1. Publication and Discovery XDS and DSUB IHE IT Infrastructure Webinar Series

2. IT Infrastructure Planning Committee XDS Cross-Enterprise Document Sharing

3. IT Infrastructure Planning Committee What is XDS ? The Cross-Enterprise Document Sharing (XDS) IHE Integration Profile facilitates the registration, distribution and access across health enterprises of patient electronic health records It provides a standards-based specification for managing the sharing of documents between any healthcare enterprise Currently only one XDS profile, based on Web Services - XDS.b (original XDS.a is now deprecated)

4. IT Infrastructure Planning Committee XDS Affinity Domains Group of healthcare enterprises that have agreed to work together using a common set of policies and standards-based infrastructures for sharing patient clinical documents, using XDS: Regional community of careRegional community of care Nationwide EHRNationwide EHR Specialized or disease-oriented (cardio, diabetes, oncology)Specialized or disease-oriented (cardio, diabetes, oncology) Government-sponsored or federation of enterprisesGovernment-sponsored or federation of enterprises Insurance provider supported communitiesInsurance provider supported communities XDS profile is designed to accommodate a wide range of policies on: Patient identification and consentPatient identification and consent Controlling access to informationControlling access to information Format, content, structure, and representation of clinical informationFormat, content, structure, and representation of clinical information

5. IT Infrastructure Planning Committee Use Cases Patient Care Summary (e.g. within a region)Patient Care Summary (e.g. within a region) –Publishing of Care Summaries by providers –Access to patient’s Care Summary in an emergency eReferral between primary and secondary care providerseReferral between primary and secondary care providers Sharing of radiology reports and images between facilitiesSharing of radiology reports and images between facilities Sharing of laboratory reports by clinical laboratories with ordering physicians and other care providersSharing of laboratory reports by clinical laboratories with ordering physicians and other care providers ePharmacy between community pharmacy and ambulatory physiciansePharmacy between community pharmacy and ambulatory physicians

6. IT Infrastructure Planning Committee Main Systems and Responsibilities A document Repository is responsible for storing documents in a transparent, secure, reliable and persistent manner and responding to document retrieval requests.A document Repository is responsible for storing documents in a transparent, secure, reliable and persistent manner and responding to document retrieval requests. A document Registry is responsible for storing information or metadata about those documents so that the documents of interest for the care of a patient may be easily found, selected and retrieved irrespective of the repository where they are actually stored.A document Registry is responsible for storing information or metadata about those documents so that the documents of interest for the care of a patient may be easily found, selected and retrieved irrespective of the repository where they are actually stored. Any IT system (e.g. point of care) may act as a Document Sources or Document Consumers submitting documents for registration, or querying/retrieving relevant documents.Any IT system (e.g. point of care) may act as a Document Sources or Document Consumers submitting documents for registration, or querying/retrieving relevant documents.Notes: Analogous to a library (book repository) and catalog/indexAnalogous to a library (book repository) and catalog/index The Registry does not have access to the documents – an important separation from security and privacy perspectiveThe Registry does not have access to the documents – an important separation from security and privacy perspective Multiple Repositories can be linked to one RegistryMultiple Repositories can be linked to one Registry

7. IT Infrastructure Planning Committee Consumer Registry Repository 1. Sources post document packages to the Repository 2. Repository registers the documents metadata and pointer with the Registry 3. Consumers search for documents with specific information 4. Consumers retrieve selected documents from Repository (-ies) XDS Document (Metadata): Class Patient Id Author Facility Date of Service … XDS Document (Metadata): Class Patient Id Author Facility Date of Service … Source of Documents XDS Flow and Interactions

8. IT Infrastructure Planning Committee XDS.b Transaction Diagram Patient Identity Source Document Registry Document Repository Document Source Document Consumer Patient Identity Feed [ITI-8] Patient Identity Feed HL7v3 [ITI-44] Provide&Register Document Set-b [ITI-41] Retrieve Document Set [ITI-43] Registry Stored Query [ITI-18] Register Document Set-b [ITI-42] Integrated Document Source/Repository

