Bill Majurski National Institute of Standards and Technology (NIST)‏ IT Infrastructure: Profiles for Health Information Exchange

Affinity Domain Profiles

HIE Profiles Categories of Profiles Basic XDS Cross Community Point-to-Point Notification Patient ID Management All focus on or support Document Sharing

What is XDS? XDS is Cross-Enterprise Document Sharing Cross-Enterprise – Elements can be owned by different organizations Document Sharing – Elements of patient record organized as 'Documents'

Basic XDS XDS.a - Original XDS.b – Updated technology

Cross Community XCA – Cross Community Access

Point-to-Point XDM – Media Interchange ( , CD, etc.)‏ XDR – Reliable networking

Notification NAV – Notification of Document Availability

Patient ID Management PDQ – Patient Demographics Query PIX – Patient Identifier Cross-Referencing

What is a Document? Cross-Enterprise Document Sharing What is a Document? Collection of bytes Persistent/Unchangeable Documented Format

What We Will Not Discuss Document Content Format Security These are covered in other talks

XDS Content XDS does not define content...just like your PC filesystem does not define file types PDF, Word, Text, JPEG files are just collections of bytes. The file type is what links the file to an application. XDS Content Profiles define what the bytes mean

XDS Content Profiles Content Profiles define document formats and XDS extensions for specific applications: –XDS-MS: Medical Summaries –BPPC: Basic Patient Privacy Consents –XPHR: Exchange of Personal Health Record Content –PPHP: Pre-procedure History and Physical –EDR: Emergency Department Referral –XDS-SD: Scanned Documents –XDS-Lab: Lab Reports –XDS-I: DICOM Images

Security is still required –ATNA: Audit Trail and Node Authentication Basic security functions: centralized audit trail, authentication of systems (not users), optional encryption for transport connections Required by IHE for all XDS implementations

What are we defining? IHE Profiles are NOT an architecture It is a collection of architectural components To build into new or existing systems To aid in integration

Focus of XDS XDS: Cross-enterprise Document Sharing –Store, register, find and access medical documents of any type –The basic foundation for the “XDS Family of IPs” ATNA: Audit Trail and Node Authentication –Basic security functions: centralized audit trail, authentication of systems (not users), optional encryption for transport connections –Required by IHE for all XDS implementations

XDS Support Profiles PIX: Patient Identifier Cross-referencing –managing multiple local Patient IDs per patient –look-up service for cross references –support for Master Patient Index (MPI)‏ PDQ: Patient Demographics Query –find Patient ID based on name, birthdate, sex etc. CT: Consistent Time –synchronize all systems to common time –needed for audit trail, access rights etc.

XDS Support Profiles XDR: XDS Reliable Interchange –point-to-point exchange of clinical documents, e. g. through XDM: XDS Media Interchange –exchange of clinical documents on storage media (CD-R, DVD-R etc.)‏ XCA: Cross-Community Access (in the works)‏ –federation of multiple XDS installations XUA: Cross-enterprise User Authentication (in the works)‏ –user authentication in a distributed system

XDS Cross-enterprise Document Sharing

XDS Big Picture Transactions and Actors Metadata How it integrates with PIX/PDQ Common configurations

XDS: Big Picture Provide support for document-based patient EHR Support for document storage within existing products Provide support for indexing of patient documents Support query and retrieval of patient documents Scalable architecture

XDS: Big Picture Points of view EHR-CR : Care-delivery Record –Patient information –Managed by a Care Delivery Organization EHR-LR : Longitudinal Record –Documents shared by EHR-CR(s)‏ –Tracked by Registry Clinical Affinity Domain : –Group of healthcare enterprises (EHR-CR)‏ –Common set of policies –Share a single registry Archival

XDS: Big Picture Foundation for Health IT Infrastructures: Shared Electronic Health Record, in a community, region, etc. Effective means to contribute and access: clinical documents across health enterprises. Scalable sharing of documents: between private physicians, clinics, long term care, pharmacy, acute care with different clinical IT systems. Easy access: Care providers are offered means to query and retrieve clinical documents of interest.

