1. September, 2005What IHE Delivers 1 IHE 2006 Workshop, June 2006 Charles Parisot, GE Healthcare IT Infrastructure co-chair Technical Committee IHE support for RHIOs, and community Health Information Exchange http://www.ihe.net/Events/upload/IHE%20Support%20for%20RHIOs-V5-Charles.ppt

2. 2 1 - Distinguish “edge” HIT systems from information exchange infrastructure

3. 3 2 - Support multiple architectures Centralized, distributed, federated, etc. Different business models, cost, legacy systems, etc.

4. 4 3 - Enrich Incrementally, no rip and replace Has been the hallmark of IHE for many years Think long-term, but specify & implement what is needed today Steal good ideas, learn form others’ mistakes Listen and collaborate Reuse, reuse previous Integration Profiles If a clear use case cannot be specified in 6 months, and implemented for testing in the next 6 month, rethink.

5. 5 Step-wise IHE RHIO strategy 1. Start with “Document Sharing” with patient identifiers management 2. Establish basic security (pipe encryption and node authentication) 3. Grow document sharing content to deliver multi-level interoperability (enabling coded information) with medical summaries & imaging info 2005 2006 2007 What is introduced in 2006-2007 ?

6. 6 Step-wise IHE RHIO strategy 1. Start with “Document Sharing” with patient identifiers management 2. Establish basic security (pipe encryption and node authentication) 3. Grow document sharing content to deliver multi-level interoperability (enabling coded information) with medical summaries & imaging info 4. Introduce point-point interchange by disfeaturing “document sharing” to enable upward evolution 5. Grown content to cover info exchange to support common care coordination use cases, basic diagnostics/therapeutic information, and simple patient input. 6. Extend security by leveraging existing edge system security capabilities to enable basic RHIO policies 2005 2006 2007

7. 7 Step-wise IHE RHIO strategy 1. Start with “Document Sharing” with patient identifiers management 2. Establish basic security (pipe encryption and node authentication) 3. Grow document sharing content to deliver multi-level interoperability (enabling coded information) with medical summaries & imaging info 4. Introduce point-point interchange by disfeaturing “document sharing” to enable upward evolution 5. Grown content to cover info exchange to support common care coordination use cases, basic diagnostics/therapeutic information, and simple patient input. 6. Extend security by leveraging existing edge system security capabilities to enable basic RHIO policies 7. Progressive introduction of consistent of coded terminologies….. 8. Cross-enterprise workflows (e.g. lab & radiology orders ……. 9. Federation of XDS domains …… 10. X-Enterprise User Authentication-Federated identity …… 2005 2006 2007

8. 8 Sharing, Sending, Interchanging and Transacting Health Information Exchange or RHIO Publish Pull Structured objects Pull Send to Write Read Switch InterchangeMedia Transactions WorkflowMgrWorkflowMgr Info Requestor DataRepository Query / Response XDS XDP

9. 9 IHE Integration Profiles for Health Info Nets What is available and has been added in 2005 and is for 2006 Patient Demographics Query Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Cross-enterprise Document Point-Point Interchange Media-CD/USB & e-mail push Emergency Referrals Format of the Document Content and associated coded vocabulary PHR Extracts/Updates Format of the Document Content and associated coded vocabulary ECG Report Document Format of the Document Content and associated coded vocabulary Lab Results Document Content Format of the Document Content and associated coded vocabulary Scanned Documents Format of the Document Content Imaging Information Format of the Document Content and associated coded vocabulary Medical Summary ( Meds, Allergies, Pbs) Format of the Document Content and associated coded vocabulary 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. Basic Patients Privacy Consents Establish Consents & Enable Access Control Document Digital Signature Attesting “true-copy and origin Notification of Document Availability Notification of a remote provider/ health enterprise Request Form for Data Capture External form with custom import/export scripting Patient Id Mgt Security Clinical and PHR Content Health Data Exchange Other

10. 10 Health Information Exchanges Interoperability: Cross-enterprise Document Sharing Cross-Enterprise Document Sharing minimizes clinical/admin data management by the infrastructure. Transparency = Ease of Evolution Patients/consumers have guaranteed portability and providers may share information without concerns of aggregation errors. Digital Documents = Patients and providers empowerment Supports both centralized and decentralized repository architectures. Ease of federation nationally. Flexible privacy, Flexibility of configurations Has received major support world-wide: National & regional projects, NHIN contractors, US EHR Vendor Assoc., complements Connecting for Health RLS.

