the patient's location information within a facility's premises. Guarantor Collect, record, and update a core set of information to ensure accurate beneficiary guarantor identification and health plan information. Provide information of Related by genealogy (blood relatives). Provide information of Related by insurance (domestic partner, spouse, guarantor). Provide information of Related by other means (e.g. epidemiologic exposure) Provider Maintain a current directory of practitioners that, in addition to demographic information, contains data needed to determine levels of access required by the EHR security system. Maintain current directory of provider information in accordance with relevant laws, regulations, and conventions, including full name, address or  physical location, and a 24x7 telecommunications address (e.g. phone or pager access number) for the purposes of the following: Provide provider location or contact information on a facility's premises. Provide provider location or contact information on a facility's premises. Provide provider location or contact information when on call. Provide locations or contact information at which the provider practices, in order to direct patients or queries. Next of Kin Collect, record, and update a core set of information to ensure accurate next of kin identification and health plan information. Supplier Collect, record, and update a core set of information to ensure accurate Supplier Information. Insurer Collect, record, and update a core set of information to ensure accurate Insurer Information. Facility Collect, record, and update a core set of information to ensure accurate Facility Information. 8

2008 Healthcare SOA Framework Based on HL7 EHR System Functional Model & Thomas Erl’s SOA Layers HL7 System Functions Direct Care Supportive Information Infrastructure Other Business Process Value Chains Composite Services (Svcs) Federated Composition (e.g., Choreograph or Orchestration) Within and Across Business Areas Core Bus Svcs Functional Areas + Focal Classes Entity Svcs IM Info Reporting/IM Agnostic Svcs C r o s s T e c h n I c a l “Common S e r v I c e s” (e.g., Security, Privacy, Auditing, Logging…) App Svcs Amb Care Sys, In Pt Care Sys Log Sys, Fin Sys, Dec Support Sys Data Marts Repositories Business Objects Imp Profiles IHE Profiles Analysis Profiles Communications Profiles/Stacks Implementation Profiles 9 9

Anatomy of Ancillary Systems LABORATORY RADIOLOGY PHARMACY CARDIOLOGY OT/PT/SPEECH IDENTITY TERMINOLOGY AUTHORIZATION SCHEDULING CORE BUSINESS SERVICES SUPPLY CHAIN (ORDER/CHARGE) DOCUMENT RECORDS MANAGEMENT s DECISION SUPPORT PERFORMANCE DATA MANAGEMENT

Contents EHR System Design Reference Model (EHR-SD RM) Background 2008 Project Results 2009 HL7 EHR SD RM Project plan What Changed in 2009 ARRA (American Reinvestment and Recovery Act) HITSP Harmonization Framework for reuse HITSP Capabilities Information Exchanges  Interface Standards Specifications HITSP Service Collaborations EHR SD RM Model Jan 2009 baseline project Sep 2009 Information Model (IM) additions 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA Vaccination and Adverse Event Reporting Prototype AHIC Use Cases EHR-S FM Next Steps

Reusable Facets  Lexical Consistency HITSP 2009 Model for IERs Information Exchange Number Exchange Action Exchange Content What System initiates this exchange? What System (s) consume this exchange? Qualifier Send Blood Lab Report Laboratory Information System PHR System EHR System Public Health Information System TBD Specimen Lab Report Reusable Facets  Lexical Consistency

A new 2009 concept HITSP Capability A HITSP capability is an implementable business service that specifies interoperable information exchanges using HITSP constructs. It is meant to supports stakeholder requirements and as part of its design, it includes workflow, information content, infrastructure, security and privacy. Capabilities include constraints and operate on specific network topologies (contexts) Capabilities have options: subsets of the data content can be sent or received as appropriate by a system implementing a capability.