9. IT Infrastructure Planning Committee XDS.b Actors Document Source – producer and publisher of documents, responsible for sending documents and their metadata to a Document Repository actorDocument Source – producer and publisher of documents, responsible for sending documents and their metadata to a Document Repository actor Document Repository is responsible for both the persistent storage of these documents as well as for their registration with the appropriate Document RegistryDocument Repository is responsible for both the persistent storage of these documents as well as for their registration with the appropriate Document Registry Document Registry maintains metadata about each registered document and a link to the Document in the Repository where it is stored. Responds to queries from Document Consumer actors about documents meeting specific criteria.Document Registry maintains metadata about each registered document and a link to the Document in the Repository where it is stored. Responds to queries from Document Consumer actors about documents meeting specific criteria. Document Consumer queries a Document Registry for documents meeting certain criteria, and retrieves selected documents from one or more Document Repository actorsDocument Consumer queries a Document Registry for documents meeting certain criteria, and retrieves selected documents from one or more Document Repository actors Patient Identity Source provides unique identifier for each patient and maintaining a collection of identity traits. This facilitates the validation of patient identifiers by the Registry Actor in its interactions with other actorsPatient Identity Source provides unique identifier for each patient and maintaining a collection of identity traits. This facilitates the validation of patient identifiers by the Registry Actor in its interactions with other actors Integrated Document Source/Repository combines the functionality of the Document Source and Document Repository actors into a single actor that does not expose the Provide and Register Document Set transactionIntegrated Document Source/Repository combines the functionality of the Document Source and Document Repository actors into a single actor that does not expose the Provide and Register Document Set transaction

10. IT Infrastructure Planning Committee XDS.b Transactions (1) Provide and Register Document Set – For each document in the submitted set, the Document Source Actor provides both the documents as an opaque octet stream and the corresponding metadata to the Document Repository. The Document Repository is responsible to persistently store these documents, and to register them in the Document Registry using the Register Documents transaction.Provide and Register Document Set – For each document in the submitted set, the Document Source Actor provides both the documents as an opaque octet stream and the corresponding metadata to the Document Repository. The Document Repository is responsible to persistently store these documents, and to register them in the Document Registry using the Register Documents transaction. Register Document Set allows a Document Repository Actor to register one or more documents with a Document Registry, by supplying metadata about each document to be registered. This document metadata will be used to create an XDS Document Entry in the registry.Register Document Set allows a Document Repository Actor to register one or more documents with a Document Registry, by supplying metadata about each document to be registered. This document metadata will be used to create an XDS Document Entry in the registry.

11. IT Infrastructure Planning Committee XDS.b Transactions (2) Patient Identity Feed conveys the patient identifier and corroborating demographic data, in order to populate the Document Registry with patient identifiers that have been registered for the XDS Affinity Domains. (At least one of the options [ITI-8] or [ITI-44] should be supported.)Patient Identity Feed conveys the patient identifier and corroborating demographic data, in order to populate the Document Registry with patient identifiers that have been registered for the XDS Affinity Domains. (At least one of the options [ITI-8] or [ITI-44] should be supported.) Registry Stored Query is issued by the Document Consumer Actor to a Document Registry. It will return registry metadata containing a list of document entries found to meet the specified criteria including the locations and identifier of each corresponding document in one or more Document Repositories.Registry Stored Query is issued by the Document Consumer Actor to a Document Registry. It will return registry metadata containing a list of document entries found to meet the specified criteria including the locations and identifier of each corresponding document in one or more Document Repositories. Retrieve Document Set – initiated by a Document Consumer. The Document Repository shall return the document set that was specified by the Document Consumer.Retrieve Document Set – initiated by a Document Consumer. The Document Repository shall return the document set that was specified by the Document Consumer.

12. IT Infrastructure Planning Committee XDS.b Actors and Transactions ActorsTransactionsOptionalitySection Document Consumer Registry Stored Query [ITI-18] Retrieve Document Set [ITI-43] RR ITI TF-2a: 3.18 ITI TF-2b: 3.43 Document Source Provide and Register Document Set-b [ITI-41] R ITI TF-2b: 3.41 Document Repository Provide and Register Document Set-b [ITI-41] Register Document Set-b [ITI-42] Retrieve Document Set [ITI-43] RRR ITI TF-2b: 3.41 ITI TF-2b: 3.42 ITI TF-2b: 3.43 Document Registry Register Document Set-b [ITI-42] R Registry Stored Query [ITI-18] R Patient Identity Feed [ITI-8] Patient Identity Feed HL7v3 [ITI-44] RR O (Note 2) ITI TF-2b: 3.42 ITI TF-2a: 3.18 ITI TF-2a: 3.8 ITI TF-2b: 3.44 Integrated Document Source/Repository Register Document Set-b [ITI-42] Retrieve Document Set [ITI-43] RR ITI TF-2b: 3.42 ITI TF-2b: 3.43 Patient Identity Source Patient Identity Feed [ITI-8] Patient Identity Feed HL7v3 [ITI-44] O (Note 1,2) ITI TF-2a: 3.8 ITI TF-2b :3.44

