1. January, 2009What IHE Delivers 1 Showcasing Interoperability National Center for Public Health Informatics (NCPHI) Monthly Partner Call Lori Fourquet e-HealthSign LLC

2. 2 What is “Integrating the Healthcare Enterprise”? A 10-year public-private initiative Driven by end-users, IHE improves patient care by harmonizing electronic health information exchange Enables approved standards to seamlessly pass health information among care providers on a local, regional and national level IHE Frameworks are freely available to all The IHE Global Standards Adoption process as approved by the International Standards Organization (ISO) as a Technical Report 28380 in August 2007

3. 3 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 IHE Demonstrations Products with IHE Timely access to information Easy to integrate products

4. 44 International Growth of IHE France  Local Deployment  National Extensions  Promotional & Live Demonstration Events  Funding USAGermanyItalyJapanUKCanadaKoreaTaiwanNorway Netherlands Spain ChinaAustria 1999 2000 2001200220032004 200520062007 2088 Pragmatic global standards harmonization + best practices sharing Australia

5. 5 IHE, global standards-based profiles adopted by several national & regional projects Quebec, Toronto, Alberta, British Columbia Canada Infoway Denmark (Funen) Italy (Veneto) Spain (Aragon) NCHICA – N. Carolina Italy (Conto Corrente Salute) Boston Medical Center - MA France DMP UK CfH (Radiology WF) Philadelphia HIE CHINA-MoH Lab results sharing KeyHIE – Pennsylvania CHINA-Shanghai Imaging Info Sharing JAPAN-Nagoya Imaging Info Sharing South Africa Malaysia Singapore VITL-Vermont CareSpark – TN & VA Netherland Amsterdam Lower Austria

6. 6 Where are Public Health Interests Addressed in IHE? New Domain: Quality, Research, and Public Health Leverages profile initiatives from multiple domains Current Domain Initiatives in:  IHE Quality, Research, and Public Health  IHE Patient Care Coordination  IHE IT Infrastructure

7. QRPH White papers Patient-Level Export of Quality Data  Identifies a set if IT Infrastructure and Patient Care Coordination profiles that can be used to retrieve quality data from multiple systems for quality reporting and aggregation. This framework can be extended to research and public health purposes White Paper: Performance Measurement Data Element Structured for EHR Extraction  Intended to identify a standard mechanism to enable extraction of quality measures from Electronic Health Record Systems 7

8. QRPH Profiles Clinical Research Data Capture (CRD)  CRD describes the content and format to be used within the Pre-population Data transaction described within the RFD Integration Profile. The purpose of this profile is to support a standard set of data in CCD format which the Form Filler provides for use in Clinical Research Drug Safety Content Profile (DSC)  DSC describes the content and format to be used within the Pre-population Data transaction described within the RFD Integration Profile. The purpose of this profile is to support a standard set of data in CCD format which the Form Filler provides for use in reporting adverse events as it relates to Drug Safety. 8

9. 9 IHE PCC Profiles Medical Summaries (C48) ED Referral Exchanging PHR Content (C32) Antepartum Care Summary Emergency Department Encounter Summary (C28) Functional Status Assessments 2005-06 2006-07 2007-08 2008-09 IntegrationContent Query for Existing Data (TP21) Care Management Antepartum Record Immunization Registry Content (C78) Cancer Registry Content

10. 10 Query for Existing Data Value Proposition Exchange of information between Data Repositories and Clinical Data Consumers for:  Drug Safety  Public Health, Biosurveillance and Disease Registries  Identifying Qualifying Patients Clinical Trials Clinical Trials Disease Management Disease Management  Quality Reporting  Claims Submission Using a single standard for query Compatible with CCD vs. 30-60 HL7 V2.X Interfaces @ $10-20K/Inteface HITSP TP21, Quality

11. 11 Immunization Content Value Proposition The value of Immunization Information Systems (IISs) improves as the patient immunization histories it maintains become more complete. Although IIS use by public health and safety net providers is widespread, IISs are challenged to obtain electronic interfaces to provider EMRs EMR implementers spend 10-20K per year per HL7 V2 connection Connections tend to be one-off in spite of HL7 V2 standards and the existence of implementation guides. The trend is toward unified HL7 V3 XML-based interactions including Continuity of Care Document (CCD) and compatible V3 document standards Immunization Content strives to provide a bridge between Version 2 and Version 3 HITSP C78, Immunization and Response Management