The 2009 Refined HITSP Framework Business Requirements Identifies interoperability business needs HITSP Capabilities Component Service Collaborations Collaboration Transaction Constructs Transaction Package HITSP Constructs Component Transaction Constructs Transaction Package Interoperability Specification Identifies what HITSP capabilities and constructs to use to meet Business Needs Defines Requirements, Context and Constraints for those capabilities and constructs Component Transaction Transaction Package Available for Internal reuse or repurposing SDOs Base Standard #1 Base Standard #2 Base Standard #... Base Standard #n Composite Standard #1 Composite Standard #... Composite Standard #m 14

2009 HITSP Reuse Framework GREEN Elements are reusable! 15

HITSP Model To Link Requirements to Design HITSP Constructs Transaction Transaction Packages Component Services

2009 HITSP Requirements Analysis Framework GREEN Elements are reusable! 17

2009 Design Specifications Framework GREEN Elements are reusable! 18

HITSP List of Priority Information Exchanges Demographics Problem List Medications Immunizations Allergies Progress Notes and Other Narrative Documents (History and Physical, Operative Notes, Discharge Summary) Departmental Reports (Pathology/Cytology, GI, Pulmonary, Cardiology etc.) Laboratory Results Microbiology Images Administrative Transactions (Benefits/Eligibility, Referral/Authorization, Claims/Remittance) Quality Measures Privacy and Security

HITSP List of Priority Capabilities HITSP/CAP117 Communicate Ambulatory and Long Term Care Prescription HITSP/CAP118 Communicate Hospital Prescription HITSP/CAP119 Communicate Structured Document HITSP/CAP120 Communicate Unstructured Document HITSP/CAP121 Communicate Clinical Referral Request HITSP/CAP122 Retrieve Medical Knowledge HITSP/CAP123 Retrieve Existing Data HITSP/CAP124 Establish Secure Web Access HITSP/CAP125 Retrieve Genomic Decision Support HITSP/CAP126 Communicate Lab Results Message HITSP/CAP127 Communicate Lab Results Document HITSP/CAP128 Communicate Imaging Information HITSP/CAP129 Communicate Quality Measure Data HITSP/CAP130 Communicate Quality Measure Specification HITSP/CAP131 Update Immunization Registry HITSP/CAP132 Retrieve Immunization Registry Information HITSP/CAP133 Communicate Immunization Summary HITSP/CAP135 Retrieve and Populate Form HITSP/CAP136 Communicate Emergency Alert HITSP/CAP137 Communicate Encounter Information Message HITSP/CAP138 Retrieve Pseudonym HITSP/CAP139 Communicate Resource Utilization HITSP/CAP140 Communicate Benefits and Eligibility HITSP/CAP141 Communicate Referral Authorization HITSP/CAP142 Retrieve Communications Recipient HITSP/CAP143 Manage Consumer Preference and Consents

Service Traceability EHR-S, HITSP and CCHIT 21 21

Contents EHR System Design Reference Model (EHR-SD RM) Background 2008 Project Results 2009 HL7 EHR SD RM Project plan What Changed in 2009 ARRA (American Reinvestment and Recovery Act) HITSP Harmonization Framework for reuse HITSP Capabilities Information Exchanges  Interface Standards Specifications HITSP Service Collaborations EHR SD RM Model Jan 2009 baseline project Sep 2009 Information Model (IM) additions 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA Vaccination and Adverse Event Reporting Prototype AHIC Use Cases EHR-S FM Next Steps

Approach Service Oriented Architecture based on Thomas Erl’s SOA layers (De Facto Standard) Business Process Value Chains, Composite Services Core Business Services, Entity Services Agnostic Services, Application Services, Implementation Profiles HL7 EHR System Functional Model (EHR-S FM) 160+ Standardizes EHR system functions Requirements and Test criteria standardized at National Level Objective Strategic Planning and Investment Portfolio line costing. HITSP Capabilities and Interoperability Specifications Federal Mandate for Design Interoperability Specifications Traceable to Enterprise Architecture ARRA Meaningful Use Measures

January 2009 EHR SD RM Project EHR System Design Reference Model (EHR-SD RM)

