Report from the Technical Committees Arlington, VA | October 6, 2008 Presented by: Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS HITSP Technical Committee Co-Chairs enabling healthcare interoperability

AHIC Use Cases 2008 Provider Consumer Population Consultations and Transfers of Care Remote Monitoring Immunizations and Response Management Personalized Healthcare Patient – Provider Secure Messaging Public Health Case Reporting

Technical Committee Leadership Provider Perspective – 210 members Allen Hobbs, PhD, Kaiser Permanente Steve Hufnagel, PhD, DoD/Medical Health System (MHS) Mike Lincoln, MD, Department of Veterans Affairs Consumer Perspective – 191 members Mureen Allen, MD, FACP, ActiveHealth Management Charles Parisot, EHR Association Scott Robertson, PharmD, Kaiser Permanente

Technical Committee Leadership Population Perspective - 166 members Floyd Eisenberg, MD, MPH, Siemens Medical Solutions Peter Elkin, MD, Mayo Clinic College of Medicine Anna Orlova, PhD, Public Health Data Standards Consortium Administrative and Financial Domain – 48 members Don Bechtel, Siemens Medical Solutions Durwin Day, Health Care Service Corporation Deborah Belcher, GE Healthcare

Technical Committee Leadership Security, Privacy & Infrastructure Domain - 166 members Glen Marshall, Siemens Medical Solutions John Moehrke, GE Healthcare Walter Suarez, MD, Institute for HIPAA/HIT Education and Research Care Management and Health Records Domain - 47 members Keith Boone, GE Healthcare Corey Spears, McKesson Health Solutions Total Technical Committee Membership – 505 individuals

Trending in Technical Committee Membership

Trending for Technical Committee Meeting Attendance

Report from the Population Perspective Technical Committee

Report from the Consumer Perspective Technical Committee IS 12 Patient-Provider Secure Messaging (PPSM) IS 77 Remote Monitoring (RMON) IS 03 & 05 Consumer Access to Clinical Information (extensions) Advance Directives Access to Consumer-Friendly Clinical Information

Report from the Consumer Perspective Technical Committee IS 12: PPSM Completed and submitted to IRT for review Public Comment Period Target: IS submission to panel for December 2008

Report from the Consumer Perspective Technical Committee PPSM Architectural Variants The most generic variant selected as foundation. First two variants are supported as simplified implementations

Report from the Consumer Perspective Technical Committee C62 Unstructured Document Component (new) Support for a wide variety of content (PPSM and advance directives-SOW) Simple/unstructured text Scanned Documents PDFs New component References: IHE XDS-SD, PDF/A ISO 19005-1b Coordination between CPTC, SPI, Admin & Finance Minimal document header (compatible with other HITSP CDA docs) to support wide applicability Secured Messaging Advance Directives

Report from the Consumer Perspective Technical Committee IS 77: Remote Monitoring Completed and submitted to IRT for review Public Comment Period Note: Access to the Continua (draft) guidelines requires to sign an NDA. Contact John Donnelly. Target: IS submission to panel for December 2008 Two main challenges: Convergence to a single interface between Device Intermediaries and Remote Monitoring Mgmt Systems (used either in Homes or in Care Delivery Organizations)  Request to IHE and Continua for harmonization Tight schedule synchronization between completion of IEEE standards, Continua Implementation Guidelines, and IS completion for panel approval in December.

Report from the Consumer Perspective Technical Committee Remote Monitoring Business Actors may be combined: e.g. RM Mgt Syst & EHR or RM Mgt Syst & PHR Significant reuse of existing & new constructs in Interfaces 3, 4, 5, 6 and 7 Interface #1 Interface #2 Device Intermediary Device Remote Monitoring Mgmt System Interface #3 Interface #6 Health Info Exchange Interface #4 Interface #7 Interface #5 PHR System EHR System

Report from the Consumer Perspective Technical Committee Devices that are being considered this cycle include: Blood pressure monitor Glucometer Pulse oximeter Thermometer Weighing scale

C74 - Remote Monitoring Observation Document Concept Specifies the medical information collected by remote health monitoring devices, based upon HL7 CDA Measurements captured by devices; notes, summaries, and other kinds of narrative information that may be added by caregivers or by the users Graphs that may be added by intermediary devices that represent trends of users’ health Example systems include PHRs, EHRs, Practice Management Applications and other stakeholders Selected Standard Implementation Guide for CDA Release 2.0 Personal Health Monitoring Report (PHMR) 15

