Integrating the Healthcare Enterprise IHE Technical Committee Status

1. Integrating the Healthcare Enterprise IHE Technical Committee Status IHE ITI Plan Committee - February 2004

2. Retrieve Information for Display Retrieve Information for Display Enterprise User Authentication Enterprise User Authentication Patient Synchronized Applications Patient Synchronized Applications Access a patient’s clinical information and documents in a format ready to be presentedto the requesting user Access a patient’s clinical information and documents in a format ready to be presentedto the requesting user Synchronize multiple applications on a desktop to the same patient Synchronize multiple applications on a desktop to the same patient Provide users a single nameandcentralized authentication processacross all systems Provide users a single nameandcentralized authentication processacross all systems Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Consistent Time Consistent Time Coordinate time across networked systems Coordinate time across networked systems Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains IHE IT Infrastructure-20045 Integration Profiles

3. IHE IT Infrastructure – Plan for 2004-2005 • IT Infrastructure Development Plan: • IHE ITI Planning Committee decision: mid-February • Issue Public Comment version: June 2004 • Public Comment Due: July 2004 • Issue Trial Implementation version: August 2004 • IHE Connectathon: January 2005 • HIMSS Demo: February 2005 • Profiles discussed this week are: • Audit Trail and Node Authentication • Personnel White Page Directory • Patient Demographics Query • EHR-Cross-Enterprise Clinical Document Sharing

4. IHE Authentication Audit Trail • Scope • Ensures that only permitted system/devices connect to network • Authentication is node-to-node • Note: User authentication covered by the EUA profile or local procedures. • Support for a central repository of audit information. Facilitates audit review and includes: • General security events such as logins, file access, and detection of unauthorized activity • Healthcare privacy events such as access to patient data and applications. • Imaging privacy/security events such as access to patient images.

5. IHE Authentication and Audit • Key technical properties • Node-to-node authentication uses X.509 certificates, but PKI is not specified by IHE yet. • Audit messages use a standardized XML format (IETF RFC Pending) • Transport for audit messages may use syslog or reliable syslog • Backwards compatibility with IHE Radiology (year 2002) is preserved.

6. Personnel White Pages DirectoryScope Lab Reporting WhitePages Server Healthcare Staff Info Healthcare Staff Info Electronic MedicalRecords Healthcare Staff Info Pharma Provide access to healthcare staff information to systems in a standard manner.

7. Personnel White Pages DirectoryTechnical Properties • LDAP based directory location service • LDAP based requests of person info leveraging inetOrgPerson. • Specializes for Healthcare: Contact Info (Phone Numbers, email address, etc), and user interface friendly info (Salutation, First name, Last name, office building, user certificate list-no PKI). • Access certificate revocation list (no use rule defined).

8. Patient Demographics QueryAbstract/Scope • Allow quick retrieval of common patient name, identifier, and location in a standard manner at the point of care. • Enable selection of correct patient when full identification data may not be available • Protect patient- and enterprise-sensitive clinical information

9. Patient Demographics QueryKey Technical Properties • Employs HL7 Conformance Based Queries • Defined in HL7 Version 2.5, Chapter 5 • Query by Parameter (QBP) with Segment Pattern Response (RSP) • User enters identifiers for patients of interest • Server returns information in HL7 V2.5 patient data segments.

10. Introduction: EHR Cross-EnterpriseClinical Document Sharing First step towards the longitudinal dimension of the EHR: Focus: Clinical Information Exchange between EHRs in care settings to communicate with a distributed longitudinal EHR. Goal: Meet a broad range of EHR-LR (Longitudinal Record) needs with a distributed, cross-enterprise, document centric document content generic

11. Continuity of Care: Patient Longitudinal Record Nursing Homes Acute Care (Inpatient) Other Specialized Care(incl. Diagnostics Services) GPs and Clinics (Outpatient) Typically, a patient goes through a sequence of encounters in different Care Setting

12. EHR-LR Integration Profiles: Publishing & Accessing the EHR-LR EHR-LR Nursing Homes Acute Care (Inpatient) Other Specialized Careor Diagnostics Services GPs and Clinics (Outpatient) The EHR-LR (Longitudinal Record) brings together patient encounter information managed by multiple care delivery systems

13. EHR-LR EHR-LR EHR-LR Read Create Update Read Identification Decide to Assess demand For care End ofEncounter Define an action plan Selection of informations Actions to order EHR-CR Define healthcare Objective Two types of Integration : EHR-CR: Health Record as used during care delivery EHR-LR: Health Record as used across-encounters Care Delivery Process EHR-Solution = EHR-LR (Longitudinal Record)+ EHR-CR (Care Delivery Record)

14. Key Statements: EHR-LR Fundamentals • Brings together patient encounter information managed by all types of care delivery systems. • Cross-enterprise, possibly across large geographical regions, and may include many clinical domains. • Typically collected and retained over a large period of time, providing a deep historic record for the patient. • Supported by multiple repositories that contribute to the patient’s longitudinal healthcare record. • Encounter data will very likely include some clinical documents, state and workflow information that willnot be stored in the EHR-LR.

