Patient Care Coordination

1. Patient Care Coordination IHE Workshop 2006 IHE Patient Care Coordination Education Keith W Boone, John Donnelly, Larry McKnight MD, Dan Russler MD

2. Primary Membership • Physician Associations & Colleges • ACP, AAP, AAFP, FACEP • EMR & Other Department System Vendors • Ambulatory, Inpatient, Emergency Dept • PHR Vendors • PC-based systems, Portal solutions • Other Stakeholders in HIT • Clinical research initiatives, Public health agencies

3. Profile Roadmap • Year 2005-2006 (Trial Implementation) • Medical Summary [MS] – Acute Care Discharge to PCP, PCP Referral to Specialist • Unstructured Document – CDA-wrapped PDF • Year 2006-2007 (Development & Testing) • Medical Summary [MS] – ED Referral [EDR] • Pre-procedure H&P [PPHP] • Basic Patient Privacy Consents [BPPC] • Exchange Personal Health Record [XPHR] • Coordination with Laboratory Domain [XDS-LAB] • Future (Profile Document / White Paper) • Medical Summary [MS] – Discharge to LTC • Forms Display for Data Capture (e.g. clinical research)

4. Domain Visibility & Support • HIMSS Annual Conference • 2006 HIMSS ‘RHIO’ Showcase – 30+ vendors exchanged XDS-MS, XDS-pdf documents • Informational Presentations from Providers & HIT Vendors • ACC Annual Conference • 2006 ACC Interoperability Showcase – ?? vendors exchanged XDS-pdf documents • Informational Presentations from HIT Vendors • Physician Association Annual Meetings • Informational Presentations Planned • Real-world RHIO Participation • NHIIN “Pilot” RHIO’s • Independent Community-sponsored RHIO’s

5. Medical Summary Profiles IHE Vendors Workshop 2006 IHE Patient Care Coordination Education Larry McKnight MD [co-chair PCC Planning Committee]

6. Abstract • Define a medical summary format for clinical documents containing at a minimum: Problems Allergies Medications Pointers to other material Medical Summaries

7. Value Proposition • Leverage Clinical Documents ontology • A common mechanism for transfer of encoded clinical data embedded in documents • Basis for ongoing harmonization of CCR/CCD • Enhances Clinical Documents criteria for key use cases: • Inpatient to Primary Care Provider • Primary Care Provider to Specialist • To be enhanced in future years to support: • Home Care • Long Term Care Medical Summaries

8. Key Technical Properties • Document Transfer (Integration Profile) • XDS/XDP for document sharing. • NAV for notification. • XDS Folders to support organization. • XDS Submission Sets to support packaging. • Identification of “Master” document or Manifest • Document Content (Content Profile) • CDA Release 2.0 • Care Record Summaries Implementation Guide Medical Summaries

9. Content Integration Profiles IHE Vendors Workshop 2006 IHE Patient Care Coordination Education Keith W. Boone, GE Healthcare [co-chair PCC Technical Committee]

10. Technical Framework • Reuse of ITI Profiles • ITI Cross Enterprise Document Sharing (XDS) • ITI Cross Enterprise Point-to-Point Sharing (XDP) • New Actors / Transactions • None Yet, but… • Content Integration Profiles • XDS Medical Summaries • Bindings • Binds Content to IHE Transactions • Medical Document to XDS • Medical Document to XDP • Declared in Integration Statements • Options • Some options defined for XDS, XDP

11. Content Integration Profiles • Content using a Specific Standard • CDA Release 2.0 • HL7 Care Record Summary • ASTM/HL7 Continuity of Care Document • Others as Needed (e.g., ASTM CCR, DICOM …) • Library of Reusable Parts • Document Types • Sections • Entries

12. Content Integration Profiles 2005-2006 XDS-MS 2006-2007 MedicalDocuments PPHP BCCP MedicalSummaries History andPhysical Consent EDR XPHR Referral DischargeSummary EmergencyDepartmentReferral PHR Extract PreprocedureHistory andPhysical XDS-LAB PHR Update Lab Report