T73 - Aggregate Device Information Communication Concept Allows a system (such as a home hub, a cell phone, a set top box, a monitoring station) to report device observations through a local or remote connection to an information management system Selected Standard The Tier 2 analysis has resulted in two alternatives: One approach is based on the use of the IHE DEC Integration Profile (HL7 V2.x). This approach is widely used today within Hospitals to connect clusters of devices to EHRs The other approach is based on the use of IEEE Device Specialization conveyed as a document (ASN1 encoded with MDER or XER)) by HITSP T31 (IHE-XDR). This approach is primarily targeted at home monitoring Public Comment is expected on the selection that should be made between these alternatives. IHE and Continua Health Alliance are currently working collaboratively to analyze the approaches and propose their recommendation to HITSP. 16

Report from the Consumer Perspective Technical Committee IS 03 & IS 05 Updates A number of items identified last year (as gaps in use cases) prioritized for possible completion this year IS03 / IS05 2008 gap items: Advance Directives  Consumer-Friendly Clinical Information  Provider Lists (2009)

Report from the Consumer Perspective Technical Committee Advance Directives (partial in 2008) C62: Unstructured document Consumer-Friendly Clinical Information / translations T81: Retrieval of Medical Knowledge Provider Lists Identified scope of work Generating provider lists – current efforts Setting permissions - TBD Other uses- TBD Working on identifying the key actors and interactions Given complexity, work extended to 2009

Report from the Consumer Perspective Technical Committee T81: Retrieval of Medical Knowledge Transaction (new) Supports the retrieval of medical knowledge References: HL7 v 3.0 Context-Aware Information Retrieval Specification: URL Implementation Guide Based on the Infobutton concept

Report from the Provider Perspective Technical Committee ISO-8 Personalized Health Care Use case Scenario's Clinical Assessment. A family health history is gathered from or by the consumer in an interoperable form to be used by consumers and clinicians. This information is accessed by clinicians and used in conjunction with personal medical history, current health status, and personal preferences to develop a diagnostic plan. Genetic Testing, Reporting, and Clinical Management. A medical testing laboratory performs genetic or genomic testing after it receives genetic/genomic test orders and any accompanying information necessary for the testing in an interoperable form. The testing laboratory performs the tests, develops the patient report, and transmits this information back to authorized providers. Clinicians utilize this new diagnostic information for the management of their patients. Both clinicians and consumers have access to this information via the PHR.

Report from the Provider Perspective Technical Committee: PHC Roadmap

Report from the Provider Perspective Technical Committee: Identified Constructs HITSP/C19 - Entity Identity Assertion HITSP/C32 - Summary Documents Using HL7 Continuity of Care Document (CCD) HITSP/C36 - Lab Result Message Component HITSP/C37 - Lab Report Document HITSP/C48 - Encounter Document Using IHE Medical Summary (XDS-MS)

Report from the Provider Perspective Technical Committee : Identified Constructs HITSP/C62 Unstructured Document Component HITSP/C69 - Generic Order Component HITSP/C80 - Clinical Document and Message Terminology Component HITSP/C84 - Consult and History and Physical Note Component HITSP/C90 – Clinical Genomic Decision Support Component

Report from the Provider Perspective Technical Committee : Identified Constructs HITSP/T15 - Collect and Communicate Security Audit Trail HITSP/T16 - Consistent Time HITSP/T17 - Secured Communication Channel HITSP/T23 - Patient Demographics Query HITSP/T29 - Notification of Document Availability HITSP/T31 - Document Reliable Interchange HITSP/T33 - Transfer of Documents on Media HITSP/T40 - Patient Generic Health Plan Eligibility Verification Transaction

Report from the Provider Perspective Technical Committee :Identified Constructs HITSP/T68 - Health Plan Authorization/Referral Request and Response HITSP/T85 – Administrative Transport to Health Plan HITSP/TP13 - Manage Sharing of Documents HITSP/TP20 - Access Control HITSP/TP22 - Patient ID Cross-Referencing HITSP/TP30 - Manage Consent Directives HITSP/TP89 – Sharing Imaging Results

Expansion of the Science Base Report from the Provider Perspective Technical Committee: Framework for Personalized Healthcare Personalized Health Care Integration into Clinical Practice Intervention Development and Review Expansion of the Science Base Health Information Technology Adapted from DHHS PHC, Opportunities, Pathways, Resources 2007