XDS: Big Picture Distributed: Each Care delivery organization “publishes” clinical information for others. Actual documents may remain in the source system. Cross-Enterprise: A Registry provides an index for published documents that can be queried! Document Centric: Published clinical data is organized into “clinical documents”. using agreed standard document types (HL7- CDA/CCD, PDF, DICOM, etc.)‏

XDS: Big Picture Document Content Neutral: Document content is processed only by source and consumer systems. Infrastructure is generic. Standardized Registry Attributes: Documents are described by standardized set of attributes. Standardized queries supported by all vendors.

XDS Actors Document Source Document Repository Document Registry Document Consumer

Document Source Has document to store Creates description (metadata) for document Submits

Document Repository Accepts document and metadata from Document Source Stores document Forwards metadata to Document Registry Later, reproduces document on request (allows retrieval)‏

Document Registry Accepts metadata from Repository Stored metadata Accepts queries about metadata Returns metadata matching queries

Document Consumer Generates queries to Registry Accepts metadata back from Registry Displays list of documents for user to choose from (probably)‏ When user selects document from list, retrieves and displays document

XDS Transaction Diagram Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set

Patient Registration Patient Identity Source Document Registry Patient Identity Feed

Document Submission Document Registry Document Repository Document Source Provide and Register Document Set Register Document Set

Query and Retrieve Document Registry Document Repository Document Consumer Query Documents Retrieve Document Register Document Set

XDS Actors Document Source –Source of documents and metadata about documents Document Repository –Stores documents, requests indexing in Document Registry, supports retrieval Document Registry –Indexes documents, supports search Patient Identity Source –Feeds identity of known patients to Document Registry Document Consumer –Initiates search and retrieval for consumer of documents

Metadata Objects Metadata is data stored in the Registry Document - represents a real document Submission Set - included in all submissions to document the submitted “package” Folder - for grouping documents (directory metaphor)‏ Association - Links other objects together

Object Structure Each Metadata Object has internal structure ebRIM standard coding used (XML)‏

Submission Set Document Association (HasMember)‏ Single Document Submission Envelope Contents Metadata

Submission Set Attributes Author –person, role, specialty, institution Title, comments, submission time Availability Status –Submitted or Approved Coded elements –contentType (type of clinical activity)‏ Identifiers –Patient ID, Source ID, Unique ID, UUID

Document Attributes Author –Person, role, specialty, institution Legal Authenticator Title, comments, creation time, service start/stop time Availability Status –Submitted, Approved, Deprecated Identifiers –Patient ID, Unique ID, UUID Demographics –Source Patient ID, Patient Demographics

Document Attributes (cont)‏ Coded Values –Kind of Document Class Code (general catagory)‏ Type Code (more detail)‏ –Event Code (main clinical event)‏ –Healthcare Facility Type –Practice Setting Type –Confidentiality Code Technical Details –MIME Type –Format Code (more detail)‏ –Size –Hash –URI –Language

Document Attributes (cont)‏ Document Metadata points to Document in Repository

Association Attributes Type –HasMember –RPLC (Replace)‏ –APND (Appends)‏ –XFRM (Transformation)‏ –Signs SubmissionSetStatus –Original or Reference Pointers –sourceObject, targetObject

Multiple Document Submission Submission Set Document Association (HasMember)‏ Document Association (HasMember)‏

Submission Set Status = Approved Document Status = Approved Association (HasMember)‏ Submission Set Status = Approved Document Status = Approved Association (HasMember)‏ Association (RPLC)‏ Document Status = Approved Status = Deprecated Document Replacement

Digital Signature Clinical Document Stored in Repository –Indexed in Registry Digital Signature (Document) Stored in Repository –Indexed in Registry How is Signature “attached” to Clinical Document?