11. 11 Cross-Enterprise Document Sharing (XDS) Standards Used Healthcare Content Standards HL7 CDA, CEN EHRcom HL7, ASTM CCR DICOM … Internet Standards HTML, HTTP, ISO, PDF, JPEG … Electronic Business Standards ebXML Registry, SOAP … Implemented world-wide by more than 30 vendors/open source. Final text published August 2005. Adopted in several national & regional projects (Italy, France, Canada, Austria, US-NHIN Contractors, RHIOs, etc.). Leverage by US EHR Vendor Association Interoperability Roadmap. IHE XDS : 40,000 “Google” references (June’ 06)

12. 12 Cross-Enterprise Document Sharing (XDS) Standards Used at the Document Content Level Ease of reuse of data (financial, clinical and consumer) XDS Infrastructure (Document sources, consumers, registries, repositories) XDS Doc Content Medical Summaries (HL7 CDA/CRS+V3) Medical Summaries (HL7 CDA/CRS+V3) Imaging (DICOM) Imaging (DICOM) ECG Reports, PDFs ECG Reports, PDFs Lab, PHR Extract (CDA) Lab, PHR Extract (CDA)

13. 13 Why is IHE-XDS a breakthrough ? Sharing of digital documents as “attested by the source”, meets the most urgent needs. A proven healthcare community data-sharing paradigm ( Message feeding to web servers hinders use of EHRs & PHRs ). Efficient to support all types of Health IT Systems (IDNs, Hospitals, Ambulatory, Pharmacy, Payers, Diagnostics Centers, etc.) and all types of information (summaries, meds, images, lab reports, ECGs, etc.), structured and unstructured. Offer a consistent, standards-based and functional record sharing for EHRs, PHRs & other IT Systems

14. 14 IHE-XDS Infrastructure Components Audit Record Repository (ATNA) – Receive audit records from other actors and securely store for audit purposes. ATNA also authenticates peer-nodes and encrypt communications. Time Server (CT) – Provides consistent definition of date/time enabling time synchronization across multiple systems. Enables events associated with patients to be sorted reliably in chronological order. Document Registry (XDS) – Queryable index of metadata and references to all documents shared within a connected community (XDS Affinity Domain) Document Repository (XDS) – Supports storage and retrieval of clinical information (as documents). May be centralized or distributed. Patient Identifier Cross Reference Manager (PIX) – Reconciles information on patients from multiple domains to a single, cross referenced set of ids for each given patient. Patient Demographics Supplier (PDQ) – Returns demographic information and identifiers for patients based on specified demographic criteria.

15. 15 XDS Affinity Domain (NHIN sub-network) Community Clinic Lab Info. System PACS Teaching Hospital PACS ED Application EHR System Physician Office EHR System XDS Scenario + use of ATNA & CT Showcased at HIMSS 2006 PMS Retrieve Document Register Document Query Document XDS Document Registry ATNA Audit record repository CT Time server Record Audit Event MaintainTime MaintainTime Event Maintain Time Provide & Register Docs Record Audit Event XDS Document Repository Secured Messaging

16. 16 XDS Affinity Domain (NHIN sub-network) Community Clinic Lab Info. System PACS Teaching Hospital PACS ED Application EHR System Physician Office EHR System XDS Scenario + use of PIX & PDQ Showcased at HIMSS 2006 A87631 PACS L-716 Affinity Domain Patient Identity Source M8354673993 Retrieve Document Provide & Register Docs Register (using Pt ID) Query Document (using Pt Id) Patient Identity Feed Document Registry 14355 M8354673993 L-716 A87631 Patient Identity Feed PIX Query PIX Query Patient Identity Feed Patient Identity XRef Mgr Patient Identity Feed PDQ Query to Acquire Affinity Domain Patient ID M8354673993 A87631 L-716 M8354673993 XDS Document Repository XDS Document Repository ATNA Audit record repository CT Time server

17. 17 S S t t r r u u c c t t u u r r e e d d C C o o n n t t e e n n t t w w i i t t h h c c o o d d e e d d s s e e c c t t i i o o n n s s : :  Reason for Referral     Vital Signs     M M e e d d i i c c a a t t i i o o n n  Studies     A A l l l l e e r r g g i i e e s s  Social History     P P r r o o b b l l e e m m s s  Care Plan XDS-MS Medical Summary Structured and Coded Header Patient, Author, Authenticator, Institution, Time of Service, etc. Header always structured and coded Title-coded sections with non-structured nor coded content (text, lists, tables).  Simple Viewing (XML Style sheet) Level 1 Level 2 Text Structure Entry Text Structure Entry Med, Problems and Allergies required as highly structured text.  Text easy to import/parse Text Structure Entry Level 3 Med Problems and Allergies have a required fine-grain structure with optional coding. Coding Scheme not standardized, but explicitly identified. Coded Section Entry Coded Section Entry Coded Section Entry Level 3 XDS-MS enables both semantical interoperability and simple viewing !

