1. September, 2005What IHE Delivers 1 The fundamentals of IHE Integrating Enterprises and building standards-based regional and national health information networks Israel Association for Medical Information Tel-Aviv May 17, 2006 Charles Parisot GE Healthcare – IHE IT Infrastructure Technical Co-chair

2. 2 Standards are critical but alone are not enough Standards offer generality, ambiguity and alternatives Standard Implementation Guides are focused on a single standard Increasing complexity IHE provides a standard process for implementing multiple standards!

3. 3 Connecting standards to care Care providers work with vendors to coordinate the implementation of standards to meet their needs  Care providers identify the key interoperability problems they face  Drive industry to develop and make available standards-based solutions  Implementers follow common guidelines in purchasing and integrating systems that deliver these solutions IHE, effective way to establish those “standards” for how to implement standards

4. 4 What is Integrating the Healthcare Enterprise? IHE provides a common framework for passing health information seamlessly:  within the healthcare enterprise  across multiple healthcare enterprises  for local, regional & national health information networks IHE is sponsored by healthcare professional associations: HIMSS, RSNA, ACC, ACCE, ESC, SFR, BIR, GMSIH, etc. IHE drives standards adoption to address specific clinical needs

5. 5 More than 40 user organizations & close to 200 healthcare vendors worldwide have contributed to IHE Delivery of ready-to-integrate products to benefit healthcare enterprises of all sizes In clinical use today in enterprises and regional networks IHE scope, today and in the future  radiology, cardiology, laboratory, oncology, eye care, devices  enterprise healthcare IT infrastructures  cross-enterprise healthcare IT infrastructures  RHIO’s and NHIN IHE Maturity and Acceptance

6. 6 Proven Standards Adoption Process Document Use Case Requirements Identify available standards ( e.g. HL7, DICOM, IETF, OASIS) Develop technical specifications Testing at Connectathons IHE Demonstrations Products with IHE Timely access to information Easy to integrate products

7. 7 IHE Connectathon

8. 8 Achievements and Expanding Scope Close to 200 vendors involved world-wide, 5 Technical Frameworks 48 Integration Profiles, Testing at Connectathons Demonstrations at major conferences world-wide

9. 9 IHE Organizational Structure Participants contribute Global Development: Radiology, IT Infrastructure, Cardiology, Lab, etc. Delegates IHE Europe IHE North America IHE Asia/Oceania Regional & National Deployment supervises reports IHE (International) Strategic Development Committee Sponsors Co-Chairs Global Interoperability IHE Domain-related Planning Committee and Technical Committee National Extensions

10. 10 What is IHE NOT? Not a standard, although it leverages them A vendor initiative, although they participate Not a certifying authority, although IHE provides compliance testing Not simply a demonstration project  Demos are only one means to the end: Adoption  Backed up by documentation, tools, testing, and publication of Technical Frameworks and Product Integration Statements. IHE, critical for standardizing interoperability

11. 11 IHE Model Actors in precisely defined roles  Abstracts a specific function of information system …Executing precisely defined transactions  Using existing standards ……To solve real world interoperability problems  Specifying Integration Profiles

12. 12 IHE Technical Frameworks Implementation Guide for each Integration Profile An Integration Profile :  A Set of Actors  Exchanging Transactions Use cases Process Flows For each transaction:  Std referenced  Options specified  Mapping required ActorsTransactions

13. 13 IHE Solutions within the Enterprise eMPI User Auth Enterprise IT Infrastructure Enterprise IT Infrastructure Laboratory LIS Auto Mgr Analyzer EMR - HIS Cardiology CIS CathECG Radiology RIS PACS Img Acq -Radiation Therapy -Patient Care Devices -Patient Care Devices -Pathology -Pathology -Eye Care -Eye Care

14. 14 IHE Solutions within the Enterprise Cardiology Radiology CardiologyLaboratory Enterprise IT Infrastructure Enterprise IT Infrastructure EMR - HIS RIS PACS Img Acq CIS CathECG LIS Auto Mgr Analyzer -Radiation Therapy -Patient Care Devices -Patient Care Devices -Pathology -Pathology -Eye Care -Eye Care Cardiology Integration Profiles Cardiac Catheterization Lab Workflow Echocardiography Lab Workflow Retrieve ECG for Display Displayable Reports Cath and Echo Evidence Documents eMPI User Auth