Digital Signature (DSG Profile)‏ Submission Set Status = Approved Clinical Document Status = Approved Association (HasMember)‏ Submission Set Status = Approved Signature Document Status = Approved Association (HasMember)‏ Association (Signs)‏

XDS Metadata handling Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set Generates Stores Interprets Adds

XDS Options Options center around Document Source actor Basic operations Submit single document Replace existing document Optional features Off-line mode Multi-document submission Document life-cycle management –Submit addendum or transformation of document Folder management –Create folder, add to folder

Affinity Domain Set of organizations/systems organized around a single Registry Common set of Codes Single Patient ID Domain Involves business and legal agreements Security model/agreements

Enterprise Imaging Center Hospital B Hospital A Emergency Room PCP Patient Admin Repository Cross- Enterprise Document Registry (XDS)‏ Cross- Enterprise Document Registry (XDS)‏ XDS Example

Healthcare Content Standards HL7 CDA, CEN EHRcom HL7, ASTM CCR DICOM … Internet Standards HTML, HTTP, ISO, PDF, JPEG … Electronic Business Standards ebXML, SOAP … XDS: Standards Used

XDS Infrastructure Standards OASIS/ebXML –Registry Information Model v2.0 Basis of XDS Registry Information Model –Registry Services Specifications v2.0 Registry Services –Messaging Services Specifications v2.0 Offline protocols ISO/IEC 9075 Database Language SQL –Registry Query Language SOAP with Attachments –Protocol for communication with XDS Registries and Repositories SHA-1 [FIPS 180-1] –Document Hashes

XDS: Standards Used XDS Infrastructure Standards (cont)‏ HL7 Version –Messages for Patient Identity Management HL7 Version 2.5 –Datatypes for XDS Registry Attribute values HL7 CDA Release 1 –XDS Document concept definition –Source of XDS Document Entry Attributes DICOM, ASTM CCR, HL7 CDA Release 2, CEN EHRcom –Sources of XDS Document Entry Attributes

XDS: Standards Used HTTP –Protocol for Retrieve Document –Online SOAP bindings SMTP –Offline ebMS bindings IETF –Language Identifiers MIME –Document Type codes UTF-8 –Encoding of Registry Attributes XDS Infrastructure Standards (cont)‏

Two “categories” of standards used XDS Infrastructure XDS Content XDS: Standards Used

XDS Content Profiles Outside scope of XDS; layer on top of XDS Content Profiles –Document use cases and translation of document content into registry metadata –Publishable separately –Generated (mostly) by other committees (PCC, Radiology, Lab etc)‏ Of concern only to Document Source and Document Consumer actors Base standards for Content Profiles include: HL7 CDA, DICOM, ASTM CCR

XDS: PIX/PDQ integration Patient Identity Feed (PIX)‏ –Notification from ADT system to Document Registry of patient admission/registration –Submission to Registry requires validated patient ID –Affinity Domain Patient ID Patient Demographics Query (PDQ)‏ –Identify patient based on query of demographic information –Needed by Document Source: assign correct patient ID –Needed by Document Consumer: query against correct patient ID

XDS: Related Infrastructure Profiles Notification of Availability (NAV)‏ –Send notification that documents are available Digital Signature (DSG)‏ –Signing of documents in repository/registry Stored Query (transaction)‏ –New query transaction for XDS Cross-Enterprise Document Media Interchange (XDM)‏ –XDS content on media (CD etc)‏ Cross-Enterprise Document Reliable Interchange (XDR)‏ –XDS content over point-to-point connection

XDS Query Catalog supported by Stored Query

Stored Query Defines a collection of queries –Name –Function/purpose they serve –Parameters they accept Must be supported by all XDS Registries!

Query Types Primary queries –Based on Patient ID Secondary queries –Based on registry identifiers

Primary Queries FindDocuments –Find documents for a patient FindSubmissionSets –Find submission sets for a patient GetAll –Get everything known about a patient Each have parameters to restrict documents ‘found’

Secondary Queries GetDocuments –Given the ids of the documents GetFolders –Given the ids of the folders GetAssociations –Related to a given document/folder/submission set

Secondary Queries (cont)‏ GetDocumentsAndAssociations –Combines GetDocuments and GetAssociations queries GetSubmissionSets –For a collection of documents and/or folders GetSubmissionSetAndContents –Given the id of the submission set, return its contents

