1 Toward a Service-Oriented Public Health Infrastructure Alean Kirnak, Software Partners LLC November 2009 Copyright 2009 Software Partners LLC

 PHDSC white paper: silos repeat functionality and don’t talk to each other  In , PHDSC developed a Service- Oriented Architecture White Paper with IHE  New standards offer new workflow possibilities and related cost savings   A Service-Oriented Architecture View of IHE Profiles, Kirnak, Moehrke, Painter.

 Messages  Documents  Services 3 Copyright 2009 Software Partners LLC

 Point-to-point communication  HL7 V2 Implementation Guides MSH|^~\&|XDSDEMO_ADT|XDSDEMO|SWPartne r_PIX|SWPartner_PIX| ||ADT^A0 4^ADT_A01| |P|2.3.1|…. 4 Copyright 2009 Software Partners LLC

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8 Identification Service OperationDescription Register This operation inserts a Source ID/Entity ID pair and supplied Traits into the index with implicit linking to other matching Source ID/ Entity ID pairs, based on the configured internal matching algorithm. Update This operation updates the Traits stored in the index for the Entity identified by the supplied Source ID/Entity ID pair. List This operation retrieves all the Source ID/Entity ID pairs that are linked to the supplied Source ID/Entity ID pair. The operation can be filtered with the sourceConstraintSet property of the EISSearchQualifier to only return entities within specified Source domains. Query This operation provides the means to perform a broad search of all records in the index whose traits match some criteria in the supplied search criteria. Link This operation provides the means to create an explicit (as opposed to automatic) linking between two Source ID/Entity ID pairs in the index. Unlink This operation provides the means to create an explicit (as opposed to automatic) linking between two Source ID/Entity ID pairs in the index. Merge This operation provides the means to explicitly consolidate index Source ID/Entity ID pairs in the index. Copyright 2009 Software Partners LLC

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Web-based Application Registry Data Store Data Stores All Registry Application Functions: Identity Resolution Retrieval/Update of Data Decision Support Population Studies HL7 V2 Hospital #2 Clinic # 2 Hospital #1 user Clinic #1 user Other user Stakeholders Other user

Point to point: Hub: Bus: 11 Copyright 2009 Software Partners LLC

 Approximately 75 U.S. Immunization Information Systems (IISs)  Completely connected point-to-point IIS network: 74 * 75 / 2 = 2775 connections  Assume 200 regional provider EHRs per IIS: 200 * 75 = 15,000 connections  Each connection costs $10K-$30K per side  $40K each * 17,775 =$711,000, Copyright 2009 Software Partners LLC

 Labs  Meds  Allergies  Problem Lists  Cancer Registries  Adverse Events  …etc.  Intra-enterprise communication  Provider-to-Provider communication ...  100 domains increases cost to $71,100,000, Copyright 2009 Software Partners LLC

 Patient Identification  Maintenance of Connections  Data Models  Decision Support  Reporting 14 Copyright 2009 Software Partners LLC

 Providers are the producers of electronic health information  Patients are the consumers Providers will not pay 15 Copyright 2009 Software Partners LLC

 Reduce number of connections through bus architecture ◦ SOA  Create repeatable connections ◦ Plug and play standards like IHE  Collapse common functionality ◦ Reuse infrastructure like Patient Identification  Create common information model ◦ Use Continuity of Care Document  Improve the delivery of information to consumers so payors will eventually pay ◦ To their other providers ◦ To public health ◦ To patients directly 16 Copyright 2009 Software Partners LLC

Service Interfaces Identity Resolution Decision Support Retrieve and Update Hospital #2 Clinic #2 Hospital #1 EMR Clinic #1 EMR Internet Browser interface Existing IIS Master Person Index Document Repository Data Stores Document Registry Services Other Service Security Data Transform HL7 V2 17 Copyright 2009 Software Partners LLC Existing IIS