13. Emergency Department Referral IHE Vendors Workshop 2006 Todd Rothenhaus, MD FACEP American College of Emergency Physicians

14. XDS-MS MedicalDocuments EDR EmergencyDepartmentReferral PPHP BCCP MedicalSummaries History andPhysical Consent EDR XPHR Referral DischargeSummary EmergencyDepartmentReferral PHR Extract PreprocedureHistory andPhysical XDS-LAB PHR Update Lab Report Emergency DepartmentReferral

15. Use Case • Health care provider determines that a patient needs to go to the ED • Provider creates an ED referral package using his or her EHR • Upon arrival, the ED provider identifies the patient as a referral • The posted referral package is imported into the Emergency Department Information System (EDIS) Provide access to critical health information in ED information systems in a standard manner\ ED Referral

16. Value Proposition • Nearly 5000 EDs in US • Significant percentage of ED visits are referrals • Shortage of critical health data for emergency department patients • Need to improve communication of intended patient care plans to ED providers and ensure that no pertinent data is lost • Streamline workflow by obviating telephone calls between busy clinicians ED Referral

17. Scope • EHR system capable of creating a care record summary would be capable of creating a referral package for a receiving system • The emergency department information systems (EDIS) will need to retrieve and read and display this data. ED Referral

18. Basic Patient Privacy Consents (BPPC) IHE Vendors Workshop 2006 IHE Patient Care Coordination Education Lori Fourquet, e-Healthsign

19. XDS-MS MedicalDocuments PPHP BCCP MedicalSummaries History andPhysical Consent EDR XPHR Referral DischargeSummary EmergencyDepartmentReferral PHR Extract PreprocedureHistory andPhysical XDS-LAB PHR Update Lab Report BCCP Consent Basic Patient Privacy Consents

20. Abstract • The Basic Patient Privacy Consents (BPPC) profile provide mechanisms to: • Record the patient privacy consent(s), • Mark documents published to XDS with the patient privacy consent that was used to authorize the publication, • Enforce the privacy consent appropriate to the use. Basic Patient Privacy Consents

21. Scope • Document Sources and Document Consumers in an XDS Affinity Domain • Document Sources and Document Receivers using Cross Enterprise Point-to-Point Document Sharing Basic Patient Privacy Consents

22. Value Proposition • An Affinity Domain can • develop privacy policies, • and implement them with role-based or other access control mechanisms supported by EHR systems. • A patient can • Be made aware of an institutions privacy policies. • Have an opportunity to selectively control access to their healthcare information. Basic Patient Privacy Consents

23. Key Technical Properties • Human Readable Consents • Machine Processable • Support for standards-based Role-Based Access Control Basic Patient Privacy Consents

24. Standards and Profiles Used • CDA Release 2.0 • XDS Scanned Documents • Document Digital Signature • Cross Enterprise Document Sharing • Cross Enterprise Point-to-Point Document Sharing Basic Patient Privacy Consents

25. Pre-procedure History and Physical (PPHP) IHE Development Team Workshop 2006 IHE Patient Care Coordination Education Dan Russler, MD, Mckesson [co-chair PCC Technical Committee]

26. XDS-MS MedicalDocuments PPHP PPHP BCCP MedicalSummaries History andPhysical History andPhysical Consent EDR XPHR EmergencyDepartmentReferral Referral DischargeSummary PHR Extract PreprocedureHistory andPhysical PreprocedureHistory andPhysical XDS-LAB PHR Update Lab Report Pre-procedure History and Physical

27. Use Case • H&P documentation required prior to procedure that is designed to assess: • Procedure Risk • Anesthesia Risk • Factors influencing procedure after-care decisions • Desired outcomes • Minimize injury during procedure • Optimize procedure after-care Pre-procedure H&P

28. Scope • To identify the required and optional PPHP document content templates including: • CDA Document Header • CDA Document Type(s) • CDA Section Types • CDA Entry Types Pre-procedure H&P