Secondary Queries (cont)‏ GetFolderAndContents –Given the id of a folder return the folder and its contents GetFoldersForDocument –Given the id of a document return all folders that ‘contain’ the document GetRelatedDocuments –Given the id of a document return all documents that are related to the document through an association

XDS.a vs XDS.b XDS.a Older standards Registry (ebRIM/ebRS 2.1)‏ Web Services (SOAP w Attachments)‏ Most transactions are WS HTTP Retrieve XDS.b Newer Standards Registry (ebRIM/ebRS 3.0)‏ Web Services (Addressing, MTOM/XOP)‏ All transactions are WS WS Retrieve

XDS Configurations Understanding how the actors work together

XDS Transaction Diagram Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set

Source/Consumer Grouping A single 'workstation' that can submit and access content.

XDS Transaction Diagram Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set

Registry/Repository Grouping Affinity Domain could offer a central Repository along with Registry to serve facilities that do not have local Repository.

XDS Transaction Diagram Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set

Source/Repository Grouping A source of documents could be an existing EHR which Registers documents in Registry Allows document retrieval via Retrieve Document transaction Stores information internally in non- document formats Must manage document persistence

What is a Document? Content/Documents have 3 formats: –Storage –Transfer/interface –Display XDS constrains the transfer/interface through Content Profiles –Use of IHE published Content Profiles is a local choice. It is not required by XDS. Transfer/interface formats are chosen locally by Affinity Domain IHE only makes recommendations

Support Profiles “Infrastructure for XDS”

XDS Support Collection of profiles that support XDS Globally Consistent Time (CT profile)‏ Patient Management (PIX/PDQ profiles)‏ Node Authentication (ATNA profile)‏ Audit Logging (ATNA profile)‏ Authorization Assertions (XUA profile)‏ Notification of Availability (NAV)‏ Digital Signature (DSG)‏

Support Profiles Consistent Time (CT)‏

Consistent Time Profile XDS describes a distributed system - time synchronization is critical Network Time Protocol ( NTP) version 3 (RFC 1305) for time synchronization Actor must support manual configuration Required accuracy: 1 second Optionally Secure NTP may be used

Support Profiles Patient Identifier Cross-referencing (PIX)‏

Patient Identifier Cross-referencing (PIX)‏ Allow all enterprise participants to register the identifiers they use for patients in their domain Participants retain control over their own domain’s patient index(es)‏ Support domain systems’ queries for other systems’ identifiers for their patients Optionally, notify domain systems when other systems update identifiers for their patients

Patient Identifier Cross-referencing (PIX)‏ Maintain all systems’ identifiers for a patient in a single location Use any algorithms (encapsulated) to find matching patients across disparate identifier domains Lower cost for synchronizing data across systems –No need to force identifier and format changes onto existing systems

Patient Identity Feed [ITI-8] ­ PIX Query [ITI-9] ­ PIX Update Notification [ITI-10] Patient Identity Source Patient Identity Cross reference Manager Patient Identity Consumer PIX Transaction Diagram

XDS: PIX integration Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set PIX XREF Manager PIX Query

Patient Identification Domain A Other IHE Actor Identity Patient Cross References Patient Identity Consumer Patient Identification Domain C Patient Identity Feed Patient Identity Source Patient Identity Cross-reference Manager Patient Identification Cross-reference Domain Patient Identity Feed & Patient Identity References Internal Domain transactions Other IHE Actor Patient Identity Cross References Patient Identity Consumer Patient Identification DomainB Patient Identity Feed Patient Identity Source Internal Domain transactions PIX: Process Flow Showing ID Domains & Transactions

Patient Identification Domain A Patient Identification Domain C Id=X456 Id=Y921 Id=D456 Id=DF45 Patient Identification Cross-reference Domain Patient Identification Domain B Id=123 Id=235 Id=3TY Id=2RT Patient Identity Cross-reference Manager B:X456 =C:2RT A:123 =B:Y921 =C:3TY B:D456 A:235 =B:DF45 A:678 Patient Identity Consumer B:X456 C: 2RT Patient ID Cross-Refs B:X456 C: ? Patient Identifier Cross-referencing (PIX)‏

