1. Integrating the Healthcare Enterprise IHE an Overview Eric Poiseau Laboratoire IDM Faculté de Médecine Université de Rennes 1

2. What is IHE about? It’s an initiative promoting and supporting the integration of systems in the healthcare enterprise. It’s an initiative promoting and supporting the integration of systems in the healthcare enterprise. Integration Goal: Improve the efficiency and effectiveness of clinical practice by: Integration Goal: Improve the efficiency and effectiveness of clinical practice by: –Improved Information Flow –Advanced Multi-System Functions

3. What is Integrating the Healthcare Enterprise ? Sponsored jointly by the user community: Sponsored jointly by the user community: – EAR, ECR, SFR, GMSIH, SIRM, DRG, ESC –BIR, RCR, IPIM, CoR, NHS (joined from UK) –RSNA, HIMSS, ACC, JRS (USA, Japan) and by the vendor community IHE focuses on the flow of information between several systems in several departments operating within a healthcare enterprise. IHE focuses on the flow of information between several systems in several departments operating within a healthcare enterprise. In Europe: 13 Vendors - 13 systems in 2001 33 Vendors - 60 systems in 2002 47 Vendors - 80 systems in 2003 49 Vendors - 82 systems in 2004

4. How is IHE related to Standards? IHE is not a new standard ! IHE is not a new standard ! Information needs to travel widely Information needs to travel widely Information is applied within a context Information is applied within a context –Workflows cross Standard borders IHE specifies how to apply Standards (DICOM, HL7, Web) to real world scenarios & integration problems IHE specifies how to apply Standards (DICOM, HL7, Web) to real world scenarios & integration problems –IHE defines a practical “phrasebook”

5. What is the Result? Vendors implement well-defined subsets of IHE (actors & profiles) on their systems Vendors implement well-defined subsets of IHE (actors & profiles) on their systems IHE is not a product; IHE is not a product; it is introduced by a software feature or upgrade Customers can request specific IHE Integration Profiles in a tender for clinical systems Customers can request specific IHE Integration Profiles in a tender for clinical systems The systems have been pre-tested at the Connectathon The systems have been pre-tested at the Connectathon

6. Unique test platform for vendors Unique test platform for vendors –Peer to peer tests –Workflow tests New collaboration culture for engineers New collaboration culture for engineers –They learn to know each other Warranty for users Warranty for users IHE Connectathon

7. The IHE process IHE Technical Framework IHE Connectathon IHE Demonstrations Planning Committee Product conform to one or more integration profiles We define We testWe show We manage

8. Technical Framework : Document Organization Domain technical frameworks : Domain technical frameworks : –RAD, CARD, LAB, IT-I Vol 1 : Actor and Integration Profiles Vol 1 : Actor and Integration Profiles Vol 2,3,.. : Transactions Vol 2,3,.. : Transactions Maintenance : Maintenance : –Change Proposals –Supplements

9. Technical Framework The IHE Technical Framework is based on actors that interact through transactions. The IHE Technical Framework is based on actors that interact through transactions. Actors are information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise. Actors are information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise. Transactions are interactions between actors that transfer the required information through standards-based messages. Transactions are interactions between actors that transfer the required information through standards-based messages. Specific sets of actors and transactions are specified in the Integration Profiles Specific sets of actors and transactions are specified in the Integration Profiles

10. Actor descriptions examples Acquisition Modality – A system that acquires and creates medical images, e.g. a Computed Tomography scanner or Nuclear Medicine camera. A modality may also create Grayscale Softcopy Presentation States for the consistent viewing of images and create Key Image Notes. Acquisition Modality – A system that acquires and creates medical images, e.g. a Computed Tomography scanner or Nuclear Medicine camera. A modality may also create Grayscale Softcopy Presentation States for the consistent viewing of images and create Key Image Notes. ADT Patient Registration – A system responsible for adding and/or updating patient demographic and encounter information. In particular, it registers a new patient with the Order Placer and Department System ADT Patient Registration – A system responsible for adding and/or updating patient demographic and encounter information. In particular, it registers a new patient with the Order Placer and Department System

11. Transaction descriptions example 1.Patient Registration – The ADT system registers and/or admits a patient and forwards the information to other information systems. 2.Placer Order Management – The Order Placer informs the Order Filler of the initiation or cancellation of an order. The Placer/Filler Order Management transaction will sometimes be referred to as “-New” when a new order is being initiated, or as “- Cancel” when an existing order is canceled.

12. Integration Profiles Description Description Actors/Transactions interaction diagram Actors/Transactions interaction diagram Actors/Transactions requirements Actors/Transactions requirements Process flow Process flow

13. Integration Profiles :Description The Scheduled Workflow Integration Profile establishes the continuity and integrity of basic radiological data. It specifies a number of transactions that maintain the consistency of patient and ordering information as well as providing the scheduling and imaging acquisition procedure steps. This profile also makes it possible to determine whether images associated with a particular performed procedure step have been stored (archived) and are available to enable subsequent workflow steps, such as reporting. The Scheduled Workflow Integration Profile establishes the continuity and integrity of basic radiological data. It specifies a number of transactions that maintain the consistency of patient and ordering information as well as providing the scheduling and imaging acquisition procedure steps. This profile also makes it possible to determine whether images associated with a particular performed procedure step have been stored (archived) and are available to enable subsequent workflow steps, such as reporting.