15. 15 IHE Solutions within the Enterprise Laboratory Radiology CardiologyLaboratory Enterprise IT Infrastructure Enterprise IT Infrastructure EMR - HIS RIS PACS Img Acq CIS CathECG LIS Auto Mgr Analyzer -Radiation Therapy -Patient Care Devices -Patient Care Devices -Pathology -Pathology -Eye Care -Eye Care Laboratory Integration Profiles Laboratory Scheduled Workflow Laboratory Information Reconciliation Laboratory Point Of Care Testing Laboratory Device Automation Laboratory Code Set Distribution eMPI User Auth

16. 16 IHE Solutions within the Enterprise IT Infrastructure (Enterprise) Radiology CardiologyLaboratory RIS PACS Img Acq CIS CathECG LIS Auto Mgr Analyzer -Radiation Therapy -Patient Care Devices -Patient Care Devices -Pathology -Pathology -Eye Care -Eye CareeMPI User Auth EMR - HIS IT Infrastructure Integration Profiles Patient Administration Management Patient Demographics Query Patient Identifier Cross-referencing Retrieve Information for Display Enterprise User Authentication Consistent Time Patient Synchronized Applications Audit Trail and Node Authentication Personnel White Pages Enterprise IT Infrastructure Enterprise IT Infrastructure

17. 17 IHE Solutions within the Enterprise Radiology Radiology CardiologyLaboratory Enterprise IT Infrastructure Enterprise IT Infrastructure EMR - HIS RIS PACS Img Acq CIS CathECG LIS Auto Mgr Analyzer -Radiation Therapy -Patient Care Devices -Patient Care Devices -Pathology -Pathology -Eye Care -Eye CareeMPI User Auth Radiology Integration Profiles Radiology Scheduled Workflow Patient Information Reconciliation Access to Radiology Information Portable Data for Imaging Consistent Presentation of Images Key Image Note Presentation of Grouped Procedures Evidence Documents Audit trail and Node Authentication (Rad option) Teaching Files and Clinical Trials Export Post-processing Workflow Reporting Workflow Charge Posting Simple Image and Numeric Reports How to use IHE ?  IHE Radiology Handbook

18. 18 IHE Scheduled Workflow (SWF) and Patient Information Reconciliation (PIR) PIR = Fulfilling a request for imaging service in the absence of key information ? How do I deal with trauma and “non-registered patients”? What if the ADT/ Patient Registration is down? What if the Order Placer is down? SWF = Fulfilling a request for imaging service with maximum efficiency ? How do I avoid reentering information on modalities? How do I avoid entering in my RIS what my modality already knows ? How do I ensure that in all cases no study is lost, remains unread, or read incomplete. How do I ensure that all necessary information is automatically on my PACS and RIS?

19. 19 Scheduled Workflow Profile Registration Orders Placed Orders Filled Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed images printed Acquisition Modality

20. 20 IHE for Regional or National EHR Sharing Health Records across different care settings

21. 21 Sharing and Accessing Electronic Health Records IHE offers interoperability for local, regional, specific, or national health information exchange Goal is to enable exchange between providers’s EHR systems and ancillary IT systems (Lab, Pharma, Payers) and personal health record systems. Objective is to empower the consumer in having “shared EHR information” between all of its potential healthcare providers (if authorized) and self. IHE goal is not:  To create a “perfect health record”, the truth about a patient health.  To create an other “health record”, next to the one(s) managed by the provider and the consumer.

22. 22 Community or sub-network Clinical Encounter Clinical IT System Index of patients records (Document-level) Aggregate Patient Info 4-Patient data presented to Physician Sharing System Clinic Record Specialist Record Hospital Record 2-Reference to Records for Inquiry Introduced at HIMSS in 2005 : IHE-XDS 3-RecordsReturned Reference to records Repository of Documents

23. 23 Health Information Exchanges Interoperability: Cross-enterprise Digital Document Sharing Cross-Enterprise Document Sharing minimizes clinical data management by the infrastructure. Transparency = Ease of Evolution Patients 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 Workflows addressed in a second step in a much simpler manner. Point-to-Point messages best suited for workflows mgt

24. 24 Cross-Enterprise Document Sharing (XDS) Standards Used Healthcare Content Standards HL7 CDA, CEN EHRcom HL7, 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, USA, etc.) IHE XDS, based on ISO 15000 standard: 15800 “Google” references (Jan’ 06)  38900 (April’ 06)

25. 25 Cross-Enterprise Document Sharing (XDS) Clinical Information in the Digital Document Two “categories” of standards used XDS Infrastructure (Document sources, consumers, registries, repostories) XDS Doc Content Medical Summaries (HL7 CDA/CRS+V3) Imaging (DICOM) Imaging (DICOM) ECG Reports (PDF+) ECG Reports (PDF+) Next lab, nursing, etc. Next lab, nursing, etc.