2010 Information Model Project Federal Health Information Model and Standards (FHIMS)

2010 Project Integrated EHR-SD RM, FHIMS, HITSP Capabilities and ARRA Meaningful Use

Benefits Faster, Better, Cheaper Integrated Requirements-Design Process Strategic Plan based on International and National Standards Objective Investment Portfolio Cost Estimation Minimize the Chance of Year of Execution Unfunded Requirements (UFRs) IM and IT aligned on Consistent Catalogue of Services MHS EHR Interoperability alignment with National Agenda Manage Care Support Contractor (MCSC) interoperability VA interoperability Consistent with Enterprise Architecture

Prototype Approach Build Integrated Requirements Design CONOPS package based on Service Oriented Architecture categorized and populated by Candidate Services Derived from following Thomas Erl’s Service Oriented Design Principles HL7 EHR System Functional Model Requirements and HITSP Interoperability Specifications

Contents EHR System Design Reference Model (EHR-SD RM) Background 2008 Project Results 2009 HL7 EHR SD RM Project plan What Changed in 2009 ARRA (American Reinvestment and Recovery Act) HITSP Harmonization Framework for reuse HITSP Capabilities Information Exchanges  Interface Standards Specifications HITSP Service Collaborations EHR SD RM Model Jan 2009 baseline project Sep 2009 Information Model (IM) additions 2010 EHR SD RM Model with HITSP Capabilities, IM & ARRA Vaccination and Adverse Event Reporting Prototype AHIC Use Cases EHR-S FM Next Steps

EHR-SD RM Prototype Requirements from 2008 AHIC Use Cases Use Case 1: Immunization and Response Management (IRM) and Use Case 2: Public Health Case Reporting (PHCR) The IRM AHIC Use Case and HITSP Interoperability Specification are intended to support current interoperability approaches between EHRs and Immunization Information Systems while allowing for a migration toward emerging interoperability implementations and document sharing environments where PHRs are able to be included in the information flow The Interoperability Specification also allows for basic electronic information exchanges to enable requirement communications and alerting mechanisms and to lay the foundation for future clinical support capabilities The Public Health Case Reporting AHIC Use Case and HITSP Interoperability Specification supports the bi-directional information exchanges of the Public Health Case Reporting process The Public Health Case Reporting Use Case addresses numerous domains which have similar content and processes at a high level, but which also are dissimilar in report content details and case management processes when considering any specific report

EXAMPLE ARTIFACT: Vaccine and Drug Administration and Reporting Information Exchanges

EXAMPLE ARTIFACT Vaccine and Drug Administration and Reporting Use Case Full use case available at: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1255&parentname=CommunityPage&parentid=1&mode=2&in_hi_userid=10741&cached=true

EHR-SD RM Prototype Information Exchange Requirements (IERs) Use Case 1: Immunization and Response Management (IRM) IER10 Identify patient IER13 Send/receive notification of document availability IER18 Send/receive clinical document IER26 Identify communication recipients IER27 Send non-patient notification message or alert IER40 Query for existing data IER42 Request/receive medical concept knowledge IER54 Query/response for clinical message data IER67 Send/receive clinical message IER78 Send/receive Vaccine Inventory Requirements IER79 Query/response for inventory usage data IER80 Send/receive Vaccine Inventory Data Blue Italics indicates IERs, which are common to 1-IRM and 2-PHCR For details, see HITSP IS 10 Immunization and Response Management, available at www.HITSP.org 33

EHR-SD RM Prototype Data Requirements (DRs) Use Case 1: Immunization and Response Management (IRM) DR08 Unstructured Data DR11 Immunization response data DR12 Adverse Event Report DR13 Drug/Vaccine Inventory Data DR14 Drug/Vaccine Inventory Usage Data DR15 Drug/Vaccine Inventory Availability Data DR16 Supply Chain Management Vaccine Recall DR17 Decision Support Data DR18 Vaccination Data DR19 Medication Administration data DR20 Aggregate Inventory of Available Vaccine DR21 Terminology Data DR22 Generic Alert Data DR23 Consumer Vaccination View Blue Italics indicates common across IRM and PHCR For details, see HITSP IS 10 Immunization and Response Management, available at www.HITSP.org 34