18. 18 Use of a shared XDS infrastructure to access Radiology Reports and Images (XDS-I) Hospital Imaging Center Physician Practice Between Radiology and : Between Radiology and : I maging specialistsI maging specialists Non-imaging cliniciansNon-imaging clinicians PACS Y PACS Z Radiology -to- Radiology Radiology -to- Physicians Same XDS Infrastructure (Registry and Repositories) for medical summaries and imaging information ! Showcased at HIMSS 2006, planned RSNA Nov 2006

19. 19 Exchange of EHR & PHR Content, Array of document content with many common modules XDS-MS Medical Documents Medical Summaries Referral Discharge Summary BCCP Consent EDR Emergency Department Referral PPHP Preprocedure History and Physical History and Physical XPHR PHR Update XDS-LAB Lab Report PHR Extract XPHR PHR Update PHR Extract

20. 20 e.g. Exchange of PHR Content The Exchange of Personal Health Record Content (XPHR) provides a standards-based specification for enabling interoperability of core personal health information between:  a Personal Health Record and  either an EHR or another PHR System Supports interchange of PHR Information:  Demographics  Insurance Information  Medications, Problems, Allergies  Health History  Other Information

21. 21 PHR System Internet Community Index of patients records (Document-level) Aggregate Patient Info Sharing System Health Payer Record Specialist Record Hospital Record 2-Reference to Records for Inquiry PHR Systems another edge system Needs sharing records/documents: IHE-XDS 4 - Health data presented to Patient Shared Repository of Documents Repository of Documents 3-RecordsReturned Reference to records

22. HIMSS IHE Interoperability Showcase February 2006 Participants Leadership Level Blue Ware Cerner GE Healthcare +IDX IBM Initiate Systems InterSystems MiSys Healthcare QuovadxSiemens Implementer Level AllscriptsCanonCapMed Cardiac Science CGI-AMSCompassCareCPSIDictaphone DR Systems Eastman Kodak Eclipsys Epic Systems HIPAAT HX Technologies INFINITT Technology KryptiqMcKesson MedAccess Plus Medical Informatics MediNotesMNI National Institute of Sci & Tech NextGen Healthcare Philips Medical ScImage Witt Biomedical Supporter Level: AcuoBondCarefxClearcube DairylandEMCIdentrusIntelMediserve Medkey Motion Comp. PicisPulseSentillion Organizational participant: American Coll. of Clinical Eng. Catholic Healthcare West US Dept of Defense US Dept of Veterans Affairs DMP–French Natl. Personal EHR Health Level 7 HTP IEEE Midmark Diagostics Group HIMSS RHIO Federation Liberty Alliance Univ. of Washington

23. 23 Results  Over 3000 attendees visited the HIMSS RHIO Showcase  37 vendors demonstrated 48 systems  700 attendees created and tracked their own health record  63 educational sessions were presented  5 International delegations  3 VIP tours  16 clinical scenarios were demonstrated

24. 24 IHE Integration Statements Explicit claim by the implementor/vendor, for a specific product version Lists IHE Integration Profiles, Actors & Options Short (1 page) & Sweet Compare apples with apples. http:// www.ihe.net /resources/ ihe_integration_statements.cfm

25. 25 Building a RHIO with IHE Leverage a large body of international contributions and experiences. Submit your gaps. Suggested Approach  Define Use Cases of interest  Match against existing IHE Integration Profiles  For each use case selected, develop a “RHIO interoperability specification” that builds by reference upon the selected set of IHE Integration Profiles. Include in RFP.  Request vendors (infrastructure and edge systems) to submit proposed product IHE Integration Statements  Verify vendor participation in IHE Connectathon

26. 26 IHE Integration Profiles for Health Info Nets What is available and has been added in 2005 and is for 2006 Patient Demographics Query Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Cross-enterprise Document Point-Point Interchange Media-CD/USB & e-mail push Emergency Referrals Format of the Document Content and associated coded vocabulary PHR Extracts/Updates Format of the Document Content and associated coded vocabulary ECG Report Document Format of the Document Content and associated coded vocabulary Lab Results Document Content Format of the Document Content and associated coded vocabulary Scanned Documents Format of the Document Content Imaging Information Format of the Document Content and associated coded vocabulary Medical Summary ( Meds, Allergies, Pbs) Format of the Document Content and associated coded vocabulary 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. Basic Patients Privacy Consents Establish Consents & Enable Access Control Document Digital Signature Attesting “true-copy and origin Notification of Document Availability Notification of a remote provider/ health enterprise Request Form for Data Capture External form with custom import/export scripting Patient Id Mgt Security Clinical and PHR Content Health Data Exchange Other

27. 27