15. Key Statements: What is in the EHR-LR? • The EHR-LR data is made of discrete, persistent, clinical documents accessed by an unique identifier. • It may also contain other dynamic objects which are not being addressed by IHE at this time. • Metadata will be provided with each document by the EHR-CR and will be stored in the EHR-LR. • EHR-LR data formats will follow relevant clinical domain standards defined by field experts. EHR-CR is responsible for converting its internal data formats to the standard EHR-LR documents. • EHR-LR documents will kept in the EHR-CR or pushed to a separate EHR-LR repository.

16. Key Statements: IHE EHR Profiles Constraints • Although the EHR-LR data domains are primarily clinical, other information and services are needed to provide a complete view of the patient longitudinal record. These include patient demographics, access security, consent policies and others – some have already been addressed by IHE integration profiles. • The EHR-LR and EHR-CR repositories may be using different Patient Identification numbers. The longitudinal view is made possible by using standard cross-patient identification services (IHE PIX Integration Profile). • The way data is stored and managed internally by the EHR-CR is out of scope for the EHR-LR IHE Integration Profiles.

17. Key Statements:Accessing the EHR-LR • EHR-LR shall make available a list of all published documents for a given patient/selection parameters. • The selection of documents is the responsibility of the EHR-LR and not of the consumer applications. This is possible because of the document metadata kept in the EHR-LR. • The EHR-LR must ensure full content fidelity for all clinical documents that have been published. • The actual location of any particular document shall be transparent to the consumer application. • EHR-CR may provide clinical data by processing, extracting, or combining multiple documents.

18. Key Statements: Deploying IHE EHR-LR Profiles • The deployment of EHR-LR integration profiles will initially be focused on a small number of specialties (cardiology, oncology, etc), disease, and/or on key information for continuity of care (e.g. CCR summaries). • The scope of the EHR-LR profiles will expand progressively as other specialties are included in the use cases.

19. EHR-LR Integration Profile: Key Actors (Application Roles) • EHR-CR Source • Healthcare point of service system where clinical information is first collected • EHR-LR Directory • Index and metadata database for all published clinical documents • EHR-LR Documents Repository • Maintains and stores published EHR-LR documents • EHR-CR Consumer • Application system that needs access to EHR-LR documents and information

20. Integration Model 1: EHR-LR with Source Repository • An EHR-CR completes a phase of care for a patient where it: • Registers documents with an EHR-LR Directory actor. • Keeps these documents in an EHR-LR Repository actor. • Any other EHR-CR may query an EHR-LR Directory actor, find out about documents related to all phases of care for the patient and chose to retrieve some of these documents from any EHR-LR Repository Actor (Used in use Case 1 & 2). EHR-LRDirectory Register EHR-CR Source Query EHR-LR Consumer EHR-LR Repository Retrieve

21. Integration Model 2: EHR-LR with Third Party Repository • An EHR-CR completes a phase of care for a patient where it: • Registers documents with an EHR-LR Directory Actor. • Provides these documents to an EHR-LR Repository Actor. • Any other EHR-CR may query an EHR-LR Directory Actor, find out about documents related to all phases of care for the patient and chose to retrieve some of these documents from any EHR-LR Repository Actor (Used in use Case 1 & 2). Register Query EHR-LRDirectory EHR-CR Source EHR-LR Consumer Provide-Transfer EHR-LR Repository Retrieve

22. Integration Model 3: Direct Patient Transfer-Referral • An EHR-CR completes a phase of care for a patient where it: • Registers and Provides an EHR-CR Recipient Actor that a specific set of documents (newly created and priors of interest documents) are available from an EHR-LR Repository • The EHR-CR Recipient Actor receive both the registration and the documents. EHR-CR Consumer EHR-CR Source Register EHR-LRDirectory Provide-Transfer EHR-LR Repository

23. Conclusion: EHR Cross-Enterprise Document Sharing • Leverages HL7 CDA (Clinical Document Architecture) and ASTM CCR (Continuity of Care Record). • The proposed strategy addresses one of the key integration problems in the realization of the EHR vision. IHE does not claim to master and address the definition and all aspects of a complete and interoperable EHR System. • In collaboration with well established standards bodies and other EHR related initiatives world-wide (EHRCOM, CCR, HL7, etc.), IHE expects to contribute at a more cost-effective and rapid deployment.

24. IHE IT Infrastructure • To join IT Infrastructure planning or technical committee: • Contact Joyce Sensmeier, HIMSS. jsensmeier@himss.org • Suggest new profiles to IHE IT Infrastructure Planning • Produce new profiles in IHE IT Infrastructure Technical Committee