Report from the Provider Perspective Technical Committee Emergency Responder Use Case SITUATION: IS04 Version 1.0 was issued Dec 07 10 GAP/Overlap closure projects NEXT STEP: IS04 Version 1.2.1 for public review 2008 ER-EHR New Constructs for for OASIS EDXL DE and CAP Other New Constructs developed by other TCs 2009 and beyond HITSP Constructs for NEMSIS and DEEDS harmonized vocabulary pre-hospital EMS document content (e.g., field and run reports) SITREP and Patient Tracking

New/Repurposed ‘2008 construct Report from the Provider Perspective Technical Committee: Emergency Responder Use Case Construct New/Repurposed ‘2008 construct HITSP/T40 Insurance Coverage and Eligibility HITSP/T63 Emergency Message Distribution Element Transaction HITSP/T64 Identify Communication Recipients (service) HITSP/T66 Terminology Service HITSP/T67 Clinical Referral Request Transport Transaction HITSP/T68 Patient Health Plan Authorization Request and Response HITSP/T85 Administrative transport to health plan HITSP/C48 Encounter/ Discharge Doc. Using IHE Medical Summary (XDS-MS) HITSP/C62 Unstructured Document Component   HITSP/C82 Emergency Common Alerting Protocol (CAP)

Report from Provider TC: ER-EHR Projects’ Status HITSP Nursing Terminology - done NEMSIS chaired work group: Finding a method of assigning and adopting unique identifiers for both incidents and patients so data from heterogeneous systems can be linked - pending Common approaches of delivering third party incident information such as telematics data to the Emergency Communications System (ECS) and emergency responders - actively working Reaching agreement between healthcare and other emergency responders on a common terminology (“Managed List”) for incident types - pending Harmonizing the data taxonomies of hospital (DEEDS), EMS (NEMSES), and other emergency responders to the extent necessary to implement the ER-EHR – October funding start of work at Univ. of Utah Additional gap area projects are: Decision Support Tool interoperability – monitoring external progress Core Services - monitoring external progress Situation Awareness Messaging - monitoring external progress Emergency Contact Registry (ECON) – done Life Critical Remote Monitoring - pending 29 29 29

Report from the Provider Perspective Technical Committee: Emergency Responder Use Case Information Exchange Requirement - Data Requirement Component Transaction Transaction Package IER01 Emergency Contact NA TP22 IER02 Clinical Summary C32 TP13 IER03 Run Report GAP PDF GAP T63, T64 IER04 Present Episode of Care C28, C48 IER05 Discharge Summary C48 IER06 Situation Report IER07 Medical Device Data GAP IER08 Info Provider Data (e.g., telematics) IER09 Decision Support IER10 Patient Identification T23 IER11 Public Health Data IER12 Public Health Protocol GAPT63, T64 IER13 Ins. Coverage & Eligibility T40 IER14 Ins. Care Authorization/Denial T68 IER15 Alert (patient en route) C82 IER16 Transfer-of-care information C28 T63

IS09 was completed September 22, 2008 Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care IS09 was completed September 22, 2008 Produced by Provider Perspective TC Input from Admin and Finance, Care Management, Security TCs Work based upon Consultation and Transfers of Care Detailed Use Case, March 21, 2008 TN900, Security and Privacy Technical Note TN901, Technical Note for Clinical Documents

For both consults and transfers Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care What it covers: Consultations: information exchange supporting consult request, performance, and resulting Transfers of care: information exchange for request and actual transfer For both consults and transfers Supports information exchange to verify eligibility and authorization for services

Summary of IS09 constructs used Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care Summary of IS09 constructs used Lab-related (C35, C36, C37, T14) Document-related (C32, C48 , C62, C84, T29, T31, T33, TP13, TP22) Radiology-related (C41, TP89) Security/infrastructure-related (T15, T16, T17, T85, TP20) Eligibility/referral-related (T40, T67, T68, T79) Entity/identity-related (C19, T23, TP22)

Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care IS09 gaps Some clinical data without a HITSP construct Example-ECG Functional status “instruments” poorly supported We need a CDA implementation guide for assessment instruments including functional status Nursing documentation Highly variable, no good standard for nursing summaries, notes, etc. CDA probably applicable here but needs development