PIX Actors Patient Identity Source –Definition Assigns patient identities within its own domain Notifies Patient Identifier Cross-reference Manager of all events related to patient identification (creation, merge, etc.)‏ Example: Registration (ADT) Actor in IHE Radiology Scheduled Workflow (SWF) Profile –Transaction Supported - Required Patient Identity Feed [ITI-8] (as sender)‏

PIX Actors Patient Identifier Cross-reference Consumer –Definition Requires information about patient identifiers in other domains Requests patient identifier information from Patient Identifier Cross-reference Manager –Transaction Supported - Required PIX Query [ITI-9] (as sender)‏ –Transaction Supported - Optional PIX Update Notification [ITI-10] (as receiver)‏

PIX Actors Patient Identifier Cross-reference Manager –Definition Serves a well-defined set of Patient Identifier Domains Receives patient identifier information from Patient Identity Source Actors Manages cross-referencing of identifiers across domains –Transactions Supported - Required Patient Identity Feed [ITI-8] (as receiver)‏ PIX Query [ITI-9] (as receiver)‏ PIX Update Notification [ITI-10] (as sender)‏

PIX: Standard Used HL7 Version 2.5 –ADT Registration and Update Trigger Events A01: inpatient admission A04: outpatient registration A05: pre-admission A08: patient update A40: merge patient –Queries for Corresponding Identifiers (ADT^Q23/K23)‏ –Notification of Identifiers Lists Updates (ADT^A31)‏

PIX Summary Patient ID management Translation of Patient IDs across Patient ID domains Patient ID feed Query & Notification of Cross Referencing

PIX as seen from XDS NOT a requirement XDS Affinity Domain allows only a single Assigning Authority for Patient IDs Implication: do your complex Patient ID management outside of the XDS environment To 'do' XDS, translate your Patient IDs to the Patient ID Domain (Assigning Authority) defined for the Affinity Domain.

Patient ID Responsibilities Who must manage? Document Source Document Consumer (known as Edge Systems)‏ Registry and Repository only see Assigning Authority defined for Affinity Domain (known as Infrastructure Systems)‏

Edge Systems Must translate local Patient ID to Affinity Domain Patient ID Use request to PIX Cross-Reference Manager –Translate PID X in local domain –To domain Affinity Domain –Return is PID in Affinity Domain

Edge Systems Management of healthcare information always starts with a Patient Identified by name and demographics PDQ query translates name/demographics to pick-list of matching Patients Produces Patient ID in a domain

Registry Registry has two uses for Patient ID What are valid Patient IDs –Consistency check against submitted documents Handle request to Merge two Patient IDs PIX profile supplies both of these to Registry

Discovering Patient IDs Discover Patient ID from Patient Demographics Patient Demographics Query profile Not required by XDS

Support Profiles Patient Demographic Query (PDQ)‏

Patient Demographics Query (PDQ)‏ Allow quick retrieval of a patient list including common patient names, identifiers, contacts, and visit information Enable selection of correct patient when full identification data may not be available Limits access to only a subset of demographic and visit information

Patient Demographics Query (PDQ)‏ Enables access on demand to diverse systems and devices –Participants that do not need continual synchronization of patient registration information –Devices that cannot participate in monitoring of ADT feeds, e.g.: Small-footprint devices Low-memory devices

Patient Demographics Query (PDQ)‏ Allow search on full or partial data Retrieve information from any domain to which the client has query access Allows use of matching algorithm (e.g., soundex) to find near matches

Patient Demographics Supplier Patient Demographics Consumer Patient Demographics Query Patient Demographics and Visit Query A departmental system that is connected on demand to the registration system. Diverse systems including bedside monitors, physician office systems, lab applications, mobile blood bank registries; might be any system at the point of contact. PDQ Transaction Diagram

PDQ Standards Used Employs HL7 Conformance Based Queries –Defined in HL7 Version 2.5, Chapter 5 –Profiles Query by Parameter (QBP^Q22) with Segment Pattern Response (RSP^K22)‏