13. IT Infrastructure Planning Committee XDS Document Content Types XDS profile is content agnostic – it can be used with a variety of document types, including: XDS-SD: Scanned document, plain text or PDF/A, in HL7 CDA R2 formatXDS-SD: Scanned document, plain text or PDF/A, in HL7 CDA R2 format XDS-MS: Medical summary in HL7 CDA formatXDS-MS: Medical summary in HL7 CDA format XDS-I: Radiology report in plain text of PDF format, or reference to a collection of DICOM SOP Instances in a manifest document in the DICOM Key Object Selection formatXDS-I: Radiology report in plain text of PDF format, or reference to a collection of DICOM SOP Instances in a manifest document in the DICOM Key Object Selection format Also supported are many other document content profiles specified by the IHE Patient Care Coordination, Laboratory, Cardiology, Pharmacy Technical Frameworks

14. IT Infrastructure Planning Committee XDS.b – Actors and Options ActorsOptionsReference Document Source Document ReplacementITI TF-1: 10.2.1 Document AddendumITI TF-1: 10.2.2 Document TransformationITI TF-1: 10.2.3 Folder ManagementITI TF-1: 10.2.4 Basic Patient Privacy EnforcementITI TF-2b:3.41.4.1.3.1 Document Repository Document Registry Patient Identity Source Patient Identity FeedITI TF-2a: 3.8 Patient Identity Feed HL7v3ITI TF-2b: 3.44 Document Consumer Basic Patient Privacy Enforcement ITI TF-2a: 3.18.4.1.3.5 ITI TF-2b: 3.43.4.1.3.1 Basic Patient Privacy ProofITI TF-2a: 3.18.4.1.3.6

15. IT Infrastructure Planning Committee Standards Used ebRIM OASIS/ebXML Registry Information Model v3.0ebRIM OASIS/ebXML Registry Information Model v3.0 ebRS OASIS/ebXML Registry Services Specifications v3.0ebRS OASIS/ebXML Registry Services Specifications v3.0 ITI TF-2x: Appendix VITI TF-2x: Appendix V –WS-I Profiles BP 1.1, BSP 1.0 –WS-* Specifications (SOAP 1.2, MTOM/XOP)

16. IT Infrastructure Planning Committee Security and Privacy Considerations All actors be grouped with a ATNA Secure Node Actor or Secure Application Actor resulting in each node (systems supporting XDS actors) of the XDS Affinity Domain should have audit and security mechanisms in placeAll actors be grouped with a ATNA Secure Node Actor or Secure Application Actor resulting in each node (systems supporting XDS actors) of the XDS Affinity Domain should have audit and security mechanisms in place Transactions between different secure nodes that use ATNA are encryptedTransactions between different secure nodes that use ATNA are encrypted Each XDS Transaction will result in an audit event record sent to an ATNA Audit Record Repository Actor from each XDS actorEach XDS Transaction will result in an audit event record sent to an ATNA Audit Record Repository Actor from each XDS actor Timestamp consistency is provided by Consistent Time (CT) profileTimestamp consistency is provided by Consistent Time (CT) profile

17. IT Infrastructure Planning Committee XDS Affinity Domain PMS Physician Office EHR System Teaching Hospital Community Clinic Lab Info. System PACS Retrieve Document Provide & Register Register Document (using Patient ID) Query Document (using Patient ID) Document Registry Document Repository ED Application PIX or PDQ Query PIX or PDQ Query ATNA CT Audit record repository Time server Patient Demographics Supplier Record Audit Event Maintain Time Maintain Time Maintain Time XDS Workflow Health Information Exchange Network 14355 M8354673993 L-716 A87631 M8354673993 A87631 14355 L-716 Patient Identity XRef Mgr Record Audit Event

18. IT Infrastructure Planning Committee Flexible Infrastructure Health Information Exchange Publish Pull Structured objects Pull Send to Switch Send to Write Read Interchange Media XDS XDR XDM Replace with agreed new version of this slide to include XCA (from Chris)

19. IT Infrastructure Planning Committee 19 IHE XDS adopted in National & Regional Projects (sample) Quebec, Toronto, Alberta, British Columbia Canada Infoway THINC- New York NCHICA – N. Carolina Italy Conto Corrente Venetto - Friuli Boston Medical Center - MA Philadelphia HIE CHINA-MoH Lab results sharing CHINA-Shanghai Imaging Info Sharing JAPAN-Nagoya Imaging Info Sharing, Nationwide PDI guideline South Africa VITL-Vermont CareSpark – TN & VA NETHERLANDS Friesland Natn’l Mamography Lower Austria France DMP Wales Imaging Belgium Flemish-Leuven Suisse St Gallen Lausane Providence Health System - OR KeyHIE Pennsylvania SHARP CA France Imaging IDF 19 For more complete list see: tinyurl.com/wwXDS To be updated and refined further by Charles P.