Identifying consultant and transfer setting Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care IS09 gaps Identifying consultant and transfer setting Few tools to identify providers and facilities meeting a complex set of preferences Patient and referring/transferring provider preferences are multi-faceted Prefs include specialty, network, location, co-pay preferences… Needs Cross TC work and SDO engagement

Decision support (IER 5) Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care IS09 gaps Decision support (IER 5) No current HITSP-defined DSS interoperability Needs cross-TC work and possibly SDO engagement (e.g., HL7)

Tight timelines met by able help of the entire TC team! Report from the Provider Perspective Technical Committee : Consultations and Transfers of Care IS09 Lessons Learned Tables relating constructs, actors, IER, and ER were very helpful to clarify/speed the work Tight timelines met by able help of the entire TC team! Particular thanks to Steve Hufnagle, Mike Glickman, & Allen Hobbs Huge debt to Suzi Hines and Gila Pyke

Questions?

Completed editorial changes to existing construct documents Report from the Security, Privacy & Infrastructure Domain Technical Committee Completed editorial changes to existing construct documents (out for Public Comment in September) Developed 10 new constructs Modified 3 existing constructs Worked with PTCs to ensure new constructs meet the requirements of the use cases

Report from the Security, Privacy & Infrastructure Domain Technical Committee Continued to work with TC-Leadership to address NHIN issues related to the use of SPI constructs in the NHIN Trial Implementations (ongoing) Longer term plan of maintenance updates to constructs and TN900 (e.g. revisions to TP30: Manage Consent Directives – to incorporate additional coding/base standards which are now available)

New & Updated SPI constructs use in Interoperability Specifications Doc # Document Name IS08 CTC IS09 PHC IS10 PHCR IS12 PPSM IS11 IRM IS77 RMON IS03 CE-Networks ER-EHR IS05 CE-Media C62 Unstructured Document  C82 Emergency Common Alerting Protocol C87 Anonymize – Public Health C88 Anonymize - Immunization T23 Patient Demographics Query (*new option) T63 Emergency Message Distribution Element T64 Identify Communication Recipients T66 Terminology Services T67 Clinical Referral Request Transport T81 Retrieval of Medical Knowledge T85 Administrative Transport to Health Plans TP22 Patient ID Cross-Reference (*new option) New Interoperability Specifications Existing Interoperability Specifications

C62 Unstructured Document Concept Capture and storage of patient identifiable, unstructured document content, such as text, PDF, images rendered in PDF Selected Standards IHE XDS-SD ISO PDF/A 19005-1b 42

C82 Emergency Common Alerting Protocol Concept Multicast notification message sent to an identified channel Intended recipients are populations such as “all emergency departments in XXX county”, “within a geographic area”, etc Construct can only be used to transport text message alerts Selected Standards OASIS CAP v1.1 43

New Approach to Anonymize Construct Existing C25 construct contains anonymization requirements for two different use cases (Bio and Quality) Adding new requirements to same construct (from new use Public Health Care Reporting and Immunization Management) would be inefficient and less effective Would require constant updates to construct, and constant updates to IS’s that use it New Approach Dedicate separate anonymize construct to each use case Modify current anonymize construct (C25) to focus only on the IS02 – Biosurveillance Develop two new anonymize constructs, one for Public Health Case Reporting (C87) and one for Immunizations and Response Management (C88) Create a new construct for the Quality IS 44

C87 Anonymize Public Health Case Reporting Data Concept Provides specific instruction for anonymizing repurposed data created as part of routine clinical care delivery Defines anonymization requirements specific to Public Health Case Reporting data Selected Standards ISO Pseudonymisation TS# 25237 45

C88 Anonymize Immunizations and Response Management Data Concept Provides specific instruction for anonymizing repurposed data created as part of routine clinical care delivery Defines anonymization requirements specific to Immunizations and Response Management data Selected Standards ISO Pseudonymisation TS# 25237 46

TP22 Patient ID Cross-Referencing Concept Identifying and cross-referencing different attributes for the same patient. It contains following transactions: Patient ID Cross-Referencing Patient Identity Feed Updated to include an optional transaction - Patient Identity Management transaction - for Pediatrics Demographics Selected Standards IHE PIX IHE Technical Framework Supplement, Pediatric Demographics HL7 v2.5 HL7 v2.3.1 47