14. Integration Profiles :Interactions diagram  Pt. Registration [1]  12: Patient Update [12] Pt. Registration [1]  Patient Update [12]   Placer Order Management [2]  Filler Order Management [3] ADT  Query Images [14]  Retrieve Images [16] Image Display Storage Commitment [10]   Modality Image Stored [8]  Evidence Documents Stored [43] Storage Commitment [10]   Creator Images Stored [18]  Procedure Scheduled [4]  Image Availability Query [11]  Patient Update [12]  Performed Work Status Update [42]  Modality Worklist Provided [5] Image Creator Performed Procedure Step Manager  Modality PS in Progress [6]  Modality PS Completed [7]  Creator PS in Progress [20]  Creator PS Completed [21]  Modality PS in Progress [6]  Modality PS Completed [7]  Creator PS in Progress [20]  Creator PS Completed [21]  Modality PS in Progress [6]  Modality PS Completed [7]  Creator PS in Progress [20]  Creator PS Completed [21] Order Placer Order Filler Acquisition Modality Image Manager Image Archive

15. Integration Profiles : Actors / Transactions table

16. Integration Profiles : Process Flow

17. Transaction descriptions Scope Scope Use case roles Use case roles References to standards References to standards Interaction diagram Interaction diagram

18. Transaction: Scope Defines the scope of application of the transaction Defines the scope of application of the transaction –« This transaction involves the patient information, including demographics, captured at the point of encounter. This may occur when the visit is scheduled, if that precedes patient arrival at the institution. This transaction is used for both in- patients (i.e., those who are assigned a bed at the facility) and outpatients (i.e., those who are not assigned a bed at the facility). »

19. Patient Registration Order Placer Department System Scheduler / Order Filler ADT Patient Registration MPI Transaction : Use case example

20. Transaction : References to standard Example for transaction 32: « Authenticate Node » Example for transaction 32: « Authenticate Node » –DICOM 2001 PS 3.15: Security Profiles. Annex B1: The Basic TLS Secure Transport Connection profile. –IETF:Transport Layer Security (TLS) 1.0 (RFC 2246) –ITU-T: Recommendation X.509 (03/00). “Information technology - Open Systems Interconnection - The directory: Public-key and attribute certificate frameworks"

21. Transaction : Interaction diagram

22. IHE Radiology Integration Profiles Patient Info. Recon- ciliation Access to Radiology Information Consistent Present- ation of Images Basic Security - Evidence Docs Key Image Notes Simple Image & Numeric Reports Presentation of Grouped Procedures Post- Processing Workflow Reporting Workflow Charge Posting Scheduled Workflow Portable Data for Imaging NM Image New

23. Workflow Most critical issue in a Radiology Environment Most critical issue in a Radiology Environment –Inter- or corrupted information chain Paper based information -> multiple re-entry of data Paper based information -> multiple re-entry of data Different non adapted subsystems don‘t cooperate Different non adapted subsystems don‘t cooperate Error correction takes huge amount of time Error correction takes huge amount of time –Stale information Brandnew information not known (cancellation, change) Brandnew information not known (cancellation, change) –Status update information Exam registered, finished, archived, reported, delivered Exam registered, finished, archived, reported, delivered

24. Store Images Storage Commitment List of Images PACS & Archive RIS ModalityPerformed Procedure Step Performed Step: Status = Completed Performed CT Head Pat Name/ID, Dose, Accession #, Study UID Complete List of Images A Closed Loop Update IS SchedulingUpdate IS Scheduling Match Procedure with OrderMatch Procedure with Order Support Billing Based on MPPSSupport Billing Based on MPPS Avoid Reading Incomplete ProceduresAvoid Reading Incomplete Procedures Modality Worklist Worklist Procedure Scheduled IHE Scheduled Workflow in Radiology

25. Order Placer Performed Procedure Step Manager ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Modality Worklist Patient Registration Procedure Scheduled Images Availability Query Images Stored Storage Commit Storage Commit Images Stored PPS In-Progress / Completed Filler Order Management Placer Order Management Q /R Images PPS In-Progress / Completed PPS In-Progress / Completed HL7 DICOM Scheduled Workflow

26. Patient Information Reconciliation Trauma patient Trauma patient Manual wrong data entry at the modality Manual wrong data entry at the modality System crashed System crashed VIP person VIP person