12. 12 Cancer Registry Pathology Report Value Proposition ~ 2 Million cancers diagnosed each year in the US  ~ 95% of these cancers have one or more pathology reports The US federally mandates reporting  serves as the foundation to reduce illness and death from cancer Making use of the EHR and IHE methodology  reduce time and resources required to meet federal mandates  improve the timeliness of reporting Being proposed to IHE Pathology for 2009 NEW DIRECTIONS DEMONSTRATION

13. 13 Care Management Scope Capability to specify care guidelines and gather pertinent information for: Public Health Public Health  Cancer Registries  Immunization Information Systems (Registries)  EHR Systems Chronic Disease Management Chronic Disease Management  Care Management Systems  EHR Systems  Other Health IT Systems Content for Newborn Screening and Diabetes under development Watch for 2010 demonstrations

14. IT Infrastructure Components Supporting Public Health Cross-Enterprise Document Sharing Cross-Enterprise Document Reliable Interchange (XDR) Cross-Enterprise Document Media Interchange (XDM) Patient Identifier Cross Reference Manager (PIX) Patient Demographics Supplier (PDQ) Retrieve Form for Data Capture (RFD) Audit Record Repository (ATNA) Time Server (CT) Personnel White Pages (PWP) Cross-Enterprise User Assertion (XUA) Cross Community Access (XCA) Basic Patient Privacy Consents (BPPC) Cross-enterprise Sharing of Scanned Documents (XDS-SD) Document Digital Signature (DSG)

15. Pediatric Demographics Pediatric Demographics Expands patient demographics for PIX/PDQ to include supported attributes of interest to immunization registries Expands patient demographics for PIX/PDQ to include supported attributes of interest to immunization registries Referral Requests Referral Requests Addresses a means to a way to convey the referral request in a form suitable for automatic processing Addresses a means to a way to convey the referral request in a form suitable for automatic processing Key to improved coordination of care (e.g. safety-net, under- insured, uninsured) Key to improved coordination of care (e.g. safety-net, under- insured, uninsured) Emergency Contact Registry Emergency Contact Registry White paper addressing bridge between the emergency response person identification and health record systems White paper addressing bridge between the emergency response person identification and health record systems Next of kin contact is a first step in a longer term interoperability initiative in support of emergency response Next of kin contact is a first step in a longer term interoperability initiative in support of emergency response 15 2008 IT Infrastructure Profiles Supporting Public Health

16. Sharing Value Sets Sharing Value Sets Addresses synchronization of content terminologies across applications Addresses synchronization of content terminologies across applications Key to semantic interoperability for quality, research and public health analysis. Key to semantic interoperability for quality, research and public health analysis. Publish/Subscribe Infrastructure for XDS.b Publish/Subscribe Infrastructure for XDS.b Currently, required to poll the Document Registry for new documents & updates Currently, required to poll the Document Registry for new documents & updates Add support for a publish/subscribe method of receiving new information for patients of interest. Add support for a publish/subscribe method of receiving new information for patients of interest. e.g. Public Health Monitoring for certain conditions e.g. Public Health Monitoring for certain conditions e.g. Subscribe to neighboring state conditions of interest e.g. Subscribe to neighboring state conditions of interest 16 2008 IT Infrastructure Profiles Supporting Public Health

17. 2008/2009 Development QRPH  Chronic Disease Management Reporting - Profile  Retrieve Protocol for Execution - Profile  Maternal child health - Profile  Diabetes Care Management - White Paper  Performance Quality Report - Profile  New-born screening - Planning White Paper  Pseudonymization - Planning Committee/ITI White Paper IT Infrastructure  Publish and Subscribe - Profile  Multi-Patient Query - Profile 17

18. HITSP Support for IHE Connectathon Foster development and implementation of the HITSP ISs  Increase awareness of available guidance and support  Encourage participation in HITSP Technical Committees Ensure 'fitness for use' of HITSP Interoperability Specifications  Debug  Identify improvements Encourage and support vendor application demonstrations supporting HITSP at the HIMSS Showcase

