1. 1 Technical Overview of the Common Framework HIT Symposium at MIT J. Marc Overhage, MD, PhD Regenstrief Institute Indiana University School of Medicine Indiana Health Information Exchange

2. 2 Common Framework Connecting for Health principles –Builds on existing systems (“incremental”) and creates early value for doctors and patients –Designed to safeguard privacy – imposed the requirements and then designed the solution –Consists of an interoperable, open standards-based “network of networks” built on the Internet –Leverages both “bottom-up” and “top-down” strategies

3. 3 Architecture is Federated and Decentralized: Once records are located, the health information flows peer-to-peer – with patient’s authorization

4. 4 The architecture supports point of care information sharing and population-based reporting

5. 5 The Connecting for Health Model for Health Information Sharing Sharing occurs via a network of networks (National Health Information Network) — not a completely new architecture The nationwide “network” is made up of smaller community networks or SNOs (Sub Network Organizations) Each SNO has an RLS (Record Locator Service) to locate patient records SNOs are interconnected through ISBs (Inter- SNO Bridges)

6. 6 NHIN: Network of Networks National Health Information Network, not National Health Information Database Bad Tradeoff: 1000x Searches for 0.1 to 0.01 increase No “Top Level” Query –Privacy –Security –Patient Trust –Source of Truth –Data Cleanliness Queries Must Be Targeted/No Fishing Built On Lines of Actual Human Trust

7. 7 What is a SNO? A group of entities (regional or non-regional) that agree to share information with each other Implements the Common Framework Provides an ISB for all external traffic Runs an RLS internally

8. 8 What is a Record Locator Service (RLS)? Like a phone book listing locations of information Contains no clinical information Only authorized participants can access it Obtaining the actual clinical record is a separate transaction not involving RLS RLS Care Delivery Organization 2 Care Delivery Organization 1 Public Health Organization Payer or Other Organization SNO (Secure Reliable Internet)

9. 9 RLS ISB SNO 1 RLS ISB SNO 3 NHIN ISB RLS SNO 2 What is a Inter-SNO Bridge (ISB)? Software that provides the interfaces that define a SNO Provides essential services

10. 10 How Multiple SNOs Connect to Form NHIN A SNO queries other SNOs when it knows: –An institution where the patient received care –A region where the patient received care Same query formatted for all remote SNOs Only need location of ISBs

11. 11 Three Standard Interfaces Required Publish local record locations to RLS (Pink) Query institution+MRN from RLS (Orange) Retrieve clinical data directly from sources (Green)

12. 12 Location: Namespaces Problem of Global Uniqueness Globally Unique Institutions IDs + Locally Unique Record Numbers = Globally Unique Record IDs Examples: John.Smith@IBM.com HHS.gov/help.html GeneralHospital/MRN:457398457

13. 13 Disambiguation: Probabilistic Match on Demographics Assume No National Health ID Use Only Demographics / No Clinical Data Use common set of patient demographics –Name/DOB/Gender/Zip/SSN/etc Pluggable Matching Algorithm Optimized To Minimize False Positives

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15. 15 Patient Match Incoming PID Fields Matched Against DB Algorithm Tuned to Local Conditions False Positives Tuned to < 1 in 100,000

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17. 17 Underlying Technologies TCP/IP SOAP Web Services HL7/NCPDP messaging standards LOINC codes NDC codes

18. 18 Security / Confidentiality Server-to-server (ISB-to-ISB) authentication via X.509 certificates Communication protected by SSL/TLS Federated identity based on single token authentication in edge systems Role based/level based access control

19. 19 What did we learn from the prototype work?

20. 20 Authentication

21. 21 Patient demographic entry

22. 22 Query options

23. 23 Viewer results display

24. 24 Viewer results display -- more

25. 25 IHIEMA-SHAREMendocino HRE Market Mixed urban and rural; dominant academic anchor (IU) Urban mix of academic, community and commercial influences Rural and underserved community medicine and health centers RHIO-related history 35+ years25+ years7 years Technology partner Regenstrief (academic not-for-profit) CSC (large commercial) Browsersoft (small commercial) Development preference J2EEMicrosoft.NETMixed Open Source Overall architecture Central data repository with standardized data Federated, with shared Record Locator Service Brokered through mirrored data at central HRE Standards Significant investment in HL7 2.x Implementing HL7 3.0; investigating XDS “Bi-lingual” (HL7 2.x and 3.0) Prototype SNOs reflect the realities of existing market and health IT variation

26. 26 Prototype Approaches Indiana Developed Disburser / Aggregator for ISB Adapted existing MPI for RLS Source systems send data to hosted HL7 Update Services for transformation and hosting in standard form Community- level registries HL7 Update Services MPI / RLS Service Clinical Data Auth / Access Control Service (AACS) Record Exchange Service (RES) Registries, Audit, etc. Mirrored Clinical Data Mendocino Developed RLS and ISB Source systems send data to HRE for hosting in native form with on demand transformation = New “NHIN” functionality IHIE / INPC (at Regenstrief) g g Supported by Browsersoft, Inc. (OpenHRE) RLS InterSNO Bridge Hosted by CSC CDX Gateway (serving as InterSNO Bridge) RLS INPC Disburser / Aggregator (serving as InterSNO Bridge) IN Cancer Registry St. FrancisSt. VincentWishard IU Medical Group Community Hospitals Clarian Indiana Medicaid Indiana DPH Beth Israel Deaconess Boston Medical Ctr. AEGIS (public health) Massachusetts Adapted its CDX Gateway as front-end to the RLS and ISB Distributed CDX Gateways fetch source data on demand from participant sites UVPMCG Ukiah Valley Medical Ctr. Consolidated Tribal Health

27. 27 What Common Framework technical resources are available?

28. 28 Types of Technical Resources Background Information On the Technical Architecture and Design Overall (T1) On Data Quality (T5) On the RLS (from the MA prototype site) (T6) Implementation Guides NHIN Message Implementation Guide including Record Locator Service/Inter-SNO Bridge (T2) Standards Guides –Medication History: Adapted NCPDP SCRIPT (T3) –Laboratory Results: ELINCS 2.0, with modifications (T4) Example Code/Interfaces Test Interfaces: CA, IN, MA www.connectingforhealth.org (under T2)www.connectingforhealth.org Code base: CA, IN, MA www.connectingforhealth.org (under T2)www.connectingforhealth.org

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