What did Continua do with CDA? Interface to EHR and PHR systems Keith Naylor December 2009

Agenda Background –Who are Continua? –The ‘Continua Technology Stack’ –The ‘HRN-IF’ (previously known as xHR) CDA, CCD and PHM within the HRN-IF Example and demo (if we have a live web connection) 2

Continua – who are they? The Continua Health Alliance’s mission: –to establish an ecosystem of interoperable personal health systems that empower people and organizations to better manage their health and wellness. The charter of Continua’s Technical Working Group (TWG): –is to select the standards and specifications necessary to meet this vision and to define Design Guidelines that further clarify the standards and specifications that guarantee seamless interoperability is achieved. 3

The Continua Technology Stack 4 WAN-Interface LAN-Interface PAN-InterfaceHRN-Interface Application Hosting Device LAN Device PAN Device Tele-Health WAN Device Health Record Device X

Heath Record Network - IF The purpose of the HRN interface: –is to transfer patient information from a Continua WAN device (HRN Sender) to either another WAN device or an electronic health record device (HRN Receiver) The HRN Sender can be: –A Remote Patient Monitoring (RPM) server of a Disease Management service provider –An Application Server of an Aging Independently or Health & Fitness service provider 5

Heath Record Network - IF The patient information for transfer may include: –report summarizing the patient’s current status, –a detailed listing of specific patient results, –readings from one or more personal health devices, –or a combination of these. The electronic health record device may contain: –hospital’s Enterprise Health Record (EHR), –physician’s Electronic Medical Record (EMR) –Personal Health Record service (PHR) used by the patient. 6

HRN-IF Standards Selection Data: To facilitate the accurate transfer of both coded patient results from personal health devices and textual summary results from patient care-givers, the HL7 Personal Healthcare Monitoring Report document format standard was chosen. NOTE:The Data Guidelines are based on the HL7 CDA R2 standard, profiled by the HL7 Personal Healthcare Monitoring (PHM) Implementation Guide. 7

HRN-IF Standards Selection Messaging: A future is envisioned where patient information is sent between providers by various methods. These methods include: secure direct connection over the Internet, secure , delivery on portable media (data stick, etc.), through a messaging hub, and through a data repository or RHIO / NHIN. To facilitate this, a messaging standard capable of supporting all five transport methods with a minimal amount of re-work was chosen. That is, once the first transport method was accomplished, incorporating additional transport methods require less work. In addition, because this interface is used to communicate with non- Continua certified electronic health records, a messaging standard supported by others that certify electronic health record systems was chosen. For these reasons, Integrating the Healthcare Enterprise’s (IHE) Cross-Enterprise Document Sharing (XDS) profile was chosen. 8

HRN-IF Standards Selection Transport Protocol: To accomplish secure direct communication of pertinent patient information between care-givers, the IHE XDR (Cross- Enterprise Document Reliable interchange) profile utilizes current standards such as SOAP 1.2 and MTOM. To accomplish secure indirect communication of pertinent patient information between care- givers, the IHE Cross-Enterprise Document Media Interchange (XDM) profile utilizes current standards such as Zip and S-MIME. 9

CDA,CCD and PHMR The data transmitted from the HRN Sender can be either summary, raw data or both. The summarization may be a result of analysis by an authentic disease management service provider. The data has multiple characteristics that include: –Representation of measurements captured by devices –Representation of notes, summary, and other kinds of narrative information that are added by care givers or by the user themselves –Representation of graphs that are added by intermediary devices that represent trends of user’s health 10

CDA,CCD and PHMR To accommodate the wide variety of data characteristics, the HL7 Clinical Document Architecture (CDA) based format is chosen. The guidelines specify constraints on the CDA in accordance with requirements set forward by the HRN interface. These constraints are laid out in the Personal Healthcare Monitoring Report (PHMR) Implementation Guide**. Wherever possible, the PHM report reuses the templates already set forth by an HL7 specification called Continuity of Care Document (CCD). Note: **HL7 PHM Report Implementation Guide will have an independent lifecycle under a project called “Personal Health Monitoring Report” under the HL7.org Structured Documents Workgroup (SDWG). 11

PHMR Implementation Guide for CDA Release 2.0 Personal Healthcare Monitoring Report (PHMR) (International Realm) Draft Standard for Trial Use Release 1 First Release November

PHMR Data Model 13 HL7 v3 - RIM

PHMR Data Model 14 PHM Report Header Creation Date/Time - when the report was generated Actors and identification Describes and identifies all individuals, organizations, locations and systems with data in this document (Patient name, Patient ID, Patient demographics, Document author ID, Author name, Author demographics, Doctor name, Doctor ID) PurposePurpose of the document (e.g., “diabetes care progress note) Remote Monitoring Notes Update/Notes/summary information by a remote monitoring service provide (e.g., narrative information that may include graphs, pictures, trends) Functional status This is a place holder for free form text written by RPM care givers, may include interpretation of care givers perspective of RPM information Device Information Information of the devices that are used to collect observations (e.g., BP cuff, glucometer)  System Type  System Model  System ID  Device Configuration ID  Production Spec (Serial Number, Part number, hardware revision, firmware revision, protocol revision)  Regulatory information Vital sign dataMeasurement observations of vital signs  Unified Code for Units of Measure (UCUM)  Nomenclature mapped primarily to SNOMED CT (with IEEE and LOINC as necessary) Medication compliance data Describes current medications and patient adherence

Example PHMR The following slides illustrate the following: –A series of readings taken by a patient using a Roche Glucose Meter –Transmitted to a Device Monitoring System, which creates the CDA/PHMR –Which is then transmitted to an IBM HRN gateway –Viewed using the NHS CfH Workbench utilising a standard XSLT transformation into HTML –If we have a live web connection I can demonstrate the retrieval and display of a PHMR from an online IBM data repository 15

Continua Connectivity Demo 16 Continua Connectivity Demo

17 ACCU-CHEK® 360˚ Diabetes Management Software Continua HRN (xHR) HRN Gateway Continua – USB Devices

Example PHMR – CfH Workbench 18

NHS CfH Workbench 19

Google Health 20

Questions ? 21