19. HITSP Accepted and Recognized Solutions IS01 - Electronic Health Records Laboratory Results Reporting IS02 – Biosurveillance IS03 - Consumer Empowerment and Access to Clinical Information via Networks IS04 - Emergency Responder Electronic Health Record IS05 - Consumer Empowerment and Access to Clinical Information via Media IS06 – Quality IS07 - Medication Management

20. On The Way (January 2009) IS08 - Personalized Healthcare IS09 - Consultation and Transfers of Care IS09 - Consultation and Transfers of Care IS10 - Immunizations and Response Management IS11 - Public Health Case Reporting IS12 - Patient - Provider Secure Messaging IS77 - Remote Monitoring

21. IHE Profiles and HITSP Additional Constraints IHEHITSPTitle EDESC28Emergency Encounter Summary Document PDQT23Patient Demographics Query Transaction PIXTP22Patient ID Cross Referencing XD*LabC37Lab Report Document Using IHE XD* Lab Component XDMT33Transfer of Documents on Media Transaction XDSTP13Manage Sharing of Documents XDS-MSC38Patient level quality data document component XDS-MSC48Encounter Document Component XDS-SDC62Unstructured Document

22. IHE Profiles and HITSP No Constraints IHEHITSPTitle ATNAT15Collect and Communicate Audit Trail ATNAT17Secured Communication Channel Transaction BPPCTP30Manage Consent Directives Transaction Package CTT16Consistent Time DSGC26Nonrepudiation of Origin Component NAVT29Notification of Document Availability Transaction QEDTP21Query for Existing Data RFDTP50Retrieve Form for Data Capture XDRT31Reliable Document Exchange XDS-ITP49/TP89Sharing Radiology Results Transaction Package XUAC19Entity Identity Assertion Component

23. Panel Approved C64 – PWP – Personnel White Pages C78, C72 – Immunization Content T67 – DRR – Referral C76 – Drug Safety Profile

24. HITSP Population Perspective TC Mondays 1 – 3 PM EST Quality IS and Measure Configuration  Stroke  VTE  Emergency Department  New constructs: QRDA, Clinical Decision Support Mondays 3 – 4 PM EST Public Health Case Reporting and Consumer Adverse Event Reporting (new extension) Consumer Adverse Event Reporting Consumer Adverse Event Reporting  Alert review  Data Content Update (Pending CSTE, CDC, AHRQ reports) Mondays 4 – 5 PM EST Immunization and Response Management  Supply Chain Management  Non-vaccine medication administration Thursday 3 – 4 PM EST Newborn Screening (new use case) Newborn ScreeningNewborn Screening Thursday 4 – 5 PM EST Maternal and Child Health (new extension) Maternal and Child HealthMaternal and Child Health

25. Overview of 2009 Population Health Scenarios Alignment with HITSP Use Cases  IS 02 – Biosurveillance  IS 06 – Quality  IS 10 – Immunization and Response Management  IS 11 – Public Health Case Reporting Quality (above) Public Health Initiatives in IHE  Immunization Scenario (same as above)  Cancer Registry – New Directions Clinical Research  Drug Safety (also indicated in HITSP Use Case)  Clinical Trials 25

26. Scenarios Many of the following scenarios have specific sponsors driving the demonstration goals Most of the scenarios are still undergoing review for clinical accuracy Extended technical options are listed, but may be adjusted based on capabilities Some of the scenarios include HITSP constructs with no IHE equivalent 26

27. Quality (HITSP IS06) SceneDescriptionProfiles/ Constructs SpecialistExamination and bloodwork for diabetes are assessed and reported for quality measure. Quality reporting content retrieved through QED. Lab Document Published. XDS, QED, XD*Lab, XDS- MS, C48, C37, TP21 PCPPatient presents to PCP. Diagnosis triggers Quality reporting forms from RFD. Data is populated from data in the EHR and retrieved from the HIE. XDS, RFD, XD*Lab, XDS- MS, C48, C37, TP50 HospitalPatient is hospitalized with a DVT following surgery. The DVT triggers quality reporting forms from RFD. Data is populated from data in the EHR and retrieved from the HIE. XDS, RFD, XDS-MS, C48, C37, TP50 Quality Measuremen t Org Quality measures are collected and aggregate analysis performed RFD 27

