Technical Overview of the Common Framework HIT Symposium at MIT

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

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

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. 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. 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. RLS SNO (Secure Reliable Internet) Care Delivery Organization 1 Care Delivery Organization 2 Public Health Organization Payer or Other Organization 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

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

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. 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. 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. 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

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

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

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. What did we learn from the prototype work?

20. Authentication

21. Patient demographic entry

22. Query options

23. Viewer results display

24. Viewer results display -- more

25. Prototype SNOs reflect the realities of existing market and health IT variation

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

27. What Common Framework technical resources are available?

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) • Code base: CA, IN, MA www.connectingforhealth.org (under T2)