26. 26 IHE-XDS is part of a family of profiles Regional, national, local or disease centric networks need a consistent set of Integration Profiles Nine Integration Profiles completed and tested, plus seven in development = Standards-based interoperability building blocks for  Rich Document Content for end-to-end application interoperability. Available is a structured medical summary (incl meds, allergies, pbs) and imaging information (incl. Images and reports). More in development.  Patient identification management  Security and privacy  Basic workflow (Notif of doc availbility) IHE-XDS + related IHE Integration profiles provide a complete interoperability solution

27. 27 IHE Integration Profiles for Health Info Nets What is available and has been added in 2005 and is for 2006 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 Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Emergency Referrals Format of the Document Content and associated coded vocabulary Patient Created Summaries 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 Cross-enterprise User Authentication Authentication & Auditing: Enhanced Access Control Cross-enterprise Document Interchange Media-CD/USB & e-mail push Notification of Document Availability Notification of a remote provider/ health enterprise 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 Document Digital Signature Attesting “true-copy and origin

28. 28 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 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

29. 29 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 (HL7 CDA) 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.  Procesable health data import Coded Section Entry Coded Section Entry Coded Section Entry Level 3 XDS-MS enables both semantical interoperability and simple viewing !

30. 30 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 !

31. 31 HIMSS Feb 2006 Interoperability Showcase

32. 32 Successful showcase - Over 3000 visitors Real-world implementations. Effective IHE interoperability  36 vendor products: EHR & Ancillary IT systems, PHR systems, Registries, Repositories, MPIs, etc.  4 Federal entities or grantees (VA, DoD, NIST, CDC/UW)  All implementations passed IHE Connectathon tests Scenario focused on health information exchange:  Within the enterprise (Cardiology, Radiology, etc.)  Across inpatient and physician offices care settings in a RHIO for health status information (meds, allergies, pbs, etc.), reports, images, legacy docs Empowered with your own health record:  Show-wide record submission and access (11 vendor booths)  “HIMSS RHIO” Infrastructure: secured access & communications, distributed repositories, document registries, patient Id X- referencing

33. 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

34. 34 Endorsements National & Regional Projects  Italy  Canada  Austria  France  Japan  USA (NHIN prototypes and RHIOs) Vendors  US EHR Vendor Association (95% market): Interoperability Roadmap: www.himssehrva.org www.himssehrva.org  Europe: COCIR

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36. 36 Participating and Contributing Vendors (America) Agfa HealthCare Algotec Allscripts Healthcare BerdyBluewareCamtronics Canon Medical Systems CapMed Cardiac Science Corp. Carefx Cedara Software Corp. Cerner Corporation CGI-AMSCSISTDictaphone DR Systems Dynamic Imaging Eastman Kodak Company EBM Technologies EclipsysEmageon Raining Data RASNA Imaging Systems ScImage Inc. Sectra Imtec Sentillion Shimadzu Corp Siemens Medical Solutns’ Softmedical Stentor, Inc St. Jude Medical StorCOMM, Inc Swissray International, Inc Tiani-Spirit Toshiba Medical Systems T-Systems UltraVisual Medical Syst. Vital Images, Inc. Voxar Limited WebMD Practice Services Witt Biomedical Corp. XIMIS Epic Systems Corp. ETIAMFujifilm GE Healthcare Heartlab HIPAAT Inc. Hitachi Medical Corp. Hologic Hx Technologies IDX Systems Corporation Imco Technologies INFINITT Initiate Systems Inc. InSiteOne Intelerad Medical Systems IBM Intersystems Corporation Konica Minolta Kryptic Marotech, Inc. McKesson In yellow, companies with IHE Committees Chairs (Spring 2006) MedAccessPlus Health MedCommons Inc Medcon Medical Informatics Eng. Medical Manager Health Mediface Co. Medinotes Medis Medical Imaging Merge eFilm Misys MNI Medicos MortaraNextGenNovell Open Text Corp. Philips Medical Systems Procom Technology Prosolv Cardiovascular QRS Diagnostics Quovadx RADinfo Systems