 75 U.S. IISs  Each connected to one Identification Service running a standard interface: 75 connections  200 provider EHRs per IIS: 200 * 75 = 15,000  Averaging 30 installations each of 500 EHR products = = 575  Each connection costs $10K-$30K ◦ Service consumer only!  $20K each * 575 =$11,500,000 total  plug and play connections means: For a single service i.e. Patient Identification 18 Copyright 2009 Software Partners LLC

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 Interoperability cost becomes function of: # of service consumers * # of services 20 Copyright 2009 Software Partners LLC

3 services * 575 EHR flavors * 20K = $34,500,000 vs $71,100,000, Copyright 2009 Software Partners LLC

22 CapabilityPatient IdentificationData Retrieval and UpdateDecision Support Standards OrgHL7 Service Specification Identification Service Functional Model (SFM)Retrieve, Locate, Update SFMDecision Support SFM Standards OrgOMG Service SpecificationIdentification Service SpecificationRetrieve, Locate, Update Tech SpecDecision Support Service Spec Profile OrgIHE SOA ProfileSOA White Paper Profile OrgIHE Immunization ProfilePIX/PDQ POIZ Scope Immunization Content Request for Clinical Guidance (Immunization Content payload) Profile OrgAIRA/CDC Immunization Profile In progress: 2.5 Implementation Guide Immunization Profile Implementation Guide Immunization Implementation Guide Standards OrgHL7 Original StandardVersion 2 Version 3 Patient Admin messagingVersion 2 Version 3 Immunization (POIZ) messaging Version 3 Care Record CDA Version 3 Care Record messaging Copyright 2009 Software Partners LLC

2. Primary Care Provider, State 2 IHE Infrastructure Immunization Information System (IIS) 1. Primary Care Provider, State 1 PHIN IHE Interoperability Showcase Public Health Immunization Scenario Decision Support Service Yellow Card Service Gateway 3. Infrastructure 4. Local Public Health Dept. State 2 An 18 month-old patient without immunization record visits PCP1 1. PCP1 queries the local EMR 2. EMR queries IIS (QED) 3. IIS returns immunization to EMR 4. PCP1 receives list of immunizations via EMR 5. Immunizations are administered 6. PCP1 updates EMR 7. EMR updates IHE Registry & Repository (XDS-MS, IC) and IIS (HL ) via Gateway The same patient, now a 5 year-old, visits PCP2 in a different state, again without an immunization record 1. PCP2 queries EMR 2. EMR queries the HIE (PIX, PDQ, XDS-MS) 3. HIE returns immunization to EMR 4. PCP2 receives list of immunizations via EMR 5. Immunizations are administered 6. PCP2 updates EMR 7. EMR updates IHE Registry & Repository (XDS-MS, IC) and IIS (HL ) via the Gateway > A measles outbreak is occurring in a large county in State 2. The child’s parent calls the local health department to confirm the child’s measles immunization status 1.Epidemiologist authenticates using a Identity Service Provider (TP 20, C19) 2.Authenticated epidemiologist queries the HIE using child’s name, gender, and birthday (PDQ) 3.IHE Infrastructure returns a list of matching records 4.Epidemiologist selects appropriate record; request for immunization records sent, then results returned (XDS, IC) 5.Request for immunization recommendations (IDSS), results returned 6.Yellow Card requested and returned as PDF to be printed and mailed HL7 V2, V3, PIX/PDQ CDA, XDS, PIX/PDQ Service 23 Copyright 2009 Software Partners LLC

 Education ◦ Little understanding of SOA yet  Broader View ◦ Groups like HITSP must take the broad view ◦ “SOA Governance”  Overcoming status quo thinking ◦ Vested interests in preserving inefficient approaches  Funding ◦ Support innovative approaches as well as status quo  Collective Action 24 Copyright 2009 Software Partners LLC

“The Internet disrupted the music business; Google disrupted the media…. Buzzwords such as “Health Care 2.0”, … could soon acquire real meaning.” - The Economist, Oct 25, Copyright 2009 Software Partners LLC