1. Slide 0 EHR SD RM - EHR Way Forward Future State Reference Architecture Alean Kirnak Cochair for Public Health and Emergency Response January 19, 2009 Constructing a Future State Reference Architecture for Immunizations

2. Slide 1 EHR SD RM - EHR Way Forward … Future State Reference Architecture HITSP and Immunization Use Case #CapabilityPatient IdentificationData Retrieval and UpdateDecision Support 1Standards OrgHL7 2Service Specification Identification Service Functional ModelRetrieve, Locate, Update SFMDecision Support SFM 3Standards OrgOMG 4Service Specification Identification Service SpecificationRetrieve, Locate, Update SpecDecision Support Service Spec 5Profile OrgIHE 6SOA ProfileSOA White Paper 7Profile OrgIHE 8Immunization Profile PIX/PDQ SC110 Query for Existing Data (QED) CAP123 SC113 Immunization Content (IC) CAP119 CAP133 SC112 Request for Clinical Guidance CAP133 (IC payload) 9Profile OrgAmerican Immunization Registry Association/CDC 10Immunization Profile Draft: 2.5 Impl Guide 11Immunization Profile 2.3.1 Impl Guide CAP131 CAP132 SC115 2.3.1 Impl Guide CAP131 CAP132 SCII5 12Standards OrgHL7 13Original Standard V2 V3 Patient Admin messagingV2 V3 Care Record messaging V3 (POIZ) Immunization messaging V3 Care Record CDA V3 Care Record messaging V3 POIZ messaging

3. Slide 2 EHR SD RM - EHR Way Forward … Future State Reference Architecture Immunization Use Case - Simplified #CapabilityPatient IdentificationData Retrieval and UpdateDecision Support 1Standards OrgHL7 2Service Specification Identification Service Functional ModelRetrieve, Locate, Update SFM Decision Support SFM 3Standards OrgOMG 4Service Specification Identification Service SpecificationRetrieve, Locate, Update Spec Decision Support Service Spec 5Profile OrgIHE 6SOA ProfileSOA White Paper 7Profile OrgIHE/American Immunization Registry Association/CDC 8Immunization Profile PIX/PDQ SC110 Future Draft: 2.5 Impl Guide Query for Existing Data (QED) CAP123 SC113 Immunization Content (IC) CAP119 CAP133 SC112 Request for Clinical Guidance CAP133 (IC payload) 12Standards OrgHL7 13Original StandardV2 V3 Patient Admin messagingV2 V3 Care Record messaging V3 Care Record CDA V3 Care Record messaging

4. Slide 3 EHR SD RM - EHR Way Forward … Future State Reference Architecture Immunization Use Case Within HL7 SAEAF ECCF Specification Stack #Patient IdentificationData Retrieval and UpdateDecision Support 1 Enterprise View (Service Functional Models) 2 Identification Service Functional ModelRetrieve, Locate, Update SFMDecision Support SFM 3 Computational View (Service Definitions) 4 Identification Service SpecificationRetrieve, Locate, Update Spec Decision Support Service Spec 5 Information View (Payloads) 6 PIX/PDQ SC110 Future Draft: 2.5 Impl Guide Query for Existing Data (QED) CAP123 SC113 Immunization Content (IC) CAP119 CAP133 SC112 Request for Clinical Guidance CAP133 (IC payload) 7 Implementation View (Vendor Implementations) 8Base Standard 9V2 V3 Patient Admin msgV2 V3 Care Record msg V3 Care Record CDAV3 Care Record mesg

5. Slide 4 EHR SD RM - EHR Way Forward … Future State Reference Architecture Service Definition Ref: A Service-Oriented Architecture (SOA) View of IHE Profiles IHE 2009

6. Slide 5 EHR SD RM - EHR Way Forward … Future State Reference Architecture Copyright 2009 Software Partners LLC 5 Meet in the Middle* *Anna Orlova, Josh Painter, Alean Kirnak, A SOA View of IHE Profiles working drafts

