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Integrating the Healthcare Enterprise. IHE IT Infrastructure Established Integration Profiles. Charles Parisot, GE Healthcare IHE IT Infrastructure co-chair. www.IHE-europe.org W W W . I H E . N E T. Providers and Vendors Coming Together to Deliver Interoperable Health Information Systems

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Integrating the Healthcare Enterprise


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    1. Integrating the Healthcare Enterprise IHE IT Infrastructure Established Integration Profiles • Charles Parisot, GE Healthcare • IHE IT Infrastructure co-chair IHE EU-Conference & Workshop

    2. www.IHE-europe.org W W W . I H E . N E T Providers and Vendors Coming Together to Deliver Interoperable Health Information Systems Within and Between Enterprises and Settings IHE EU-Conference & Workshop

    3. IHE IT Infrastructure 2003-2004 IHE IT Infrastructure 2003-2004 IHE IT Infrastructure 2004-2005 Personnel White Page New Access to workforcecontact information New Retrieve Information for Display Retrieve Information for Display Retrieve Information for Display Cross-Enterprise Document Sharing 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 Access a patient’s clinical information and documents in a format ready to be presentedto the requesting user Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Patient Demographics Query New Audit Trail & Node Authentication Patient Synchronized Applications Patient Synchronized Applications New Centralized privacy audit trail and node to node authentication to create a secured domain. Synchronize multiple applications on a desktop to the same patient Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Enterprise User Authentication Enterprise User Authentication Consistent Time Consistent Time Provide users a single nameand centralized authentication processacross all systems Provide users a single nameand centralized authentication processacross all systems Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains Coordinate time across networked systems Coordinate time across networked systems IHE EU-Conference & Workshop

    4. Patient Demographics Query New Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains IHE IT Infrastructure 2004-2005Patient Identity IHE EU-Conference & Workshop

    5. Personnel White Page New Access to workforcecontact information Audit Trail & Node Authentication New Centralized privacy audit trail and node to node authentication to create a secured domain. Enterprise User Authentication Enterprise User Authentication Consistent Time Provide users a single nameand centralized authentication processacross all systems Coordinate time across networked systems IHE IT Infrastructure 2004-2005Security IHE EU-Conference & Workshop

    6. New Retrieve Information for Display Retrieve Information for Display Cross-Enterprise Document Sharing 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 Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record IHE IT Infrastructure 2004-2005Access to Patient Records IHE EU-Conference & Workshop

    7. Retrieve Information for Display Retrieve Information for Display 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 Enterprise User Authentication Enterprise User Authentication Consistent Time Provide users a single nameand centralized authentication processacross all systems Coordinate time across networked systems IHE IT InfrastructureEstablished Integration Profiles Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains IHE EU-Conference & Workshop

    8. Retrieve Information for Display Retrieve Information for Display 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 Patient Identifier Cross-referencing for MPI Enterprise User Authentication Enterprise User Authentication Consistent Time Provide users a single nameand centralized authentication processacross all systems Map patient identifiers across independent identification domains Coordinate time across networked systems IHE IT Infrastructure Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient IHE EU-Conference & Workshop

    9. Patient Identifier Cross-referencing for MPIAbstract / Scope • Allow all enterprise participants to register the identifiers they use for patients in their domain • Participants retain control over their own domain’s patient index(es) • Support domain systems’ queries for other systems’ identifiers for their patients • Optionally, notify domain systems when other systems update identifiers for their patients IHE EU-Conference & Workshop

    10. Patient Identifier Cross-referencing for MPIValue Proposition • Maintain all systems’ identifiers for a patient in a single location • Use any algorithms (encapsulated) to find matching patients across disparate identifier domains • Lower cost for synchronizing data across systems • No need to force identifier and format changes onto existing systems • Leverages standards and transactions already used within IHE IHE EU-Conference & Workshop

    11. Patient Identifier Cross-referencing for MPITransaction Diagram IHE EU-Conference & Workshop

    12. Patient Identifier Cross-referencing for MPIProcess Flow Showing ID Domains & Transactions IHE EU-Conference & Workshop

    13. Patient Identifier Cross-referencing for MPI B:X456C: ? B:X456C: 2RT Patient Identity Cross References IHE EU-Conference & Workshop

    14. Patient Identifier Cross-referencing for MPIStandards Used HL7 Version 2.5 • ADT Registration and Update Trigger Events • A01: inpatient admission • A04: outpatient registration • A05: pre-admission • A08: patient update • A40: merge patient • Queries for Corresponding Identifiers (ADT^Q23/K23) • Notification of Identifiers Lists Updates (ADT^A31) IHE EU-Conference & Workshop