T23 Patient Demographics Query Concept Involves request for patient demographic information, and a response with a list of patient demographics for matching patients, if any were found Updated to include Pediatric Demographics option which makes use of six additional demographic fields to aid record matching in databases with many pediatric records Selected Standards IHE PDQ IHE Technical Framework Supplement, Pediatric Demographics HL7 v2.5/v2.5.1 48

T29 Notification of Document Availability Concept Defines mechanism for a healthcare stakeholder (e.g. provider, public health, etc) to notify providers or the patient about information that is available for retrieval pertaining to an identified patient Updated to expand the use of this construct for notifications from other contexts such as public health, or other sources Selected Standards IHE NAV 49

T63 Emergency Message Distribution Element Concept Multicast notification message sent to an identified radio channel Intended recipients are populations such as “all emergency departments in XXX County” Selected Standards OASIS EDXL-DE 50

T64 Identify Communication Recipients Concept Identification of communication recipients Delivery of alerts and bi- directional communications (e.g., public health agencies notifying a specific group of service providers about an event) Selected Standards IHE PWP 51

T66 Terminology Service Concept Selected Standards Used to transform human or computer vocabularies. Retrieve and resolve a value set with the appropriate terminology or code system Retrieve a value set with an appropriate map from one terminology to another Selected Standards IHE SVS HL7 CTS Release 1 52

T67 Clinical Referral Request Transport Concept Transport for provider-to- provider referral request interaction. Bundle referral request document & other relevant clinical documents of interest, and optionally send a trigger message to receiving provider system Selected Standards IHE Document-based Referral Request (DRR) 53

T81 Retrieval of Medical Knowledge Concept Enables request and receipt of additional knowledge about medical concept based on specific context parameters Does not prescribe knowledge content of message returned Provides specifications for query/receipt of additional knowledge Selected Standards HL7 v3.0 Context-Aware Information Retrieval 54

T85 Administrative Transport to Health Plan Concept Transport for administrative transactions between provider and health plan Example: pharmacy obtaining health plan eligibility, or physician requesting referral or authorization information from a health plan Selected Standards CAQH CORE Phase II, #270 rule 55

Report from the Care Management & Health Records Domain Technical Committee

Completed editorial changes Report from the Administrative and Financial Domain Technical Committee Current Work Completed editorial changes T40 - Patient Health Plan Generic Eligibility Verification Transaction Completed new construct T68 - Patient Health Plan Authorization Request and Response Transaction T79 - Pharmacy to Health Plan Authorization Request and Response Transaction Reviewing proposed 2009 Use Cases Long Term - Develop a Technical Note document for Administrative and Financial Domain TN902

Report from the Administrative and Financial Domain Technical Committee Construct Work HITSP Doc # TITLE 2008 Use Cases 2007 Use Case RMON IS77 PPSM PHC IS08 CTC IS09 IRM PHCR E-EHR IS04 T40 Patient Health Plan Eligibility Verification Transaction x T68 Patient Health Plan Authorization Request and Response Transaction T79 Pharmacy to Health Plan Authorization Request and Response

Report from the Administrative and Financial Domain Technical Committee Existing Constructs Modified to Meet New Use Case Requirements Doc # Construct Change Description T40 Patient Health Plan Eligibility Verification Transaction Updates to support service/procedure specific inquiry and response Replaced CORE Phase 1 rules with new CORE Phase 2 rules Renamed to remove word “Generic” in the name

Construct Description Report from the Administrative and Financial Domain Technical Committee New Construct Development Work New Construct Construct Description Selected Standards T68 – Patient Health Plan Authorization Request and Response Used by a healthcare provider (other than a retail pharmacy) to request approval from a health plan to authorize certain healthcare services, when required by the patient’s health plan contract. The health plan responds to the healthcare provider authorization request. ASC X12 278 v4010A T79 – Pharmacy to Health Plan Authorization Request and Response Transaction Used by a retail pharmacy to request approval from a health plan to authorize certain healthcare services, when required by the patient’s health plan contract. The health plan responds to the healthcare provider authorization request. NCPDP Telecommunication Standard Implementation Guide version 5.1

Report from the Administrative and Financial Domain Technical Committee Current Work Plan Project/task Target date Support Prospective TC with 2008 Use Cases 11/16/2008 Draft Administrative and Financial Technical Note 902 12/15/2008 Review & Comment on Proposed 2009 Use Cases 10/16/2008