20. IT Infrastructure Planning Committee Who Is Using XDS? Stable specification since 2009 (See IHE ITI Technical Framework)Stable specification since 2009 (See IHE ITI Technical Framework) First implementation in clinical use in region of Genoa - Italy) since early 2006.First implementation in clinical use in region of Genoa - Italy) since early 2006. Several since: Lower Austria region, State of Vermont, Nagoya city, South Africa region, Dutch regions, etc.Several since: Lower Austria region, State of Vermont, Nagoya city, South Africa region, Dutch regions, etc. Adopted by several national programs world-wide:Adopted by several national programs world-wide: France, Canada, Switzerland, USA, Slovenia, China, etc. Numerous product implementations world-wide:Numerous product implementations world-wide: Close to 100 EMR/Clinical Systems products shipping More than 20 Infrastructure products shipping To be refined further

21. IT Infrastructure Planning Committee Open Source Implementations Numerous open source implementations tested at Connectathon are available for XDS, ATNA and CT: –NIST under Source Forge http://sourceforge.net/projects/iheos/ http://sourceforge.net/projects/iheos/ –HIE-OS under Source Forge http://sourceforge.net/projects/hieos/ http://sourceforge.net/projects/hieos/ –Microsoft under codeplex http://ihe.codeplex.com/ http://ihe.codeplex.com/ –OHT – IHE Profiles Charter https://iheprofiles.projects.openhealthtools.org https://iheprofiles.projects.openhealthtools.org –OHT – Open Exchange Forge https://openexchange.projects.openhealthtools.org https://openexchange.projects.openhealthtools.org –OHT – Model Driven Health Tools-Charter https://mdht.projects.openhealthtools.org https://mdht.projects.openhealthtools.org 21 To be refined further

22. IT Infrastructure Planning Committee XDS References PrimaryPrimary –ITI TF-1 Section 10 Cross-Enterprise Document Sharing (XDS.b) Underlying Technical Framework ContentUnderlying Technical Framework Content –ITI TF-1 Appendix J Content and Format of XDS DocumentsAppendix J Content and Format of XDS Documents Appendix K XDS Concept DetailsAppendix K XDS Concept Details Appendix M Cross-Enterprise Document Sharing and IHE RoadmapAppendix M Cross-Enterprise Document Sharing and IHE Roadmap –ITI TF-2a Section 3.8 Patient Identity FeedSection 3.8 Patient Identity Feed Section 3.18 Registry Stored querySection 3.18 Registry Stored query –ITI TF-2b Section 3.41 Provide and Register Document Set-bSection 3.41 Provide and Register Document Set-b Section 3.42 Register Document Set-bSection 3.42 Register Document Set-b Section 3.43 Retrieve Document SetSection 3.43 Retrieve Document Set –ITI TF-2x Appendix V “Web Services for IHE Transactions”Appendix V “Web Services for IHE Transactions” –ITI TF-3 Section 4.1 XDS Metadata ModelSection 4.1 XDS Metadata Model

23. IT Infrastructure Planning Committee DSUB Document Metadata Subscription supplement

24. IT Infrastructure Planning Committee DSUB Overview The Document Metadata Subscription (DSUB) supplement contains two related parts: Publish/Subscribe Infrastructure: General framework for defining web-services based publish/subscribe interactionsPublish/Subscribe Infrastructure: General framework for defining web-services based publish/subscribe interactions Document Metadata Subscription (DSUB) Integration Profile: Use of subscriptions within an XDS Affinity Domain or across communitiesDocument Metadata Subscription (DSUB) Integration Profile: Use of subscriptions within an XDS Affinity Domain or across communities

25. IT Infrastructure Planning Committee Publish/Subscribe Infrastructure Presents a framework for building event-driven information exchange patterns using a publish/subscribe data exchange model (See ITI TF Volume 3 section 4.4)Presents a framework for building event-driven information exchange patterns using a publish/subscribe data exchange model (See ITI TF Volume 3 section 4.4) Defines the transport of publish, subscribe and notify messages.Defines the transport of publish, subscribe and notify messages. Supports IHE profiles which define the use case specific content to be carried in the publish, subscribe and notify messagesSupports IHE profiles which define the use case specific content to be carried in the publish, subscribe and notify messages  Document Metadata Subscription (DSUB) first profile to use this framework.