7. Slide 6 EHR SD RM - EHR Way Forward … Future State Reference Architecture Cost Effectiveness Proposition Target cost function of healthcare IT connectivity # of service consumers * # of services

8. Slide 7 EHR SD RM - EHR Way Forward … Future State Reference Architecture Approximately 75 U.S. Immunization Information Systems (IISs) Completely connected point-to-point IIS network: 74 * 75 / 2 = 2775 connections Assume 200 regional provider EHRs per IIS: 200 * 75 = 15,000 connections Each connection costs $10K-$30K per side $40K each * 17,775 =$711,000,000 Point to Point Messaging Economics 7Copyright 2009 Software Partners

9. Slide 8 EHR SD RM - EHR Way Forward … Future State Reference Architecture Labs Meds Allergies Cancer Registries Joint Replacement Registries Chronic Disease Registries Adverse Event Reporting …etc. Intra-enterprise communication Provider-to-Provider communication... 100 domains increases cost to $71,100,000,000 Expand to Multiple Domains 8Copyright 2009 Software Partners

10. Slide 9 EHR SD RM - EHR Way Forward … Future State Reference Architecture Schools Drug stores Airports … Growth of Points of Care 9Copyright 2009 Software Partners

11. Slide 10 EHR SD RM - EHR Way Forward … Future State Reference Architecture Tethered Untethered Wireless devices … Growth of Personal Health Records 10 Copyright 2009 Software Partners

12. Slide 11 EHR SD RM - EHR Way Forward … Future State Reference Architecture Bus architecture Plug-and-play connections Common information model How to Solve? 11 Copyright 2009 Software Partners

13. Slide 12 EHR SD RM - EHR Way Forward … Future State Reference Architecture Bus architecture –Build common carrier once –Hide routing, translation Plug and play connections –Eliminates cost on one side of each connection Common information model –multiple platform-specific models for a single platform- independent model –Basis for passing data from service to service Cost Reduction Opportunities 12 Copyright 2009 Software Partners

14. Slide 13 EHR SD RM - EHR Way Forward … Future State Reference Architecture 75 IISs each accessing one service 15,000 EHRs, 500 products @ 30 installations ea = 500 connections Cost @$20K is per service consumer only $20K * (500 + 75) =$11,500,000 + cost of carrier Drive down the $20K Cost Reduction Opportunities 13 Copyright 2009 Software Partners

15. Slide 14 EHR SD RM - EHR Way Forward … Future State Reference Architecture Meaningful Use Rules and Regs #CapabilityPatient IdentificationData Retrieval and UpdateDecision Support 1Standards OrgHL7 2Service Specification Identification Service Functional ModelRetrieve, Locate, Update SFMDecision Support SFM 3Standards OrgOMG 4Service Specification Identification Service SpecificationRetrieve, Locate, Update Spec Decision Support Service Spec 5Profile OrgIHE 6SOA ProfileSOA White Paper 7Profile OrgIHE 8Immunization Profile PIX/PDQ SC110 Query for Existing Data (QED) CAP123 SC113 Immunization Content (IC) CAP119 CAP133 SC112 Request for Clinical Guidance CAP133 (IC payload) 9 Profile Org American Immunization Registry Association/CDC 10Immunization Profile Draft: 2.5 Impl Guide 11Immunization Profile 2.3.1 Impl Guide CAP131 CAP132 SC115 2.3.1 Impl Guide CAP131 CAP132 SCII5 12Standards OrgHL7 13Original StandardV2 V3 Patient Admin msgV2 V3 Care Record msg V3 (POIZ) Immunization msg V3 Care Record CDA V3 Care Record messaging V3 POIZ messaging

16. Slide 15 EHR SD RM - EHR Way Forward … Future State Reference Architecture Proposed Meaningful Use Comments Propose use of service interfaces to satisfy need for transport layer standards for immunizations Fill gaps in immunization standards –Include immunizations in medical summary –Use CAP133 Immunization Content in Table 2A –Include immunizations in decision support clauses Note the immunization use case includes patient identification