March 17, 2005IHE and medical Standards in Denmark 1 Integrating the Healthcare Enterprise IHE for cross-enterprise interoperability Charles Parisot, GE Healthcare IHE IT Infrastructure Technical Committee Co-chair IHE Europe Committee Copenhagen, March 17th 2005

March 17, 2005IHE and medical Standards in Denmark 2 W W W. I H E. N E T Providers and Vendors Working Together to Deliver Interoperable Health Information Systems In the Enterprise and Across Care Settings W W W. I H E – Europe. o r g

March 17, 2005IHE and medical Standards in Denmark 3 IHE drives healthcare standards based-integration

March 17, 2005IHE and medical Standards in Denmark 4 A Proven Standards Adoption Process IHE Integration Profiles B IHE Integration Profile A Easy to Integrate Products IHE Connect-a-thon Product With IHE IHE Demonstration User Site RFP Standards IHE Technical Framework Product IHE Integration Statement IHE Connect-a-thon Results IHE Integration Profiles at the heart of IHE : Detailed selection of standards and options each solving a specific integration problem A growing set of effective provider/vendor agreed solutions Vendors can implement with ROI Providers can deploy with stability Process started in1998 with continuous improvements

March 17, 2005IHE and medical Standards in Denmark 5 Achievements and expanding scope Over 100 vendors involved world-wide, 4 Technical Frameworks 27 Integration Profiles, Testing at yearly Connectathons, Demonstrations at major exhibitions world-wide To claim compliance to IHE Integration Profiles vendors shall publish for each product an IHE Integration Statement. Patient care Coordination, Quality, Pharmacy, Anatomical Pathology, Surgery, etc.

March 17, 2005IHE and medical Standards in Denmark 6 IHE IT Infrastructure Enterprise User Authentication Provide users a single name and centralized authentication process across all systems Retrieve Information for Display Access a patients clinical information and documents in a format ready to be presented to the requesting user Retrieve Information for Display Access a patients clinical information and documents in a format ready to be presented to the requesting user Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Consistent Time Coordinate time across networked systems Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. New Patient Demographics Query New Personnel White Page Access to workforce contact information New Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record New

March 17, 2005IHE and medical Standards in Denmark 7 Introduction: EHR Cross-Enterprise Document Sharing Enables the seamless information sharing between healthcare IT systems (e.g. EHRs) serving all types of care delivery organizations in a region or nation.

March 17, 2005IHE and medical Standards in Denmark 8 community Clinical Encounter Clinical IT System Index of patients records (Document-level) 1-Patient Authorized Inquiry Temporary Aggregate Patient History 4-Patient data presented to Physician Sharing System 3-RecordsReturned Reference to records Laboratory Results Specialist Record Hospital Record 2-Reference to Records for Inquiry Sharing records that have been published

March 17, 2005IHE and medical Standards in Denmark 9 Acute Care (Inpatient) PCPs and Clinics (Ambulatory) Long Term Care Other Specialized Care or Diagnostics Services Building and accessing Documents EHR-CR: Care Record systems supporting care delivery Documents Registry Document Repository EHR-LR: Longitudinal Record as used across-encounters Submission of Document References Retrieve of selected Documents

March 17, 2005IHE and medical Standards in Denmark 10 XDS – Value Proposition 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.

March 17, 2005IHE and medical Standards in Denmark 11 XDS - Value Proposition Distributed: Each Care delivery organization publishes clinical information for others. Actual documents may remain in the source EHR-CR. Cross-Enterprise: A Registry provides an index for published information to authorized care delivery organizations belonging to the same clinical affinity domain (e.g. an RHIO). Document Centric: Published clinical data is organized into clinical documents. using agreed standard document types (HL7-CDA, PDF, DICOM, etc.) Document Content Neutral: Document content is processed only by source and consumer IT systems. Standardized Registry Attributes: Queries based on meaningful attributes ensure deterministic document searches.

