A Primer on Healthcare Information Exchange John D. Halamka MD CIO, Harvard Medical School and Beth Israel Deaconess Medical Center

The National Effort Office of the National Coordinator HIT Policy Committee –Meaningful Use Workgroup –Certification Workgroup –Health Information Exchange Workgroup HIT Standards Committee –Clinical Operations Workgroup –Clinical Quality Workgroup –Security and Privacy Workgroup HITSP and CCHIT Nationwide Healthcare Information Network

Architectures Push and Pull Point to Point Decentralized Messaging - Massachusetts Centralized and Normalized - Indiana

The Massachusetts Approach Built on a common messaging gateway framework Placed on the network of each participating institution CDX Rx Gateway Pharmacy Directory Formulary Service Drug Eligibility Medication History eRX Adaptors Prescription Routing Publishing Service Record Index Management Record Locator Service EHR Adaptors XDS Repository Adaptor Security Trading Partner Registry Logging Validation Translation Routing Guaranteed Delivery Security Trading Partner Registry Logging Validation Translation Routing Guaranteed Delivery Core Gateway NEHEN NEHEN Express Direct Data Entry Billing / PMS Adaptors ADT Adaptors NEHEN Express Direct Data Entry Billing / PMS Adaptors ADT Adaptors

Hosted Portal Hosted by service provider (MA-SHARE) Provides document / data storage, HTTP viewing for subscribers, and common provider index for dissemination to local gateway participants Local Gateway Participant Local gateway users control integration, etc. Can leverage infrastructure for internal integration Interfaces can be direct or use interface engine or similar tools Architecture Overview Local Provider Directory Internet / Network Published Patient Data EMRs and Other Enterprise Systems Secondary Local System Server CCD Standard Messages, or fax encapsulation Interface Engine or Portal HIE Application Server / Gateway Fax ServerWeb Server Network Subscriber No infrastructure support requirement – just Internet connection, fax or e- mail Summary / Results Viewer Fax Summary / Results Viewer Server Web Server Printer , fax or HTTP encapsulation Published Patient Data Community Provider Directory Local Gateway Participant EMRs and Other Enterprise Systems Secondary Local System Server Interface Engine or Portal Fax ServerWeb Server Published Patient Data HIE Application Server / Gateway Local Provider Directory HIE Application Server / Gateway CCD Standard Messages, HTTP encapsulation Summary / Results Viewer External Networks

 Patient visits PCP or specialist and establishes trusted relationship and consents for release of data  As a result of a referral, admission, or emergency, patient registers in hospital  Patient is discharged from hospital  Standard format discharge summary or ER report is transmitted to HIE network  HIE service checks provider directory for routing instructions  HIE service routes discharge summary to PCP, specialist or other interested and trusted party (e.g., health insurance case manager)  Consents and provider routing preferences are sent to HIE service  Patient receives care and details are noted in hospital medical record Visit/Discharge Summary Exchange Send / push / route hospital data to interested parties

Referrals Send / push / route visit and other data in support of referral consultation  Patient visits PCP or specialist and establishes trusted relationship and consents for release of data; consents and provider routing preferences are sent to HIE service  Provider refers patient to a specialist, hospital or other provider for consultation or service  Standard format visit summary with consultation notes transmitted to HIE network  HIE service checks provider directory for routing instructions and sends referral request with pertinent patient information / history, diagnosis and service requested to consulting provider; business rules can be stored in HIE service for elements of real-time decision support  HIE service routes visit summary to PCP, specialist or other interested and trusted party (e.g., health insurance case manager)  Patient visits consulting provider, receives services, and details are noted in patient chart, electronic medical record or other result is created (e.g., at lab)  HIE service submits referral authorization request to payer for approval and referral #

Admission Notification Send / push / route admission notification to payers and providers  Patient visits hospital or other provider and establishes trusted relationship and consents for release of admission notification data  Consents, provider routing preferences, and admission notification notice are sent to HIE service  HIE service checks provider directory for routing instructions and sends admission notification to patient’s preferred payer and provider  Authorized payers and providers are notified of patient hospital admission

Laboratory Results  Patient undergoes tests from his or her physician, establishes trusted relationship and consents for release of laboratory data  Consents, lab results, and provider routing preferences are sent to HIE service  HIE service checks provider directory for routing instructions and sends laboratory results to patient’s preferred provider  Authorized providers can access patient’s laboratory results

Standardized Quality Data Send / push / route visit and other data for standardized quality reporting (and other reporting)  Patient visits PCP, specialist, hospital or other provider and establishes trusted relationship and consents for release of data  Consents, provider routing preferences and applicable data are sent to HIE service  Standard format visit summary or batch with data for determining quality metrics is sent to payer, government agency or other quality metrics organization based on patient consent and business rules in HIE service

Community Provider Directory  Provider organizations track and maintains internal provider directory  Provider information from each provider organization is sent to HIE service  HIE service consolidates organizational provider information into a single community provider directory  Authorized HIE users can access community provider directory

Indiana Health Information Exchange Copyright © 2009 Indiana Health Information Exchange, Inc. Health Information Exchange – General Concept Data Stewardship

Indiana Health Information Exchange Copyright © 2009 Indiana Health Information Exchange, Inc. Layer I: Including Interface Engine, Community Trust, … Layer II: Including Mapped/Normalized Data… New Value- added Service Layer III: Including Repository Services… New Value- added Service Medication Profile Public Health Surveillance Clinical Messaging Clinical Quality Services Ambulatory Results Review ED Abstract and Results Review New Value- added Service Inpatient Results Review Value-added services that can be built upon the HIE investment A layer of necessary investment Interdependency of HIE Components HIE assets are interdependent and, once created, can be leveraged to deliver additional services.

Summary Several Health Information Exchanges are operational today Architectures and Standards differ Policies and trust are very important Local and regional business cases drive adoption Loosely coupled messaging approaches and centralized repositories both work