27. Patient Update Procedure Update Order Placer Performed Procedure Step Manager ADT Patient Registration Image Archive Image Manager Image Display Image Creator Acquisition Modality Department System Scheduler – Order Filler – Procedure Scheduled Images Availability Query Images Stored Storage Commit Storage Commit Images Stored PPS In-Progress / Completed Modality Worklist Patient Registration Filler Order Management Placer Order Management Q /R Images PPS In-Progress / Completed PPS In-Progress / Completed HL7 DICOM Patient Information Reconciliation

28. IHE-Laboratory Provide users a single name and centralized authentication process across all systems Point of Care Testing(Future) Extend laboratory testing with bedside testing devices Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Laboratory Scheduled Workflow Admit, Discharge, Transfer a patient, order lab tests, collect specimen, perform tests, report results. Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Cooperation with external laboratory Outside Healthcare Enterprise Testing (Future) Provide users a single name and centralized authentication process across all systems Laboratory Patient Information Reconciliation (Future) Updates resulting from unidentified or misidentified Patient

29. IHE IT Infrastructure Enterprise User Authentication Provide users a single name and centralized authentication process across all systems Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications 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. New Patient Demographics Query New Personnel White Page Access to workforce contact information New Cross-Enterprise Document Sharing (XDS) Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record New

30. Audit Trail & Node Authentication : ATNA Protect Patient Privacy and System Security: Protect Patient Privacy and System Security: –Meet ethical and regulatory requirements Enterprise Administrative Convenience: Enterprise Administrative Convenience: –Unified and uniform auditing system –Common approach from multiple vendors simplifies definition of enterprise policies and protocols. –Common approach simplifies administration Development and support cost reduction through Code Re-use: Development and support cost reduction through Code Re-use: –Allows vendors to leverage single development effort to support multiple actors –Allows a single development effort to support the needs of different security policies and regulatory environments.

31. Patient Identifier Cross-referencing for MPI : PIX Allow all enterprise participants to register the identifiers they use for patients in their domain Allow all enterprise participants to register the identifiers they use for patients in their domain Participants retain control over their own domain’s patient index(es) Participants retain control over their own domain’s patient index(es) Support domain systems’ queries for other systems’ identifiers for their patients Support domain systems’ queries for other systems’ identifiers for their patients Optionally, notify domain systems when other systems update identifiers for their patients Optionally, notify domain systems when other systems update identifiers for their patients

32. Patient Synchronized Applications : PSA Patient Synchronization of Multiple Disparate Applications Patient Synchronization of Multiple Disparate Applications Single Patient Selection Single Patient Selection When combined with PIX Profile, allows patient synchronization across patient identifier domains When combined with PIX Profile, allows patient synchronization across patient identifier domains When combined with EUA Profile, provides user Single Sign-on (SSO) When combined with EUA Profile, provides user Single Sign-on (SSO)

33. Retrieve Information for Display : RID Simple and rapid access to patient information Simple and rapid access to patient information Access to existing persistent documents in well- known presentation formats: CDA, PDF, JPEG. Access to existing persistent documents in well- known presentation formats: CDA, PDF, JPEG. Access to specific key patient-centric information for presentation to a clinician : allergies, current medications, summary of reports, etc.. Access to specific key patient-centric information for presentation to a clinician : allergies, current medications, summary of reports, etc.. Links with other IHE profiles - Enterprise User Authentication, Patient Identifier Cross- referencing and Cross Enterprise Document Sharing Links with other IHE profiles - Enterprise User Authentication, Patient Identifier Cross- referencing and Cross Enterprise Document Sharing

34. Enterprise User Authentication Support a single enterprise governed by a single set of security policies and having a common network domain. Support a single enterprise governed by a single set of security policies and having a common network domain. Establish one name per user to be used for all IT applications and devices. Establish one name per user to be used for all IT applications and devices. Facilitate centralized user authentication management. Facilitate centralized user authentication management. Provide users with single sign-on. Provide users with single sign-on.

35. Patient Demographics Query : PDQ Allow quick retrieval of a patient list including common patient names, identifiers, contacts, and visit information Allow quick retrieval of a patient list including common patient names, identifiers, contacts, and visit information Enable selection of correct patient when full identification data may not be available Enable selection of correct patient when full identification data may not be available Limits access to only a subset of demographic and visit information Limits access to only a subset of demographic and visit information

36. Personnel White Pages : PWP Provide access to basic information about the human workforce members Provide access to basic information about the human workforce members –Does not include Patients Defines method for finding the PWP Defines method for finding the PWP Defines query/access method Defines query/access method Defines attributes of interest Defines attributes of interest

37. IHE Integration Statement IHE Integration Statement Product UVW supports the IHE K Actor with the IHE X and Y Integration Profiles IHE J Actor with the IHE J Actor with the IHE T Integration Profile

38. IHE Integration Statement

39. Connectathon Results Browser

40. More Information Links Links –http://www.ihe-europe.org –http://www.rsna.org/IHE –http://www.ihe-uk.org Technical Frameworks Technical Frameworks Thank you