March 17, 2005IHE and medical Standards in Denmark 12 XDS Document A set of attested clinical information (structured or not) which form an element of a patient record to be shared. It may already exist within the source IT system. XDS Submission Set A set of documents related to a patient that a (team of) clinician(s) in the same source system have decided to make available to potential consumers. XDS Folder A means to group documents for a number of other reasons: Team work across several physicians, Episode of care, Emergency information for a patient, etc. XDS leaves open the use of folders to affinity domain clinicians. Key Concepts IHE XDS Integration Profile: Key Concepts

March 17, 2005IHE and medical Standards in Denmark 13 EHR Cross-Enterprise Document Sharing What does IHE deliver ? A set of practical scenarios: Submission of documents, submission set, folder, affinity domains, etc are derived from use case scenarios. Example: cardiac care network. A definition of the Actors involved: XDS relies on 5 Actors implemented by the IT systems involved. A complete specification of the Transactions involved : XDS include 5 Transactions specifying exchange of one or more standards-based messages. XDS leverages the most appropriate standard(s) (e.g. HL7, ebXML Registry, W3C, etc.) and resolves any options to ensure interoperability. A number of implementation scenarios are discussed.

March 17, 2005IHE and medical Standards in Denmark 14 XDS Actors and Transactions

March 17, 2005IHE and medical Standards in Denmark 15 Secured Node Document Consumer Retrieve Document Query Documents Patient Identity Source Patient Identity Feed Document Source Document Registry Document Repository Provide&Register Document Se t Register Document Set Secured Node ATNA creates a secured domain: User Accountability (Audit trail) Node-to-Node Access Control Node-level user authentication User access control provided by node BUT Registry/repository based User-Level Access Control and policy agreements is beyond XDS.. Security for XDS Security for XDS Leverages IHE Audit Trail & Node Authentication

March 17, 2005IHE and medical Standards in Denmark 16 Integration Model 1: EHR-CR with Repository at Source An EHR-CR completes a phase of care for a patient where it: Has these documents available as Repository Actor. Registers documents with a Registry actor. Any other EHR-CR may query the Registry actor, and chose to retrieve some of these documents from any Document Repository Actor.

March 17, 2005IHE and medical Standards in Denmark 17 Integration Model 2: EHR-LR with Third Party Repository An EHR-CR completes a phase of care for a patient where it: Provides the documents to a Repository Actor of its choice. Documents are Registered with a Registry Actor. Any other EHR-CR may query the Registry actor, and chose to retrieve some of these documents from any Document Repository Actor.

March 17, 2005IHE and medical Standards in Denmark 18 Integration Model 3: EHR-CR feed a EHR-CR/EHR-LR hub An EHR-CR completes a phase of care for a patient where it: Provides and Registers a set of documents to a Document Repository in an EHR-CR. The EHR-CR Consumer Actor has the documents and may respond to queries and provide them to other document consumers.

March 17, 2005IHE and medical Standards in Denmark 19 Patient Access also possible A patient accesses own record: Query and Retrieve a set of documents using for example a portal application that offers the ability to display documents content. This is a particular case of an EHR-CR, where the patient is interested her/his own care. Patient may also register and provide documents.

March 17, 2005IHE and medical Standards in Denmark 20 Standards selection for IHE XDS No single standard can address Cross-enterprise Document Sharing Marriage of healthcare standards facilitates implementation and leverages complementary technologies (e.g. security & privacy). Healthcare Content Standards HL7 CDA, CEN EHRcom HL7, ASTM CCR DICOM, etc. Internet Standards XML, HTTP, ISO, etc. Electronic Business Standards ebXML Registry, ebMS, SOAP, etc.

March 17, 2005IHE and medical Standards in Denmark 21 How real is XDS ? Specification work since Nov 2003 Under Public Comments June-July constructive comments received. 600 constructive comments received. Validity of XDS approach confirmed (e.g. CfH Collaborative Response). Validity of XDS approach confirmed (e.g. CfH Collaborative Response). Stable specification IHE Technical Framework Published Aug 15 th, 2004 (TI Supplement) IHE Connectathon - January 2005 (USA) 14 Vendors passed 14 Vendors passed HIMSS Feb show-wide demonstration 17 EHRs, 800 patients, 7700 documents registered, queries. 17 EHRs, 800 patients, 7700 documents registered, queries. IHE Connectathon - April 2005 (Europe) 22 Vendors registered 22 Vendors registered Several Implementation Projects by health authorities in 2005 Italy: Linguini & Veneto Regions - Canada: Newfoundland – France: Trials – Norway-Region

March 17, 2005IHE and medical Standards in Denmark 22 HIMSS Highlights

March 17, 2005IHE and medical Standards in Denmark 23 HIMSS IHE Highlights HIMSS: 700 Exhibitors - 23,000 Attendees Over 2000 visited the IHE Booth. 49 participants in IHE Interoperability booth 15 vendors participated in XDS from their booth 732 Attendees registered for their own EHR 7,772 Documents registered in XDS Registry 40,984 Queries to XDS Registry US National IT Coordinator (Dr Brailer) held his press conference in IHE Booth and thanked IHE. 50 members of press toured.