37. 37 Participating and Contributing Vendors (Europe) AGFA Healthcare AISoftw@re Medical Algotec ARES SA aycan Digitalsysteme CEGEDIM Cerner Corp. CHILI CMT Medical Tech. Conto Corrente Salute ConVis CTI Mirada Solutions Data Processing SPA DEDALUSDianoema Eastman Kodak Co. Ebit Sanita EDL ELFIN s.r.l. Engineering Sanità ESAOTE MEDASYS SA Medavis Medical Communications Medigration GmbH MEDIMON Ltd. MEDIWARE MEDOS AG Merge eFilm METAFORA Mevis Diagnostics Konica Minolta Omnilab Philips Medical Systems POLYMEDIS Rasna Imaging Systems RAYPAX INC. REMRogan-Delft Sago spa Sectra Imtec AB SeeBeyond Technology ETIAMFerraniaFujifilm GE Healthcare GIE Convergence-Profils Global Imaging Online GWI Research Hi. tech IASI Srl IdeoPassINFINITTINFOPATIENTINOVITINSIEL Intersystems Corp. Invita ITZ Medicom iSoftMcKessonMED2RADMEDarchiver In yellow, companies with IHE Committees Chairs (Winter 2005) Siemens Medical Soluzioni Informatiche srl Stentor Inc. St. Jude Swissray Medical AG Symphonie On Line SynapsisSynchro-MedTECHNIDATA TELEMIS S.A. Tiani-Sprit Tomtec Imaging TOREX GAP Medical Toshiba Medical Systems TSI groupe europMedica T-SystemsUni-medicine VEPRO AG VISUS Technology Transfer WAID XR PARTNER

38. 38 Participating and Contributing Vendors (Asia) JapanEBMJPSPPANASONICALOKA KONICA MINOLTA Hitachi Medical Co. KODAKHITACHISBSINFOCOMCLIMBMSTECHMATRIXCANONVIEWSEND TaiwanINFINITT Shing Shian INQ GEN TEP Tah Ya Korea AGFA Korea GE Healthcare Korea INFINITT LG CNS Marotech, Inc. Medical Standard Peoplenet Communications Samsung SDS JapanITECWINTCSNECAGFAJMACGEYMSAJSTOSHIBAYOKOGAWAGOODMANFUJITSUAANDTFUJIFILM

39. 39 What can you do? Learn about IHE Insist on IHE compliance in your RFPs and contract documents:  Select Integration Profiles, and Appropriate Actor(s)  Ask vendors for their products “IHE Integration Statements”. Need more interoperability ?  Join IHE Israel  Contribute to Global IHE Committees

40. 40 Call for Tenders Be Brief (but ineffective) ?  “The system must support DICOM”  “The system must support HL7” Be Effective (but lengthy) ?  “The system must support the following DICOM or HL7 services according to the following 100 pages of specifications: …” Be Both brief and effective:  Quote IHE profiles and actors: “The system must support the IHE Scheduled Workflow as the Order Filler actor.” Request IHE Integration Statements  Version 2.1 of the SuperX CT supports IHE Scheduled Workflow, Patient Information Reconciliation and Key Image Note as an Acquisition Modality

41. 41 IHE Integration Statements Explicit claim by the vendor, for a specific product version Lists profiles, actors, options Short (1 page) & Sweet Compare apples with apples. e.g.: The number of IHE Integration Profiles actually delivered on different PACS products varies greatly:  http:// www.ihe.net /resources/ ihe_integration_statements.cfm

42. 42 As a Provider or Vendor Contributor Offer Clinical Use Case Input to Drive IHE Profile Development Become a member of relevant domain’s Planning or Technical Committees Become a member of relevant Regional/National Committees  IHE Israel Help to shape IHE’s future direction As a Vendor Participant Respond to Public Comments of Domain Supplements Attend Educational Workshops Participate in Connect-a-thons and Demonstrations As a Provider/Consultant Participant Respond to Public Comments of Domain Supplements Attend Educational Workshops Include IHE Integration Profiles in your RFPs and Integration Projects. How can I participate?

43. 43 IHE Web site: www.IHE.net Frequently Asked Questions Integration Profiles in Technical Frameworks: See Volume 1 of each TF for Use cases  Cardiology  IT Infrastructure  Laboratory  Patient Care Coordination  Radiology Connectathon Result: www.ihe.net/Events/connectathon_results.cfm Vendor Products Integration Statements Participation in Committees & Connectathons

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