PDQ Actors Patient Demographics Consumer Definition –Requestor of patient demographic (and perhaps current visit) information –Allows user to associate information with a patient at the point of care Transaction Supported – Required –Patient Demographics Query (as sender)‏ Transaction Supported – Optional –Patient Demographics and Visit Query (as sender)‏

PDQ Actors Patient Demographics Supplier Definition –Repository of patient information that can be searched on demographic or visit-related fields Transaction Supported – Required –Patient Demographics Query (as receiver)‏ Transaction Supported – Optional –Patient Demographics and Visit Query (as receiver)‏

PDQ Operation Patient Demographics Query User enters full or partial demographic information (e.g., partial last name and first initial) for patients of interest Application associated with Patient Demographics Consumer sends HL7 QBP^Q22 to Patient Demographics Supplier to find matching information –May request specific domains from which to return identifier information

XDS: PIX/PDQ integration Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set Patient Demographics Supplier PIX XREF Manager PIX Query Patient Demographics Query

Support Profiles Audit Trail and Node Authentication (ATNA)‏

Content Profiles

Definition XDS defines a mechanism for sharing ‘Documents’ ‘Document’ defined as a byte stream with a size, hash, and mime type Content Profiles are standardized document formats defined within IHE

Domains The following IHE Domains have defined XDS Content Profiles IT Infrastructure (ITI)‏ Radiology Laboratory Patient Care Coordination (PCC)‏

IT Infrastructure XDS-SD Scanned document Stored in PDF format Wrapped in CDA/R2 Basic Patient Privacy Consents (BPPC)‏ More than a Content Profile Includes privacy processing rules enforced by the Document Registry in queries

Radiology XDS-I (XDS for Imaging)‏ Normal XDS actors plus –Image Document Source (extension to XDS Document Source)‏ –Image Document Consumer (extension to XDS Document Consumer)‏ –Image Document Source stores Radiology images locally in Image Archive –Image Manifest Document stored in XDS Repository –Manifest (also called Key Object Select - KOS) references specific DICOM content in Image Archive

Retrieving Radiology Content Query Registry, receive metadata –Metadata describes Image Manifests Choose and retrieve Image Manifest(s) from Document Repository Decode Manifest and retrieve Image content from Image Archive

Laboratory Lab Report

Patient Care Coordination Many, many Clinically oriented Content Profiles

XDR / XDM Point-to-point transmission of documents

XDM Cross-Enterprise Document Media Interchange

XDM Big Picture Documents and XDS Metadata shared via media

XDM Cross-Enterprise Document Media Interchange (XDM)‏ Options USB CD-R ZIP over

XDM Imposes File/Directory structure on the media Transport Multiple XDS Submission Sets Each Submission Set has –Metadata describing documents –Documents Protocol structure of XDS imposed on file/directory organization

XDM Uses Release of documents to patient Manual (in pocket or ) transfer of documents Local display after receipt –Index.htm file required to support display These are manual operations!

XDS Family of Profiles XDS - the base XDM - exchange of XDS metadata and documents on Media XDR - exhange of XDS metadata and documents over reliable protocols XD* - refers to XDS, XDM, XDR together

XDR Cross-Enterprise Document Reliable Interchange

XDR Cross-Enterprise Document Reliable Interchange (XDR)‏ Point-to-point transmission of XDS content over reliable communications Uses Provide and Register transaction (from XDS)‏ A new profile but really just documents how to use Provide and Register to perform point-to-point transfers.

XDR Reliable asynchronous point-to-point transfer of XDS metadata and documents Reliable transfer comes from ebMS Messaging Services Specification v2.0

XDR Single Submission Set per transfer –More like XDS than XDM Optionally identify intended recipients

XDS + XDR + XDM How do XDR and XDM work with XDS? XDS Query/Retrieve can feed XDR/XDM transmission Point-to-point transfer via XDR/XDM can feed XDS submission

XCA Cross-Community Access

XCA Big Picture XDS defines the operation of an Affinity Domain (single Registry +...)‏ XCA defines interchange between multiple communities. An Affinity Domain is one type of community.

XCA Features of an XCA community Accept Query and Retrieve transactions from other communities –Allows sharing of local documents A community could be an Affinity Domain...or not.

