IHE Profiles and CDA HL7 UK 2007 Keith W. Boone Interoperability Architect, GE Healthcare Co-chair, IHE Patient Care Coordination TC Co-chair, HL7 Structured Documents Member, ANSI/HITSP CE, CD and PH TCs Member, ASTM

Agenda IHE Profiles Templates IHE CDA Based Templates IHE Privacy and Security Framework Basic Patient Privacy Consents

IHE Actor and Transaction Diagrams Actors –Analogous to HL7 Application Roles –A UML "Interface" Transactions –A sequence of one or more standards based interactions –Somewhat analogous to HL7 Interactions

Cross Enterprise Document Sharing - XDS [ITI-8]HL7 V2 ADT [ITI-14, 15, 16]ebRIM (Registry Information Model) ebRS (Registry Services) [ITI-17]HTTP

Cross Enterprise Document Sharing Metadata WhoWhatWhereWhen Document Patient Identifiers, Name, Address, Gender, Date of Birth Author Institution, Person, Role, Specialty Legal Authenticator Service Event Confidentiality Document Type Class Format Language Title URI Healthcare Facility Practice Setting Service start Service end Creation Folder OwnerCode(s) Description Update Submission Set Patient Identifier Author Institution, Person, Role, Specialty ContentSourceSubmitted Searchable Metadata, Stored Metadata

Consistent Time - CT [ITI-1] RFC-1305 (NTP), RFC-2030 (SNTP)

Audit Trails and Node Authentication - ATNA [ITI-1]RFC-1305 (NTP), RFC-2030 (SNTP) [ITI-19]RFC-2246 (TLS), X.509 [ITI-20]RFC-3164 (Syslog), RFC-3881

Patient Identity Cross Referencing - PIX [ITI-8]HL7 V2.3.1 ADT or HL7 V3 Patient Administration [ITI-9]HL7 V2.5 Query or HL7 V3 Patient Administration [ITI-10]HL7 V2.5 ADT or HL7 V3 Patient Administration

Patient Demograpics Query - PDQ [ITI-20,21]HL7 V2.5 ADT or HL7 V3 Patient Administration

Request Form for Data Capture - RFD XForms 1.0, WSDL, XML

Query for Existing Data - QED HL7 V3 Care Record, Care Record Query ASTM/HL7 Continuity of Care Document

Putting it Together EHR Registration System Audit System eMPI Time Server eMPI HIE Audit System

CDA Templates What is a Template? How can it be expressed? What can I do with it?

What is a Template? A template is an expression of a set of constraints on the RIM that is used to apply additional constraints to a portion of an instance of data which is expressed in terms of some other Static Model. HL7 Specification and Use of Reusable Constraint Templates

Expression of Templates Formal Written Definition –In human readable form Explicit or Implicit HL7 Static Model –Application results in a Static Model Implementation Specific Representations –Static Model –W3C Schema –ISO Schematron

Features of a Template Has an Identity Can Require, Prohibit, or Suggest (constrain) –RIM Attributes –Relationships –Other Templates –Specify Cardinality –Conditional and Co-relationships Can Inherit from other Templates

IHE Patient Care Coordination Templates Are Content Profiles or Modules Have a formal Written Definition Result in an Implicit HL7 Static Model Use ISO Schematron for Implementation Inherit from ASTM/HL7 CCD when possible Provide Constraints on –Documents –Sections –Entries

Document Level Templates Template ID Summary Description Format Code for use with XDS Standards Used Data Element Table (needs Definitions) Specification –Sections –(Header) Entries Conformance Sample XML (abbreviated) Schematron

Document Template Specification

IHE PCC Document Templates (12) Medical Documents Specification Medical Summary Specification Referral Summary Specification Discharge Summary Specification PHR Extract Specification PHR Update Specification Emergency Department Referral Specification Antepartum Summary Triage Note Nursing Note Composite Triage and Nursing Note ED Physician Note

Section Level Template Template ID Parent Template(s) Summary Description LOINC Code Required and Optional Sub-sections Required and Optional Entry Templates Sample XML (abbreviated) Schematron

Section Template Example

IHE PCC Section Templates (71) Reasons for Care (4) Other Condition Histories (12) Medications (5) Physical Exams (28) Relevant Studies (5) Plans of Care (7) Procedures Performed (3) Impressions (3) Administrative and Other Information (4)