EHR-SD RM Prototype IRM Information Exchange Requirements (IERs) Use Case 2: Public Health Case Reporting (PHCR) IER10 Identify patient IER13 Send/receive notification of document availability IER18 Send/receive clinical document IER26 Identify communication recipients IER27 Send non-patient notification message or alert IER29 Send/receive electronic form for data capture IER40 Query for existing data IER42 Request/receive medical concept knowledge IER49 Report confirmation Blue Italics indicates common across 1-IRM and 2-PHCR For details, see HITSP IS 10 Immunization and Response Management, available at www.HITSP.org 35

EHR-SD RM Prototype Data Requirements (DRs) Use Case 2: Public Health Case Reporting (PHCR) DR08 Unstructured Data DR17 Decision Support Data DR21 Terminology Data DR24 Case Report Pre-populate Data DR22 Generic Alert Data DR23 Consumer Vaccination View DR25 Case Report Content DR26 Reporting Criteria Content DR59 Generic Alert Data Blue Italics indicates common across IRM and PHCR For details, see HITSP IS 10 Immunization and Response Management, available at www.HITSP.org 36

EHR-SD RM Prototype Information Exchange Requirements (IERs) HITSP Security and Privacy IER01 Provide authorization and consent IER02 Send data over secured communication channel IER03 Create audit log entry IER04 Synchronize system time IER05 Verify entity identity IER06 Provide proof of document integrity and origin IER55 Anonymize patient identifiable data IER56 Pseudonymize patient identifying information Blue Italics indicates common across IRM and PHCR For details, see HITSP IS 10 Immunization and Response Management, available at www.HITSP.org 37

EHR System Functional Model Interoperability Specifications EXAMPLE ARTIFACT HL7 Requirements and Certification Criteria and HITSP Design HL7 EHR System Functional Model HITSP Interoperability Specifications