XCA A few details Uses Stored Query and XDS.b Retrieve to access foreign community content A query can be broadcast to multiple communities (document discovery)‏ Introduces homeCommunityId to identify/address communities Uses ebRIM/ebRS 3.0 (like XDS.b)‏

XCA Tough problems still to be solved Patient ID management –How to manage translation between communities –PIX/PDQ provide some of the necessary features Configuration Management –How to translate/manage coding

Community Network B Document Registry Practice Clinic Hospitals Hospital Diag Test Other Practice Hospital Community Network C Document Registry Practice Clinic Hospitals IHE transactions (future) Cross Community Gateway Cross Community Gateway Cross Community Gateway National Network A Non-IHE National EHR Which community holds records for a patient ? XDS Cross Community…Access Cross-Community Gateways query and retrieve records (2007 & future)‏ National or Regional Networks not required to be IHE-based Mapping to & from IHE Transactions performed by X-Community Gateways

Regional Network B Acute Care (Inpatient)‏ PCPs and Clinics (Ambulatory)‏ Long Term Care Other Specialized Care or Diagnostics Services Document Registry Document Repository Longitudinal Record as used across-encounters Regional Network C Acute Care (Inpatient)‏ PCPs and Clinics (Ambulatory)‏ Long Term Care Other Specialized Care or Diagnostics Services Document Registry Document Repository Longitudinal Record as used across-encounters Regional Network A Acute Care (Inpatient)‏ PCPs and Clinics (Ambulatory)‏ Long Term Care Other Specialized Care or Diagnostics Services Document Registry Document Repository Longitudinal Record as used across-encounters Cross Community Gateway Which community holds records for a patient ? Cross Community Gateway Gateway Community Locator service IHE Transactions (future)‏ Cross-Community…Location Each region notifies Community Location Service when new patient is registered or first data is stored. Cross Community Gateways query Community Locator Service (future)‏ Cross-Community Gateways query and retrieve records (2007 & future)‏

Other Cross-community Issues… Management of Patient IDs –Normally managed within Affinity Domain Clinical Coding –Normally managed within Affinity Domain

Cross Community Access: Value Proposition Sharing of documents beyond the XDS Affinity Domain (community) boundary. Part of a larger vision for regional and national sharing – 2006 whitepaper on Cross Community Information Exchange –Cross Community Access (2007)‏ –Cross Community Location (2008)‏ Scoped to document sharing between XDS Affinity Domains. Future goal to define sharing with other types of communities.

Cross Community Access: Technical Solution Cross Community Gateway –A new actor which supports all inter-community communications. Encapsulates in one actor all activities required to communicate outside the community. –Every community would have one cross community gateway which would interact with actors within the community and remote cross community gateways. Cross Community Consumer –Initiator of a request for information beyond the community. Technical Issues: –Need for asynchronous transactions in the cross community environment –Interaction with existing XDS actors –Reliable identification of the patient

Community Network B Document Registry Practice Clinic Hospitals Hospital Diag Test Other Practice Hospital Community Network C Document Registry Practice Clinic Hospitals 18 edge systems 4 infrastructure systems 5 edge systems 4 infrastructure systems 13 edge systems 3 infrastructure systems 3 infrastructure Systems Community Network A Document Registry Practice Clinic Hospitals Diag Test HIMSS Interoperability Showcase The largest multi-vendor prototype ever built !

XDS Transaction Diagram Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed Query Documents Retrieve Document Provide and Register Document Set Register Document Set

Patient Information Options PIX Feed to Document Source/Consumer PDQ queries from Document Source/Consumer Use of Patient ID Cross-Referencing by Document Source/Consumer These are all optional within XDS!

Patient ID Merge

Merge Issues Patient Management is an imperfect art Documents get assigned to the wrong Patient ID Multiple Patient IDs identify single Patient Single Patient ID identifies content for multiple Patients

Merge Merge Supplement starts to offer tools to manage these issues in XDS Relies on PIX notification of Patient ID related problem Current scope is to merge two Patient IDs that are found to represent same Patient Early work... still evolving