Reasons for Care The sections described below describe various reasons why healthcare is being provided to the patient. Reason for Referral Coded Reason for Referral Chief Complaint Hospital Admission Diagnosis

Other Condition Histories History of Present Illness Hospital Course Active Problems Discharge Diagnosis Resolved Problems Encounter Histories History of Outpatient Visits History of Inpatient Visits List of Surgeries Coded List of Surgeries Allergies and Other Adverse Reactions Family Medical History Coded Family Medical History Social History The sections defined below provide historical information about the patient's conditions. Functional Status Coded Functional Status Pain Scale Assessment Braden Score Assessment Geriatric Depression Scale Physical Function Review of Systems Hazardous Working Conditions Pregnancy History Estimated Delivery Date Section Medical Devices Foreign Travel History of Tobacco Use Current Alcohol/Substance Abuse

Medications This section contains section content modules that describe activities surrounding the use of medication. Medications Admission Medication History Medications Administered Hospital Discharge Medications Immunizations

Physical Exams Physical Exam Physical Exam (with subsections) Hospital Discharge Physical Exam Vital Signs Coded Vital Signs General Appearance Visible Implanted Medical Devices Integumentary System Head Eyes Ears, Nose, Mouth and Throat Ears Nose Mouth, Throat, and Teeth Neck Endocrine System Thorax and Lungs Chest Wall Breasts Heart Respiratory System Abdomen Lymphatic System Vessels Musculoskeletal System Neurologic System Genitalia Rectum

Relevant Studies Results Coded Results Hospital Studies Summary Coded Hospital Studies Summary Consultations

Plans of Care This section provides content modules for sections that describe the plan of care intended for the patient. Care Plan Assessment and Plan Discharge Disposition Discharge Diet Advance Directives Coded Advance Directives Transport Mode

Procedures Performed Patient Education and Consents Coded Patient Education and Consents Procedures Performed

Impressions ACOG Visit Summary Flowsheet Section Progress Note ED Diagnoses

Administrative and Other Information Payers Referral Source Mode of Arrival ED Disposition

Entry Level Template Template ID Summary Description Standards Parent Template(s) Specification –Example XML (abbreviated) –Line by Line Specification –Code Tables –References to Other Templates –(Schematron coming)

Entry Template Example

IHE PCC Entry Templates (50) Language Communication Employer and School Contacts Healthcare Providers and Pharmacies Patient Contacts Authorization Consent Service Events Authors and Informants Linking Narrative and Coded Entries Severity Problem Status Observation Health Status Comments Patient Medication Instructions Medication Fulfillment Instructions External References Internal References Concern Entry Problem Concern Entry Allergy and Intolerance Concern Problem Entry Allergies and Intolerances Medications Immunizations Supply Entry Product Entry Simple Observations Vital Signs Organizer Vital Signs Observation Family History Organizer Family History Observation Social History Observation Pregnancy Observation Estimated Delivery Date Observation ACOG Visit Summary Battery Advance Directive Observation Blood Type Observation Encounters Update Entry Procedure Entry Transport Intended Encounter Disposition Coverage Entry Payer Entry Pain Score Observation Braden Score Observation Braden Score Component Geriatric Depression Score Observation Geriatric Depression Score Component Survey Panel Survey Observation

IHE Security and Privacy Framework Consistent Time – NTP Audit Trails and Node Authentication –Bidirectional Certificate Based Node Authentication –Encrypted Communication (AES 128) –Audit Trails (RFC 3881) Basic Patient Privacy Consents –CDA Based Document –Header Entries Describe Consent Event Document Sensitivity Document Digital Signature –XADES –XML Digital Signature –X.509 –ASTM E1762 Cross Enterprise User Authentication –SAML

BPPC Consent Framework For a Consent, Documentation is of: –A Consent Act Identifiers for the Consent Policies Agreed To Effective Time –Performed by the Patient –Attested to by Patient or other Authority –Document Content is Human Readable description of Policy Within a Document, its Sensitivity –Is specified in authorization/consent –Indicates policies applied to "this" document

Sample Consent Matrix

More information…. IHE Wiki: IHE Web site: Lists Technical Frameworks Technical Framework Supplements – Trial Implementation Non-Technical Brochures : –Calls for Participation –IHE Fact Sheet and FAQ –IHE Integration Profiles: Guidelines for Buyers –IHE Connect-a-thon Results –Vendor Products Integration Statements Questions?