28. Biosurveillance & Public Health Case Reporting: Bi-directional Communications (HITSP IS02, IS11) SceneDescriptionProfiles/ Constructs PCPPatient presents to the PCP with Influenza-like-illness symptoms (supports foodborne pathway and influenza pathway). Submits summary of the visit to the HIE. Takes samples and sends to lab for analysis. EDR, C48 Public Health Lab Samples are sent to the public health lab for typing revealing …. (multi-drug-resistant strain). Notification is sent to care providers, PH; results posted to XDS; XD*Lab, NAV, C37, C35, T29 Public Health/HIE Retrieves data from HIE. Puts data into surveillance system and spike is detected; Alert with specific recommendations is created -- Recommendation may be influenced by lab typing. Forms variant for alerts. Forms and Knowledge service provider reviewed RFD, NAV, XDS-SD, PWP, C62 PCPPatient presents to PCP. Presenting complaints trigger alert to clinician. Morbidity form is retrieved from PH Server, gets prepopulated from EMR, Clinician adds in additional information and submits to PH (RFD) RFD TP50, T81, C76 28

29. Immunization (HITSP IS10) SceneDescriptionProfiles/ Constructs PCP State 1 Child is immunized in PCP office according to recommended schedule. Submits the immunization document to the HIE. Document is transformed to required 2.3.1 message format via a service gateway IC, XDS, TP22/T23, C78, TP13 PCP State 2 Parents move to another state and visit new pediatric PCP. PCP queries for records in both affinity domains IC, XDS, XUA, C78, TP13, C19 TP20 Service Gateway The gateway transforms immunization document formats to messages enabling IIS a bridge to the HIE XDS, IC, TP13, C78 School/ Public Health Parents attempt to register child for kindergarten. School nurse/public health nurse looks up immunization information IC, XDS, XUA, C78, TP13, C19, TP20 Infrastruct ure The infrastructure surrounding the secure information exchange is reviewed XUA, BPPC, ATNA, TP30, C19, TP20, C15, C17 29

30. IHE Public Health New Directions Cancer Registries SceneDescriptionProfiles Pathology Lab In the pathology lab, a biopsy sample is analyzed and it is identified as malignant. Pathology report is sent as an electronic submission using traditional HL7 messaging as constrained by IHE for pathology. Cancer Registry Pre- profile HospitalFollowing surgery and follow-up inpatient treatment, Cancer case report form is pre-populated with case reporting data from within the EHR. RFD, C76 PCPPCP provides follow-up care to the cancer patient. RFD is leveraged with pre-populate capabilities to enable improved reporting from the Physician offices. RFD, C76 HospitalPatient presents to ED. Hospital retrieves clinical records. Hospital receives generic alerts and case specific alerts from Public health. XDS, XDS- SD, NAV, C62, C82, T63 Infrastruct ure RFD Form management and analysis reviewed. Local registry reporting and analysis reviewed RFD Cancer Registry Public health cancer registry. Electronic reporting and analysis Cancer Registry pre- profile 30

31. Additional Scenarios Clinical Research not Specifically Covered Drug Safety  Leveraging IHE Drug Safety Profile as constrained by HITSP. This is a late profile and not part of the current connectathon tests Clinical Trials and Drug Safety  One variant is expected to include Digital Signature as a collaborative initiative with CDISC and SAFE Biopharma  The specific scenario will be generated through efforts between CDISC and SAFE Biopharma 31

32. HIMSS 2009 Interoperability Showcase 32 More public health scenarios Participation by ImplementationTestbeds Security and Policy More content available for PHIN 2009

33. January, 2009What IHE Delivers 33 Questions? Lori Reed-Fourquet, E-HealthSIgn 1056 Durham Road Wallingford, Ct. 06492 phone: (203)294-0479 Fax: (203) 294-9623 e-mail: lori.fourquet@sbcglobal.net