    15. PIX Integration Profile & MPIThe typical view Master Patient Index Patient Identity Cross-reference Manager Master (A) PatientIdentity Source Patient Identification Domain A (Master Domain) Patient Identification Domain B Patient Identification Domain C IHE EU-Conference & Workshop

    16. PIX Integration Profile & MPIThe Equivalent IHE Model Master Patient Index Patient Identity Cross-reference Manager Patient Identification Domain A (Master Domain) Master (A) PatientIdentity Source Patient Identification Domain B Patient Identification Domain C IHE EU-Conference & Workshop

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

    18. Retrieve Information for DisplayAbstract / Scope • Simple and rapid access to patient information • Access to existing persistent documents in well-known presentation formats: CDA, PDF, JPEG. • Access to specific key patient-centric information for presentation to a clinician : allergies, current medications, summary of reports, etc.. • Links with other IHE profiles - Enterprise User Authentication, Patient Identifier Cross-referencing and Cross Enterprise Document Sharing IHE EU-Conference & Workshop

    19. Retrieve Information for DisplayValue Proposition • User Convenience: • Healthcare providers can "see" the information. A significant integration step. • Workflows from within the users’ on-screen workspace or application. • Complements multiple simultaneous apps workflow of Patient Synchronized Apps • Broad Enterprise-Wide access to information: • Web technology for simple clients • Clinical data handling fully assumed by the information source that holds clinical data. IHE EU-Conference & Workshop

    20. Retrieve Information for DisplayKey Technical Properties • Standards Used: • Web Services (WSDL for HTTP Get). • General purpose IT Presentation Formats: XHTML, PDF, JPEG, CDA L1 (HL7) • Client may be off-the-shelf browser or display application. • Two services : • Retrieve of Specific Information: • Patient centric: patient ID • Type of Request (see next slide) • Date, Time, nMostRecent • Retrieve a Document • Object Unique Instance Identifier (OID) • Type of Request • Content Type Expected IHE EU-Conference & Workshop

    21. Retrieve Information for Display Retrieve Specific Info for Display [11] Summary of All Reports Retrieve Document for Display [12] Summary of Laboratory Reports Summary of Radiology Reports Summary of Cardiology Reports Summary of Surgery Reports Summary of Intensive Care Reports Summary of Emergency Reports Summary of Discharge Reports List of Allergies List of Medications Persistent Document Transaction Diagram Display Information Source Types ofRequests IHE EU-Conference & Workshop

    22. Parameter Name REQ Description RequestType R requestType specifies what type of information shall be retrieved. This parameter shall always be valued. patientID R This attribute identifies the subject of the results being queried for. Its value shall include identification of assigning authority. lowerDateTime O Used to constrain the earliest date/time of creation of information. upperDateTime O Used to constrain the latest date/time of creation of information. MostRecentResults R The numeric value that indicates the number of most recent results to be included into the response, i.e., 1 indicates to provide the latest result. Query Keys – Transaction [11]Retrieve Specific Information for Display IHE EU-Conference & Workshop

    23. Parameter Name REQ Description RequestType R This parameter is required to have a value of “DOCUMENT”. DocumentUID R PreferredContentType R Identifies document’s UID as known to both actors. This parameter is required to identify the preferred format: JPEG. PDF, CDA L1 that the document is to be provided (as MIME content type). Query Keys – Transaction [12]Retrieve Document for Display IHE EU-Conference & Workshop

    24. IHE IT Infrastructure 2004-2005 Retrieve Information for Display Retrieve Information for Display 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 Enterprise User Authentication Enterprise User Authentication Consistent Time Provide users a single nameand centralized authentication processacross all systems Coordinate time across networked systems Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains IHE EU-Conference & Workshop

    25. Patient Synchronized Applications Abstract / Scope • Patient Synchronization of Multiple Disparate Applications • Single Patient Selection • When combined with PIX Profile, allows patient synchronization across patient identifier domains • When combined with EUA Profile, provides user Single Sign-on (SSO) IHE EU-Conference & Workshop

    26. Patient Synchronized Applications Value Proposition • User Convenience: • Eliminates the repetitive task of selecting the patient in each application • Permits the user to select the patient in the application for which they are most familiar and / or appropriate to the clinical workflow • Patient Safety: • Ensures all data being viewed across applications is for the same patient • Leverage Single Development Effort: • Allows vendors to leverage single CCOW enablement effort to support multiple actors: • Patient Context Participant (PSA) • User Context Participant (EUA) IHE EU-Conference & Workshop