EXAMPLE ARTIFACT EHR-S Requirements

EXAMPLE ARTIFACT EHR-S FM Dependencies

EXAMPLE ARTIFACT HITSP Interoperability Design Specifications

Sample of Standards used within HITSP Components within IS10 Standard: HITSP Construct Accredited Standards Committee (ASC) X12 Standards Release 004010 HITSP/C80 - Clinical Document and Message Terminology American Medical Association (AMA) Current Procedural Terminology (CPT®) Fourth Edition (CPT-4); CPT Evaluation and Management Codes HITSP/C80 - Clinical Document and Message Terminology ASTM International Standard Guide for Electronic Authentication of Health Care Information: # E1762-95 (2003) HITSP/C26 - Nonrepudiation of Origin CDC Race and Ethnicity Code Sets HITSP/C80 - Clinical Document and Message Terminology Center for Disease Control and Prevention Implementation Guide for Immunizations Data Transaction using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol. Implementation Guide Version 2.2 June 2006 HITSP/C70 - Immunization Query and Response, HITSP/C72 - Immunization Message, HITSP/C80 - Clinical Document and Message Terminology Digital Imaging and Communications in Medicine (DICOM) Part 3.12: Media Formats and Physical Media for Media Interchange HITSP/T33 - Transfer of Documents on Media European Telecommunications Standards Institute (ETSI) Technical Specification TS 101 903: XML Advanced Electronic Signatures (XadES) HITSP/C26 - Nonrepudiation of Origin Federal Information Processing Standards (FIPS) Codes for the Identification of the States, the District of Columbia and the Outlying Areas of the United States, and Associated Areas Publication # 5-2, May, 1987 HITSP/C80 - Clinical Document and Message Terminology Food and Drug Administration (FDA) - Unique Ingredient Identifier (UNII) HITSP/C80 - Clinical Document and Message Terminology Food and Drug Administration (FDA) - National Drug Code (NDC) HITSP/C80 - Clinical Document and Message Terminology Health Care Provider Taxonomy HITSP/C80 - Clinical Document and Message Terminology Health Level Seven (HL7) Clinical Document Architecture (CDA) Release 2.0 HITSP/C78 - Immunization Document, HITSPC83 - CDA Content Modules Health Level Seven (HL7) Common Terminology Services (CTS) Release 1 HITSP/T66 - Retrieve Value Set Health Level Seven (HL7) Implementation Guide for CDA Release 2: History and Physical (H&P) Notes HITSP/C83 - CDA Content Modules Health Level Seven (HL7) Implementation Guide for CDA Release 2: Consultation Note HITSP/C83 - CDA Content Modules Health Level Seven (HL7) Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), April 01, 2007 HITSP/C83 - CDA Content Modules Health Level Seven (HL7) Standard Code Set CVX - Vaccines Administered HITSP/C80 - Clinical Document and Message Terminology Health Level Seven (HL7) Standard Code Set MVX - Manufacturers of Vaccines HITSP/C80 - Clinical Document and Message Terminology Health Level Seven (HL7) V3 RBAC, R1-2008, HL7 Version 3 Standard: Role Based Access Control (RBAC) Healthcare Permissions Catalog, Release 1, February 2008, HITSP/TP20 - Access Control Health Level Seven (HL7) Version 2.3.1 HITSP/C70 - Immunization Query and Response Health Level Seven (HL7) Version 2.3.1 Chapter 2 – Control, Chapter 3 – Patient Administration HITSP/TP22 - Patient ID Cross-Referencing Health Level Seven (HL7) Version 2.5, Chapter 2 – Control, Chapter 3 – Patient Administration, Chapter 5 – Query HITSP/TP22 - Patient ID Cross-Referencing Health Level Seven (HL7) Version 2.5, Chapter 2 – Control, Chapter 3 – Patient Administration, Chapter 5 - Query HITSP/T23 - Patient Demographics Query Health Level Seven (HL7) Version 2.5.1 HITSP/C80 - Clinical Document and Message Terminology Health Level Seven (HL7) Version 3.0 - Vocabularies and Value Sets HITSP/C80 - Clinical Document and Message Terminology Health Level Seven (HL7) Version 3.0 Context-Aware Information Retrieval Specification: URL Implementation Guide HITSP/T81 - Retrieval of Medical Knowledge

Work Plans EHR-SD RM Next Steps EHR SD RM Framework Populate the framework with candidate healthcare Information Exchanges/ capabilities/ services, based on HL7 EHR-S Functional Model Information Model Loosely-coupled top-down Framework Rigorously specified bottom up structure/ content Publish HL7 HSSP Practical Guide for SOA in Healthcare Part 2: Case Study Socialize EHR SD RM Collaborate with others Informative ballot in 2010 1 - Populate a framework of candidate healthcare services, with IERs, based on SAEAF service categories Define priority Information Exchange Requirements (IERs) Define priority Data Requirements (DRs) along with IERs Map IERs and DRs to the framework of candidate healthcare services Build Catalog of candidate Services from 2008 H-SOA-RA work Show AHIC-HITSP traceability (e.g., AHIC IERs to HITSP ISs to standards) Show NHIN traceability (align with NHIN services) Show CCHIT traceability (align with CCHIT test criteria) Compare and contrast framework of candidate healthcare services with Canada Infoway’s SOA and/or other SOA 2 - Define EHR-SD RM Map Priority IERs and DRs to EHR-S FM Map candidate services to EHR-S FM Define EHR-SD RM based Business Transformation Architecture methodology for Identify gaps and overlaps in HL7’s portfolio Identify artifacts that do not now exist but are indicated in the EHR-S FM Identify the extent of duplication that may exist across HL7 artifacts 3 - Create prototype EHR-SD RM validation case study prototype, using AHIC-HITSP Public Health and Emergency Response use cases and Interoperability Specifications Services Aware Enterprise Architecture Framework (SAEAF) HITSP Multi-Enterprise Architecture of Networked Services Standards (MEANS) and HL7 HSSP Practical Guide for SOA in Healthcare “sample health” example specifications Include mapping to MHS and DOD specific IERs and DRs Publish HL7 HSSP Practical Guide for SOA in Healthcare Part 2: Case Study To show HITSP, NHIN and CCHIT conformance criteria, use OMG Object Constraint Language and/or OWL Semantic Ontology specification language

