1 Integrated Architecture – Public Health Perspective Cecil O. Lynch, MD, MS Chief, Office of Informatics & Surveillance, DCDC, California Department of Health Services Chair, Graduate Group Medical Informatics, Assistant Professor, Medical Informatics, University of California - Davis

2 Infrastructure Entry: in·fra·struc·ture Function: noun 1 : the underlying foundation or basic framework (as of a system or organization) 2 : the permanent installations required for military purposes 3 : the system of public works of a country, state, or region; also : the resources (as personnel, buildings, or equipment) required for an activity Merriam-Webster Online Dictionary

3 The Problem P PricePiecesPartitionsPrivacyPolitics

4 Price Technology is expensive Funding has been inadequate compared to expectations Budget constraints at the State level Funding mechanism has restrictions High cost of bureaucracy

5 Pieces Multiple vendors Disparate technologies Legacy systems and legacy development of new systems Focus on function not on integration

6 Partitions Department level development Reproduction of infrastructure Persistent stovepipe approach “My needs are special” mentality No “big picture” approach

7 Privacy HIPAA concerns State legislative barriers Learned behavior Inadequate security I. T. isolation

8 Politics Maintenance of control Fear of change Out of touch decision makers Publication worries Unaligned priorities

9 Separate Silos

10 Common Components Demographic Data Analysis & Reporting Provider Information Mapping Security Privacy Coded terms Messaging

11 Common Components Patient Registry Analysis Engine Clinician Registry GIS Engine Two Factor Authentication Public Health Directory Central Terminology Server Integration Hub

12 Active Directory Clinician Registry Patient Registry Two Factor Authentication Public Health Directory HAN

13 Interoperability Requirements Equivalent data types –Preferably derived from the data model Common terminology –Unambiguous coding Agreed upon format –Must be readable Appropriate connection –Message must be routed appropriately

14 Interoperability Layers 1 Physical 2 Data Link 7 Application 8 Semantic 6Presentation 5Session 4Transport 3Network Vocabulary Semantic model Data exchange Data encoding Security Communication Medical Informatics Information Technology OSI Network Model Concept for slide from Ted Klein and Tim Morris

15 Why Code Data? Cold –February is a cold month. –She met his gaze with a cold stare. –Julia is in bed with a cold. February is a month. She met his gaze with a stare. Julia is in bed with a

16 Why Code Data? myocardial infarction cardiac infarction heart attack infarction of heart MI - Myocardial infarction myocardial infarct TermConcept ID Description ID

17 Vocabulary HL7 V3 messaging is complex Byproduct of semantic necessity A library of post coordinated terms is essential CDC vocabulary mapping has not reached this level of detail yet Example: –Bilateral symmetrical muscle weakness –A prominent symptom of botulism Central Terminology Server

18 Vocabulary bilateral symmetrical muscle weakness: Present - - -

19 Vocabulary bilateral symmetrical muscle weakness: Present

20 Vocabulary -

21 Vocabulary

22 Messaging Is not –Shared database –Exchange of data on media –FTP of a data file –Submitting a web form Is –High speed asynchronous program to program communication with reliable delivery 1 1. G.Hohpe,B. Woolf Enterprise Integration Patterns

23 Simple Messaging Sending Application Receiving Application Message Gateway Document Message Message Channel Message Router Message Translator Message Endpoint

24 Example Application

25 System Message Excerpt

26 Real life messaging Integration Hub

27 STV Example GIS Engine

28 SaTScan & RNNH Clusters Analysis Engine

29 CHI NCVHS Data Standards Drugs –Active Ingredients – FDA UNII codes –Clinical Drugs – RxNORM –Manufactured Dosage Form – FDA/CDER –Packaged drug product – NCD –Medication Package – FDA/CDER –Labeling Section Headers - LOINC –Drug Classifications – NDF-RT –Race and ethnicity labeling – HL7 tables

30 CHI NCVHS Data Standards HL7 for messaging standard (current version) LOINC for laboratory test orders and test results SNOMED CT for clinical terms Immunizations – HL7 2.4 messaging and CVX and MVX codes DICOM for imaging

31 Resources PHIN Standards PHIN Messaging NCVHS/CHI Standards LOINC codes and RELMA HL7 Tools and specifications SNOMED and others Jterm