29. Value Proposition • A procedure risk assessment must be present and evaluated by the operative and after-care teams before the patient is allowed to have the procedure. Missing information is frequently a reason for canceling the procedure for the day, which leads to expensive underutilization of resources and dissatisfied patients. Further, incomplete information about the patient’s clinical or home status may create a situation where a procedure is performed that ultimately results in an injury, inadequate aftercare or other undesirable outcome. Pre-procedure H&P

30. Key Technical Properties • PPHP Profile inherits specifications required for other IHE PCC Medical Documents • PPHP Profile follows documentation practices for all IHE PCC Medical Documents • PPHP Profile emphasizes re-usability of CDA template identifiers in order to reduce un-necessary variability in IHE Content Profiles Pre-procedure H&P

31. Standards Used • IHE Medical Document Content Profiles • HL7 Reference Information Model ANSI Standard • HL7 CDA R2 ANSI Standard • HL7 Care Provision Domain DSTU (in process) • Implementation Guides • HL7 Care Record Summary CDA R2 Implementation Guide (in process) • HL7/ASTM Continuity of Care Document Implementation Guide (in process)

32. Exchange of PHR Content(XPHR) IHE Vendors Workshop 2006 IHE Patient Care Coordination Education Keith W. Boone, GE Healthcare [co-chair PCC Technical Committee]

33. XDS-MS MedicalDocuments PPHP BCCP MedicalSummaries History andPhysical Consent XPHR Referral DischargeSummary PHR Extract PreprocedureHistory andPhysical EDR EmergencyDepartmentReferral XDS-LAB PHR Update Lab Report XPHR PHR Extract PHR Update Exchange of PHR Content

34. Abstract • The Exchange of Personal Health Record Content (XPHR) provides a standards-based specification for managing the interchange of documents between a Personal Health Record and an EHR System to enable better interoperability between these systems. Exchange of PHR Content

35. Scope • Personal Health Record (PHR) Systems • Electronic Health Record (EHR) Systems Exchange of PHR Content

36. Value Proposition • Supports interchange of PHR Information • Demographics • Insurance Information • Medications, Problems, Allergies • Health History • Other Information Exchange of PHR Content

37. Standards Used • CDA Release 2.0 • ASTM Continuity of Care (CCR) Data Set • ASTM/HL7 Continuity of Care Document (CCD) • HL7 Care Record Summary • AHIMA PHR Common Data Elements • XDS, XDP • Document Digital Signature Exchange of PHR Content

38. Key Technical Properties • Information is Human Readable • and Machine Processable • Support Static and Dynamic Information Sharing Domains (XDS and XDP) • Protects Information using Digital Signature • Update Model for EHR to PHR Changes Exchange of PHR Content

39. Sharing of Lab Reports IHE Vendors Workshop 2006 IHE Patient Care Coordination Education Francois Macary, Agfa [co-chair Lab Technical Committee]

40. XDS-MS MedicalDocuments PPHP BCCP MedicalSummaries History andPhysical Consent XPHR Referral DischargeSummary PHR Extract PreprocedureHistory andPhysical EDR EmergencyDepartmentReferral XDS-LAB PHR Update Lab Report XDS-LAB Lab Report XDS Laboratory Report

41. Scope • The clinical laboratory report is: • A report of a set of final results (the fulfillment process being completed) to be shared as “historical information”. • Human-readable, shared between care providers of various specialties and patients (e.g. through a PHR) • May contain machine readable coded entries (decision support, bio-surveillance) • All clinical laboratory specialties in scope, except: • Blood banks (blood products out of scope, but blood tests in scope) • Pathology (has its dedicated domain in IHE) Sharing of Lab Reports