Questions?? What was omitted? Suggestions for improvement? How should the model be represented? What should be balloted in 2010?

Project info available at: Questions? Contact us: Nancy.Orvis@tma.osd.mil Stephen.Hufnagel.ctr@tma.osd.mil Project info available at: http://hitsp.wikispaces.com/HITSP+MODEL http://hssp.wikispaces.com/Reference+Architecture

Backup

Learning Objective Understand how to leverage SOA and Information Exchange Requirements (IER) in the System Design Reference Model Audience: Developers and Managers Analytic Process: How to integrate a healthcare system design or acquisition specification, with national standards HL7, HITSP and CCHIT standards Benefits: Understand what is needed to create standards-based EHR interoperability at the Service level Management level understanding supports funding justification Understanding of services as automating business functions Consistent reqmts, design-specs and implementations Better costing

Candidate Services Sources 2008 H-SOA-RA: Identity, Terminology, Authorization, Scheduling, Supply Chain (Order/charge), Document Records Management, Decision Support, Performance, Data Management DoD-VA Sharing Project: Pharmacy Data, Clinical Data (Theater), Allergy Data, Lab Results, Discharge Summaries, SADR, Radiology Reports, Assessments (Pre/Post), Inpatient Consults NHIN Services: Subject Discovery, Query for Documents, Retrieve Documents, Query Audit Log, Authorization Framework, Consumer Preference Profile, Messaging Platform, Pseudonymization, Health Information Event Messaging, NHIE Service Registry HITSP Constructs as Services: Document Sharing, Patient Indexing, Security, Content Definition, Healthcare Services, Health Coverage, Decision Support, Dynamic Data, Data Aggregation, General Communication

Discussion Topics H-SOA Reference Architecture Project deliverables 2009 HITSP work on Information Exchanges (IEs) among Use Cases Building content of System Domain Reference Model (RM) From HL7, HITSP, DOD components Use Case Public Health & Emergency Response (PHER) System Domain (SD) analysis on PHER

2009 Tasks 2009 Work Through HITSP Prototype HITSP IER Model Candidate Services Next Steps / Work Plan

2008 Results Healthcare SOA Reference Architecture H-SOA-RA H-SOA-RA: Overall Goal Service Traceability EHR System Functional Model (EHR-S) Healthcare SOA Reference Architecture Notional Functional Example

HITSP Exchange Content Contain Data Requirements (DRs) Exchange Content Number Exchange Content Name Definition of the Exchange Content Data Requirements Genomic Decision Support Data Information from genetic/genomic knowledge sources and/or decision support modules within EHRs (including Fx HX and Test Results) DR1 Demographic Data DR3 Clinical History DR4 Personal genetic/genomic data DR5 Family genetic/genomic information DR8 Unstructured Data CDA and ANSI X12 Data Modules Reusable DRs  Lexical Consistency

HL7 EHR System Functional Model (EHR-S) > 230 System Functions in 4 level categorization (see separate spreadsheet for full enumeration) Business Choreography Choreography Business Entity (Information) Service Types Business System Functions Infrastructure Entity (Information) Infrastructure Infrastructure Infrastructure Business Choreography Other O-1 Electronic Resource Planning (ERP) O-2 Finances O-3 Other NOTE: “Other” Category - The EHR-S model does NOT include Electronic Resource Planning (ERP) / Logistics and Financial components, which are needed for completeness of a military EHR. 53