    27. Patient Synchronized ApplicationsActors Context Manager Actor • The IHE Context Manager Actor may encompass more than a CCOW context manager function. It may include a number of other components such as the context management registry and patient mapping agent. Patient Context Participant Actor • The Patient Context Participant Actor shall respond to all patient context changes. This actor shall set the patient context provided the application has patient selection capability. IHE EU-Conference & Workshop

    28. Patient Synchronized Applications Transactions Diagram These transactions are required for both Actors for compliance IHE EU-Conference & Workshop

    29. Patient Synchronized Applications Key Technical Properties • Standards Used: • HL7 Context Management “CCOW” Standard, Version 1.4 • Support for both Windows and Web Technology • Support of “Patient Subject” • IHE Constraints: • Specifies use of Patient.Id.IdList item • Ensures maximum interoperability with PIX Profile • Protects against future deprecation of patient identifier items (HL7 2.3.1, 2.4, 2.5, CCOW). IHE EU-Conference & Workshop

    30. IHE IT Infrastructure 2004-2005 Retrieve Information for Display Retrieve Information for Display 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 Enterprise User Authentication Provide users a single nameand centralized authentication processacross all systems Consistent Time Coordinate time across networked systems Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains IHE EU-Conference & Workshop

    31. Enterprise User AuthenticationScope • Support a single enterprise governed by a single set of security policies and having a common network domain. • Establish one name per user to be used for all IT applications and devices. • Facilitate centralized user authentication management. • Provide users with single sign-on. IHE EU-Conference & Workshop

    32. Enterprise User AuthenticationValue Proposition • Meet a basic security requirement • User authentication is necessary for most applications and data access operations. • Achieve cost savings/containment • Centralize user authentication management • Simplify multi-vendor implementations • Provide workflow improvement for users • Increase user acceptance through simplicity • Decrease user task-switching time. • More effective security protection • Consistency and simplicity yields greater assurance. IHE EU-Conference & Workshop

    33. Consistent TimeScope and Value Proposition • Meet a basic security requirement • System clocks and time stamps of the many computers in a network must be synchronized. • Lack of consistent time creates a “security hole” for attackers. • Synchronization ±1 second is generally sufficient. • Achieve cost savings/containment • Use the Network Time Protocol (NTP) standard defined in RFC 1305. • Leverage exisisting Internet NTP services, a set-up option for mainstream operating systems. IHE EU-Conference & Workshop

    34. EUA and CTKey Technical Properties • Standards Used • Kerberos v5 (RFC 1510) • Stable since 1993, • Widely implemented on current operating system platforms • Successfully withstood attacks in its 10-year history • Fully interoperable among all platforms • HL7 CCOW, user subject • Network Time Protocol (RFC 1305) • Minimal Application Changes • Eliminate application-specific, non-interoperable authentication • Replace less secure proprietary security techniques • Leverage NTP interfaces built-into operating systems IHE EU-Conference & Workshop

    35. Enterprise User AuthenticationKey Attributes • Limited network overhead • Kerberos is network-efficient, developed at a time when high-speed networks were rare. • CCOW is similarly network-efficient • Kerberos and CCOW work with any user authentication technology • Tokens, biometric technologies, smart cards, … • Specific implementations require some proprietary components, e.g., biometric devices. • Once user authentication is complete, network transactions are the same for all technologies. IHE EU-Conference & Workshop

    36. Enterprise User AuthenticationTransaction Diagram with CCOW Option IHE EU-Conference & Workshop

    37. Consistent TimeTransaction Diagram Time Server Maintain Time [ITI-1]↑ Time Client IHE EU-Conference & Workshop

    38. IHE IT Infrastructure Retrieve Information for Display Retrieve Information for Display 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 Enterprise User Authentication Enterprise User Authentication Consistent Time Provide users a single nameand centralized authentication processacross all systems Coordinate time across networked systems Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains IHE EU-Conference & Workshop

    39. Synergy between IHE IT Int. ProfilesRID with EUA/CT & PIX Example of support ofmultiple actors/profiles Patient Identity X-ref Manager Display Information Source Client AuthenticationAgent Patient Identity Consumer Time Client KerberosAuthenticationServer TimeServer IHE EU-Conference & Workshop 40

    40. Synergy between IHE IT Int. ProfilesApps with PSA, EUA & PIX Example of support ofmultiple actors/profiles Patient Identity X-ref Manager Application B Context participant Patient Identity Consumer Application A Context participant Context Manager Client AuthenticationAgent Time Client KerberosAuthenticationServer TimeServer IHE EU-Conference & Workshop 41