March 17, 2005IHE and medical Standards in Denmark 24 HIMSS RHIO with IHE-XDS Cross-enterprise doc sharing Over 700 attendees experienced their HIMSS-Wide Electronic Health Record Ambulatory Showcase Booth Home PCP Multispecialty Clinic Diag Center Vendor Booth HL7 Demo Booth Cardiology Workup Comprehensive Patient Care Radiology Coordinated Patient Evaluation IT Infrastructure Cross-enterprise Showcase Booth

March 17, 2005IHE and medical Standards in Denmark 25 IHE Profiles for a RHIO Available Integration Profiles completed Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record New Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Patient Demographics Query New 2004 Consistent Time Coordinate time across networked systems Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. New 2004 Personnel White Page Access to workforce contact information New

March 17, 2005IHE and medical Standards in Denmark 26 IHE Profiles for RHIOs What is available and what will be added in 2005 Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Consistent Time Coordinate time across networked systems Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. Patient Demographics Query Personnel White Page Access to workforce contact information Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Notification of Document Availability Notification of a remote provider/ health enterprise Cross-enterprise User Identity and Accountability Authentication & Auditing: Basis for Access Control Imaging Information Content Format of the Document Content and associated coded vocabulary For Display Document Content Format of the Document Content Lab Results Document Content Format of the Document Content and associated coded vocabulary Continuity of Care Document Content Format of the Document Content and associated coded vocabulary

March 17, 2005IHE and medical Standards in Denmark 27 IHE and HL7 V3 Continuity of Care Document Content Format of the Document Content and associated coded vocabulary IHE relies only on approved standards. HL7 V2 is widely used. Official relation with HL7, effective cooperation with HL7 affiliate world-wide. Early 2005, foundations elements of HL7 V3 have been approved, but only a few application level are. One of this element based on HL7 V3 based on the RIM has been approved in January 2005: CDA Release 2 (nothing to do with HL7V2). IHE considers that HL7 CDA based on HL7-V3-RIM as the strategic means to introduce HL7V3 in the real world. In 2005, IHE is developing in cooperation with HL7 an integration profile for care record summary. It will allow the sharing with XDS of the basic care information in a form both structured and human displayable in a consistent manner.

March 17, 2005IHE and medical Standards in Denmark 28 EHR-CR Push-like Integration : Adding Notifications Using « an notification that need not be secured» to turn a Pull Model into a like Push Model. 4 Retrieve 3 Query Document Source Document Consumer Document Repository Document Registry Notification Register

March 17, 2005IHE and medical Standards in Denmark 29 Local & Regional RHIOs Infrastructure and Interoperability Cross-Enterprise Document Sharing (XDS) minimizes clinical data management by the infrastructure. Transparency = Ease of Evolution XDS works with other IHE Integration Profiles: Audit Trail and Node Authentication (ATNA) and Consistent Time (CT) Patient Id Cross-referencing (PIX) Patient Demographics Query (PDQ) In 2005, IHE plans to finish base set of integration profiles to build regional health networks and interoperable EHRs: Security: Identity Management+ Accountability Content Profiles: DICOM, HL7-CDA-r2/CCR, HL7-Lab, PDF. Notification of Document Availability (with XDS document reference)

March 17, 2005IHE and medical Standards in Denmark 30 IHE: RHIOs Interoperability Partner IHE offers a solid technical foundation to establish interoperability for Regional/National Health Information Organizations (RHIO). Standards-based, open, multi-vendor, provider-led. Yearly progress, validation testing built in, backed by a proven process. Implementation by many vendors. IHE welcomes RHIOs technical architects active involvement. The IHE Technical Framework accelerates RHIOs pilot project development ( XDS Affinity Domain Concept ).

March 17, 2005IHE and medical Standards in Denmark 31 W W W. I H E. N E T Providers and Vendors Working Together to Deliver Interoperable Health Information Systems In the Enterprise and Across Care Settings W W W. I H E – Europe. o r g