SOA Layers Focus on the Business Processes and Services [Thomas Erl] process layer Business Business Capabilities and Services orchestration service layer interface layer Services business service layer application service layer System Components and Services Application layer Source: Service-Oriented Architecture, Thomas Erl .NET J2EE Legacy 54

SOA Service Models Potential Service Layers [Thomas Erl] Description Application Service A generic category used to represent services that contain logic derived from a solution or technical platform. Services are generally distinguished as application services when creating abstraction layers. Business A generic category used to represent services that contain business logic. When establishing specialized service layers, services that fall into the business service layers are collectively referred to as business. However, individually these services are classified as entity-centric (e.g., information) or task-centric business services. Controller A Service that composes others. Variations of this model exist, depending on the position of the controller in the composition hierarchy. The patent controller service can be classified as the master controller and a service that composes a subset of a larger composition can be labeled as sub-controller. Coordinator Services Three service models are derived from the concept of coordination: the coordinator, the atomic transaction coordinator, and the business activity coordinator. All three models are specific to the WS-Coordination specification and related protocols. 55

SOA Service Models Potential Service Layers [Thomas Erl] (cont) Description Entity-centric Business Service A business process-agnostic variation of the business service that represents one or more related business entities. This type of service is created when establishing a business service layer. Hybrid Service A service that contains both business and application logic. Most services created as part of traditional distributed solutions fall into this category. When organizing services into abstraction layers, hybrid services are considered part of the application service layer. Integration An application service that also acts as an endpoint to a solution for cross-referencing integration purposes. Process A service that represents a business process as implemented by an orchestration platform and described by a process definition. Process services reside in the orchestration service layer. Task-Centric A business process-specific variation of the business service that represents an atomic unit of process logic. Task-centric services are different from process services in that the process logic is provided by the underlying service logic, not by a separate process definition.

EHR Data Reuse Through H-SOA-RA Across Episodes of Care Previous Episode Of Care EHR Current Episode Of Care EHR IDENTITY Patient Demographics Provider Demographics Insurer Demographic Data Must Be Verified And Updated Terminology Chronic Diagnoses Procedure History Reusable Services Document Patient History Summary Lists - Medication List - Allergy/Adverse Reaction List - Immunization

Federated Services [1] Federation is a state achieved by extending SOA into the realm of service-oriented integration A number of key WS-* extensions provide feature-sets that support the attainment of federation Most notable among these are the specifications that implement the concepts of orchestration and choreography Establishing SOA within an enterprise does not necessarily require that you replace what you already have One of the most attractive aspects of this architecture is its ability to introduce unity across previously non-federated environments While web-services enable federation, SOA promotes this cause by establishing and standardizing the ability to encapsulate legacy and non-legacy application logic and by exposing it via a common, open, and standardized communications framework WSRP (Web Services for Remote Portals) is the cornerstone of federated services SAML (Security Assertions Markup Language) is commonly used ALSO: WS-Security, WS-Trust, WS-Policy, WS-Federation Additional info at: https://www120.livemeeting.com/cc/bea/viewReg [1] SOA: Principles of Service Design, by Thomas Erl, Prentice Hall, July 07 58

Leveraging SOA Processing in the Enterprise Business Services Information Infrastructure Application Choreographies (Orchestration Services) Legacy SOA Services in a SOA are designed and architected with focused reuse and consumability in mind. Business Services generally align with business use cases resulting from a domain analysis. In nearly all cases, they expose the state of a business focal object, and their interfaces allow for the manipulation of that business focal object. Information services expose information assets to consumers. They are characterized by a comprehensive and explicit information model that is enumerated in the service description and specification. Information services may leverage other information services to formulate other informational capabilities. Infrastructure Services are IT components, like security, context synchronization, and policy rules that are generally separate architectural components from information and business-level services. Infrastructure services can reference and leverage other infrastructure services to simplify infrastructure needs. 59

