September, 2005What IHE Delivers Content Integration Profiles Ana ESTELRICH, GIP-DMP, FRANCE Charles PARISOT, GE Grateful thanks to Charles Parisot, Keith Boone, Lori Forquet, Liora Alschuler, Larry McKnight, René Spronk, Thom Kuhn, Todd Rothenhaus, John Donnelly whose work contributed to the creation of this presentation

2 Content Integration Profile IHE-XDS is neutral regarding content Will exchange any type of document as an opaque octet of information Content Profiles address clinical information

3 Content Integration Profiles Support profiles addressing integration issues that combine providers, patient problems or time. Deal with general clinical care aspects rather than technology infrastructure. Address workflows and information sharing needs that are common to multiple specialty areas. Started in 2005 and now supports 9 Content Profiles

4 A content profile is… A sharable information component that can be exchanged…   within an HIE or RHIO (XDS)   via Media or USB Device (XDM)   via Reliable Messages Point to Point (XDR) Document content using standards   CDA Release 2.0   HL7 Care Record Summary   ASTM/HL7 Continuity of Care Document More complex documents have a library of reusable parts

5 Content profiles – full picture BPPC XDS- SD

September, 2005What IHE Delivers Cross-sharing of scanned documents XDS-SD

7 XDS-SD Most basic exchange of documents CDA header pdf or text content CDA (Clinical Document Architecture) header needed to preserve the document’s integrity and its context of creation The XDS-SD profile specifies the minimum requirements needed as a CDA header, but it is not restricted only to that.

8 Creation of a pdf or text document within the XDS-SD context

9 The specification for the XDS-SD The specification for the construction of XDS-SD type of documents are found on: anned_Docs_TI_2007_08_20.pdf

September, 2005What IHE Delivers Patient Care Coordination

11 PCC Content Profiles - Reminder Key Technical Properties Human readable Machine processable Digital Signature enabled Can be shared multiple ways  RHIO or HIE (XDS)  CD or USB Media (XDM)  Point to Point (XDR)

September, 2005What IHE Delivers Medical Summary Profiles

13 What's in a Medical Summary? Intended Audience Problem Scope Broad Focused Broad Episode Care Collaborative Care Permanent Care

14 Medical Summary – Use Case Episode Care  Purpose: summarize an episode  Author participation in care continues (generally)  Scope: problems involved in episode  Ex: Admit H&P (History and Physical), Discharge Summary, Procedure Note Collaborative Care  Purpose: request help in Patient Management  Broad Audience is a side effect  Scope: focus on a problem  Ex: Referral, admit to long term care Permanent Care:  Purpose is Transfer Care  Author participation in care does not continue  Scope: all aspects of care  Ex: discharge from military, patient relocation

15 Medical Summary - Scope Define a medical summary format for clinical documents containing at a minimum that provides essential information to the HCP:  Problems  Allergies  Medications  Pointers to other material Medical Summaries

16 Value Proposition A common mechanism for transfer of encoded clinical data embedded in documents To be used in millions of care coordination across settings everyday  Inpatient to Primary Care Provider (Discharge)  Primary Care Provider to Specialist (Referral) Medical Summaries

17 Key Technical Properties Document Transfer (Integration Profile)  XDS/XDM/XDR for document sharing.  NAV for notification.  XDS Folders to support organization.  XDS Submission Sets to support packaging. Document Content (Content Profile) - Standards  CDA Release 2.0  Continuity of Care Document Implementation (CCD) Guide  Key Medical Terminologies subject to national extensions Medication, Problems, Allergies, etc. Medication, Problems, Allergies, etc. Medical Summaries

September, 2005What IHE Delivers Emergency Department Encounter Summary

19 Use Case The patient undergoes assessments by a triage nurse, is assigned a triage category (i.e. emergent, urgent, nonurgent) – * may or may not happen like that in all countries The patient is then registered and demographic data is obtained. The patient undergoes additional assessments by a primary RN* The patient is seen by an ED physician who performs a history and physical, orders various diagnostic tests, determines a course of therapy, orders medications to be administered in the ED and performs procedures on the patient. Upon completion of ED care, the patient is either admitted to the hospital, discharged from the ED, or transferred to another facility.

20 Scope Emergency Department Information Systems (EDIS) Inpatient EHR Systems Ambulatory EHR Systems

21 Value Proposition In US alone there were 110 million emergency department visits in 2004 ED visits account for as much as 40% of hospital admissions The ED Chart is the most common medical summary in use today This profile supports sharing of the clinical information in the ED chart with inpatient care providers and the patient's primary care physician.

September, 2005What IHE Delivers Emergency Department Referral

23 Use Case Health care provider determines that a patient needs to go to the ED Provider creates an ED referral package using his or her HER Upon arrival, the ED provider identifies the patient as a referral The posted referral package is imported into the Emergency Department Information System (EDIS) ED Referral

24 Value Proposition Provide access to critical health information in ED information systems in a standard manner Nearly 5000 EDs in US Significant percentage of ED visits are referrals Shortage of critical health data for emergency department patients Need to improve communication of intended patient care plans to ED providers and ensure that no pertinent data is lost Streamline workflow by obviating telephone calls between busy clinicians ED Referral

25 Scope EHR system capable of creating a care record summary would be capable of creating a referral package for a receiving system The emergency department information systems (EDIS) will need to retrieve and read and display this data. ED Referral

26 Profile contents based on CDA Interoperability   Human The “paper world” with documents, forms...   Application Storage, management of clinical data Context driven analysis Reusability application interoperability Stepwise approach to application interoperability   Immediate human interoperability (compliant users)   Incremental interoperability between machines – very much sought-after by clinicians

27 12 steps to semantic interoperability Liora Alschuler 2007

28 Clinical Document Architecture René Spronk

29 CDA Structure René Spronk

30 Section Levels René Spronk

31 CDA - Three Levels René Spronk

32 Why CDA? Content integration profiles and templates What is a template? How can it be expressed? What can I do with it?

33 Whatis a Template? 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.

34 IHE Content Integration 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

35 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

36 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

37 Document Template Specification

38 IHE PCC Document Templates Medical Summary Specification XDS-SD Scanned Documents Referral Summary Specification Discharge Summary Specification PHR Extract Specification PHR Update Specification Emergency Department Referral Specification Emergency Department Encounter Summary Antepartum Summary Triage Note Nursing Note Composite Triage and Nursing Note ED Physician Note

39 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

40 Section Level Template

41 Section Templates Reasons for Care Other Condition Histories Medications Physical Exams Relevant Studies Plans of Care Procedures Performed Impressions Administrative and Other Information

42 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)

43 Entry Template Example

44 Entry Level Templates 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 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 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

45 Navigating the wiki Or type in Google “IHE wiki” – demonstration by Charles Parisot, GE Schematrons for the Connectathon Questions?