    41. www.IHE-europe.org W W W . I H E . N E T Integrating the Healthcare Enterprise A Pause for Questions ? IHE EU-Conference & Workshop

    42. IHE IT Infrastructure 2003-2004 IHE IT Infrastructure 2003-2004 IHE IT Infrastructure 2004-2005 Personnel White Page New Access to workforcecontact information New Retrieve Information for Display Retrieve Information for Display Retrieve Information for Display Cross-Enterprise Document Sharing 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 Access a patient’s clinical information and documents in a format ready to be presentedto the requesting user Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Patient Demographics Query New Audit Trail & Node Authentication Patient Synchronized Applications Patient Synchronized Applications New Centralized privacy audit trail and node to node authentication to create a secured domain. Synchronize multiple applications on a desktop to the same patient Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Patient Identifier Cross-referencing for MPI Enterprise User Authentication Enterprise User Authentication Consistent Time Consistent Time Provide users a single nameand centralized authentication processacross all systems Provide users a single nameand centralized authentication processacross all systems Map patient identifiers across independent identification domains Map patient identifiers across independent identification domains Coordinate time across networked systems Coordinate time across networked systems IHE EU-Conference & Workshop

    43. IHE IT Infrastructure 2004-2005 Personnel White Page New Access to workforcecontact information New Retrieve Information for Display Retrieve Information for Display Cross-Enterprise Document Sharing 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 Patient Demographics Query New Audit Trail & Node Authentication Registration, distribution and access across health enterprises of clinical documents forming a distributed patient electronic health record New Centralized privacy audit trail and node to node authentication to create a secured domain. Enterprise User Authentication Enterprise User Authentication Consistent Time Provide users a single nameand centralized authentication processacross all systems Coordinate time across networked systems Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains IHE EU-Conference & Workshop

    44. Introduction: EHR Cross-Enterprise Document Sharing First step towards the longitudinal dimension of the EHR Focus: Support document sharing between EHRs in different care settings and organizations IHE EU-Conference & Workshop

    45. Typically, a patient goes through a sequence of encounters in different Care Settings Long Term Care Acute Care (Inpatient) Other Specialized Care(incl. Diagnostics Services) GPs and Clinics (Ambulatory) Continuity of Care: Patient Longitudinal Record IHE EU-Conference & Workshop

    46. community Hospital Record Laboratory Results Specialist Record Records Sent Clinical Encounter Finding the records of a patient-Manual & tedious The challenge: Finding and accessing easily documents from other care providers In the community. Clinical IT System IHE EU-Conference & Workshop

    47. Sharing records that have been published community Hospital Record Laboratory Results Reference to records Specialist Record 4-Patient data presented to Physician Temporary Aggregate Patient History Index of patients records (Document-level) 3-Records Returned Clinical IT System Sharing System 2-Reference to Records for Inquiry 1-Patient Authorized Inquiry Clinical Encounter IHE EU-Conference & Workshop

    48. Building and accessing Documents DocumentRepository Submission of Document References Retrieve of selected Documents Documents Registry EHR-LR:Longitudinal Recordas usedacross-encounters Long Term Care Acute Care (Inpatient) Other Specialized Careor Diagnostics Services PCPs and Clinics (Ambulatory) EHR-CR: Care Record systemssupporting care delivery IHE EU-Conference & Workshop

    49. XDS – Value Proposition • Foundation for Health IT Infrastructures: Shared Electronic Health Record, in a community, region, etc. • Effective means to contribute and access clinical documents across health enterprises. • Scalable sharing of documents between private physicians, clinics, long term care, pharmacy, acute care with different clinical IT systems. • Easy access: Care providers are offered means to query and retrieve clinical documents of interest. IHE EU-Conference & Workshop

    50. XDS - Value Proposition • Distributed: Each Care delivery organization “publishes” clinical information for others. Actual documents may remain in the source EHR-CR. • Cross-Enterprise: A Registry provides an index for published information to authorized care delivery organizations belonging to the same clinical affinity domain (e.g. an LHII). • Document Centric: Published clinical data is organized into “clinical documents”. using agreed standard document types (HL7-CDA, ASTM-CCR, PDF, DICOM, etc.) • Document Content Neutral: Document content is processed only by source and consumer IT systems. • Standardized Registry Attributes:Queries based on meaningful attributes ensure deterministic document searches. IHE EU-Conference & Workshop