INTEGRATED REQUIREMENTS DESIGNS: Putting the H-SOA-RA Pieces Together Ancillary Systems INTEGRATED REQUIREMENTS DESIGNS: Putting the H-SOA-RA Pieces Together LABORATORY PT/OT/SPEECH RADIOLOGY PHARMACY SPECIALTY CARE RESPIRATORY CARDIOLOGY DIETARY IDENTITY TERMINOLOGY Inter-Service TEST ONLY AUTHORIZATION INPATIENT SCHEDULING Inter-Agency Federated Business Services SUPPLY CHAIN: (ORDERS/CHARGES) Core Business Services ER DOCUMENT RECORDS MANAGEMENT ASU Federated Services, may be categorized by: -- Encounter Types -- CMS billing category -- Record type -- Care setting type -- etc. DECISION SUPPORT Across Providers PERFORMANCE CLINIC DATA MANAGEMENT OUTPATIENT OTHER ANALYTIC Agnostic Services SUPPORT Data sets are defined for each system functional-capability-service module IT PLATFORM

CASE MANAGEMENT COORDINATION ACROSS CARE CONTINUUM IT PLATFORM SUPPORT ANALYTIC DATA MANAGEMENT PERFORMANCE DECISION SUPPORT RECORDS MANAGEMENT DOCUMENT (ORDER/CHARGE) SUPPLY CHAIN: SCHEDULING AUTHORIZATION TERMINOLOGY IDENTITY RADIOLOGY LABORATORY PHARMACY CLINIC ASU TEST ONLY OUTPATIENT OTHER INPATIENT ER CARDIOLOGY PT/OT/HSPEECH DIETARY SPECIALTY CARE Ancillary Applications Core EHR-S Services RESPIRATORY Patient Encounter Types Federated Composite Services, which may be categorized by: -- CMS billing category -- Record type -- Care setting type -- etc. Data sets are defined for each service – application – encounter type module ACROSS CARE CONTINUUM ACROSS SERVICES (SOAs) COORDINATION

Case Management Coordination Across SOAs and the Continuum COORDINATION ` ACROSS LEVELS OF CARE, PROVIDERS and LOCATIONS Skilled Long Term Care Custodial Long Term Care Prevention/ Wellness Wartime Theater Acute Inpatient Acute Rehab. Chronic Rehab. Home Health ER Outpatient Care Continuum Coordination ACROSS SOAS ORDERS & SCHEDULING BENEFIT MANAGEMENT AUTHORIZATION & UTILIZATION MGT. COMMUNICATION (FACILITATION ADVOCACY) DISCHARGE/ TRANSFER PLANNING CARE PLANNING ASSESSMENT REFERRAL RECORD EDUCATION. TRANSPORT ROLE OF CASE MANAGER

Potential Benefits: Process Improvement through H-SOA-RA Elimination of Process Obstacles would result in: Length of Stay Reduction Improved Patient Outcomes / Reduced Risk Revenue Improvement Staff Efficiencies Improved Patient and Staff Satisfaction Reduced IT Expenditure/Maintenance Costs Improved Information Accuracy and Availability

Addressing Real Business Issues Through H-SOA-RA Incomplete/Inaccurate Demographic Data Identity Service Incomplete/Inaccurate Insurance Information Authorization Service Unauthorized Service Diagnosis/Procedure Coding Errors Terminology Service Service Delays Scheduling Service Incomplete and Inefficient Charge Capture Supply Chain Service

Addressing Real Business Issues Through H-SOA-RA Non-indicated or Contra-indicated Services Decision Support/Authorization Services Delays in EHR Document Production and Provision Document Service) Billing Delays and Errors (Supply Chain/ Billing/Collection Services) Not fully coordinated Scheduling Scheduling Service) Lack of fully integrated Patient Assessment and Treatment Plan (Document Service/ Decision Support Service) Delayed or Lack of Medical Record Access (Record Service)