42. Value Proposition • Use case 1: Hospital lab report  RHIO  EHRsAt discharge time, a hospital physician selects the most significant laboratory reports produced during patient stay, and issues these reports individually to a health information exchange (e.g. XDS Affinity Domain) shared by a number of healthcare enterprises and primary care providers. • Use case 2: Ambulatory lab report  RHIO  PHRA private laboratory having signed a final report for a patient, sends this report in an electronic format to the patient record in the national EHR. • Use case 3: Lab report  PHRA physician reviews the results received from a reference laboratory for his patient. The doctor, as requested by the patient, sends this laboratory report in the patient’s personal health record in an electronic format. • Use case 4: Lab report automatically shared  RHIOA community or hospital laboratory, systematically (with some degree of automatism) shares its final reports with a regional healthcare network. • Use case 5: Hospital’s EHR Lab report  RHIOAt discharge time of an inpatient, a hospital physician selects the most significant lab results, produced by one or more laboratories of the healthcare enterprise during patient stay, and builds a cumulative report sent to an health info exchange shared by a number of healthcare enterprises and primary care providers. Sharing of Lab Reports

43. Standards Used • CDA Release 2.0 • ASTM/HL7 Continuity of Care Document (CCD) • HL7 V3 Laboratory DMIM • HL7 Care Record Summary • LOINC & SNOMED • HIPAA Lab Claim Attachment NPRM • IHE XDS (registry/repository) & XDP (pt-pt) • Document Digital Signature Sharing of Lab Reports

44. Key Technical Properties • Information is Human Readable (two levels of sections) and machine processable • Full alignments with HL7 V3 lab messages • Supports custom report organizations and results rendering regulations (e.g. CLIA in the USA). • Complements the real-time result return to ordering provider (e.g. ELINCS). • Used both in sharing (XDS) & pt-pt interchange (XDP) • May protect Information using Digital Signature Sharing of Lab Reports

45. PCC Wrap-up IHE Workshop 2006 IHE Patient Care Coordination Education John Donnelly, IntePro Solutions [co-chair PCC Planning Committee]

46. PCC RoadMap • Care Transfers • Medical Summary 2005 • EDR, PPHP 2006 • Labs 2006-7 • Growth Charts • Consumer Empowerment • PHR 2006 • Consents 2006 • Provider Ordering • Ambulatory Ordering 2006 • Medication Lists 2007 • Clinical Data Reuse • Clinical Trials (RFD) 2006-7 • Biosurveillance 2007-8

47. How to Get Involved? As a Provider or Vendor Contributor • Offer Clinical Use Case Input to Drive IHE Profile Development • Become a member of relevant domain’s Planning or Technical Committees • Become a member of relevant Regional/National Committees • Help to shape IHE’s future direction As a Vendor Participant • Respond to Public Comments of Domain Supplements • Attend the June Educational Workshop • Participate in Connect-a-thons and Demonstrations As a Provider/Consultant Participant • Respond to Public Comments of Domain Supplements • Attend the June Educational Workshop • Attend Demonstrations and include IHE Integration Profiles in your RFPs and Integration Projects.

48. Special Call for Participation • Reach out to Physicians as Liaisons • Expand presence at annual physician society and association meetings (e.g. ACP, ACEP, ASP, etc) • Help with Use Case component of PCC profiles • Assistance with ASTM/CCR – HL7 CDA/CCD Transforms • Focal point of harmonization effort between medical summary initiatives of two SDO’s • Facilitate widespread interoperability between product offerings in EHR and PHR segments

49. IHE Patient Care Coordination – Plan for 2006 • Development Schedule: • Planning Committee decision: mid-March • Issue Public Comment version: June 2006 • Public Comment Due: July 2006 • Issue Trial Implementation version: August 2006 • IHE Connectathon: January 2007 • HIMSS Demo: February 2007 • Final text: April 2007 • New Profiles For 2006 – Public Comment June 19, 2006 • Medical Summary (MS) – ED Referral [EDR] • Pre-procedure H&P [PPHP] • Basic Patient Privacy Consents [BPPC] • Exchange Personal Health Record [XPHR]

50. IHE Web Site - http://www.ihe.net Technical Frameworks Technical Framework Supplements – Trial Implementation Calls for Participation IHE Fact Sheet and FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connectathon Results Vendors’ Product Integration Statements Sponsors’ IHE sites http://www.himss.org/IHE http://www.rsna.org/IHE http://www.acc.org/quality/ihe.htm More Information Questions?