26. IT Infrastructure Planning Committee Publish/Subscribe Infrastructure Actors and Transactions Publisher Publish 4.4.2.3 Notification Broker Notification Recipient Subscriber Subscribe 4.4.2.1 Notify 4.4.2.2

27. IT Infrastructure Planning Committee Possible Combined Actors Publisher Notification Broker Notification Recipient Subscriber Subscribe Notify Publish Publisher Notification Broker Notification Recipient Subscriber Subscribe Notify Notification Broker Notification Recipient Subscriber Subscribe Notify Publisher

28. IT Infrastructure Planning Committee Document Metadata Subscription (DSUB) Integration Profile Defines a subscription which allows for the matching of metadata during the publication of a new document for a given patient, and results in the delivery of a notification.Defines a subscription which allows for the matching of metadata during the publication of a new document for a given patient, and results in the delivery of a notification. Enabled within an XDS Affinity Domain or XCA environmentEnabled within an XDS Affinity Domain or XCA environment Use CasesUse Cases –Emergency Department: Notification of new document availability during treatment –Primary Care Management: PCP receives notification when new documents for patient are available

29. IT Infrastructure Planning Committee DSUB Actors and Transactions Document Metadata Publisher Document Metadata Publish [ITI-54] Document Metadata Notification Broker Document Metadata Notification Recipient Document Metadata Subscriber Document Metadata Subscribe [ITI-52] Document Metadata Notify [ITI-53]

30. IT Infrastructure Planning Committee Transactions Document Metadata Subscribe : start a subscription for a particular topic and filtering within that topic. Supports full and minimal notifications and where to send the notification.Document Metadata Subscribe : start a subscription for a particular topic and filtering within that topic. Supports full and minimal notifications and where to send the notification. Document Metadata Notify : send a notification about the availability of a document or documents of interest, based on the subscribers' filters on selected topicsDocument Metadata Notify : send a notification about the availability of a document or documents of interest, based on the subscribers' filters on selected topics Document Metadata Publish : notify that an event occurred for which there may be a subscription.Document Metadata Publish : notify that an event occurred for which there may be a subscription.

31. IT Infrastructure Planning Committee XDS Document Consumer XDS Document Registry XDS Document Source DSUB Process Flow Publisher Notification Broker Notification Recipient Subscriber Subscribe Publish Publish Notify Notify Unsubscribe Publish

32. IT Infrastructure Planning Committee DSUB Subscription Topics and Standards DSUB Topic TreeDSUB Topic Tree –ihe:FullDocumentEntry : subscribes to Document Entry registration events; the notification shall contain the full metadata describing each matching Document Entry – ihe:MinimalDocumentEntry : subscribes to Document Entry registration events; the notification shall contain a minimal set of data (identifiers only) describing each matching Document Entry DSUB StandardsDSUB Standards –OASIS Web Services Notification Family of Standards WS-BaseNotification 1.3 OASIS StandardWS-BaseNotification 1.3 OASIS Standard WS-BrokeredNotification 1.3 OASIS StandardWS-BrokeredNotification 1.3 OASIS Standard WS-Topics 1.3 OASIS StandardWS-Topics 1.3 OASIS Standard ITI TF-2x: Appendix VITI TF-2x: Appendix V –Filter expression Registry Stored Query [ITI-18]Registry Stored Query [ITI-18]

33. IT Infrastructure Planning Committee Security and Privacy TBD - (see notes)TBD - (see notes)

34. IT Infrastructure Planning Committee DSUB References PrimaryPrimary –DSUB Supplement Rev 1-4 2010-08-10 Underlying Technical Framework ContentUnderlying Technical Framework Content –ITI TF-2a Section 3.18 Registry Stored querySection 3.18 Registry Stored query –ITI TF-2b Section 3.42.4.1 Register Document Set-b RequestSection 3.42.4.1 Register Document Set-b Request Section 3.43.4.2.2 Message SemanticsSection 3.43.4.2.2 Message Semantics –ITI TF-2x Appendix V “Web Services for IHE Transactions”Appendix V “Web Services for IHE Transactions”