Laboratory to Ambulatory EHR Workflows Charles Parisot GE Healthcare IHE IT Infrastructure Technical Committee co-chair

July 2005Interoperability for Lab - IHE Canada2 W W W. I H E. N E T Providers and Vendors Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings

July 2005Interoperability for Lab - IHE Canada3 Lab to Ambulatory EHR Interoperability Workflows Two primary workflows models are used around the world: –Contract to Lab model: the ambulatory physician is the lab customer and sends the patient or specimen to selected lab. –Collaborative Lab Model: the patient selects lab and follows physicians lab prescription. Both models exist is most countries but one of the two often is the most prevalent Workflow contains two time segments: –Electronic Order/Real-Time Result Communication: ordering physician, patient and laboratory. Completes when result delivered. –Access to Historical Results: Same patient but in later encounters need access to previous performed lab studies. Does IHE offers today the corresponding basic interoperability ?

July 2005Interoperability for Lab - IHE Canada4 Patient Administration Clinical laboratoryWard or EHR Lab-1: Placer order Lab-2: Filler order Rad1, Rad-12 Patient demographics & visit Lab-5: Results Rad-1, Rad-12 Lab-3: Results Lab-4: Work order Order Result Tracker ADT Automation Manager Order Placer Order Filler IHE Laboratory: LSWF What is different in hospitals and ambulatory ? Different Applicable Non Relevant

July 2005Interoperability for Lab - IHE Canada5 Lab to Ambulatory EHR Interoperability Workflows Contract to Lab Model Collaborative Lab Model e Order Access Historical Lab Results Assessment and use case positioning (non-acute care) Access to Other Records Real-Time Result Paper Order

July 2005Interoperability for Lab - IHE Canada6 Lab to Ambulatory EHR Interoperability Workflows Contract to Lab Model Collaborative Lab Model e Order Access Historical Lab Results Assessment and use case positioning (non-acute care) ? ? Access to Other Records Real-Time Result IHE Lab Scheduled Workflow IHE Lab scheduled Workflow Important ? Real Time Result : critical for acute care and possibly ambulatory contract, not obvious for collaborative model. Paper Order ?

July 2005Interoperability for Lab - IHE Canada7 Lab to Ambulatory EHR Interoperability First Set of Conclusions IHE Lab Scheduled Workflow has a critical role to play: –Solid and proven specification with HL7 V2.5 critical improvements –Bring the rigor and effectiveness of IHE –Consistent approach for laboratories in acute care and ambulatory –Best springboard to HLV3 and Infoway strategic direction Remaining gaps that need to be addressed by a LSWF Integration Profile Extension (multi-jurisdiction ?): –Results and Orders Coded Terminology –Jurisdictions specific elements Need a address the historical lab results access case in a non-lab specific manner –This is the topic of the next presentation

Sharing Laboratory Results in Regional & National Networks Sharing Laboratory Results in Regional & National Networks Charles Parisot GE Healthcare IHE IT Infrastructure Technical Committee co-chair

July 2005Interoperability for Lab - IHE Canada9 Local & Regional RHIOs Infrastructure and Interoperability IHE has been focusing significant efforts on cross- enterprise health information sharing for the past three years We will provide an update on this work and some of the major accomplishments in this area that do benefit the access to laboratory results. Discuss what can be implemented today.

July 2005Interoperability for Lab - IHE Canada10 Selected IHE Integration Profiles for RHIOs What is available and is added in 2005 Consistent Time Coordinate time across networked systems Audit Trail & Node Authentication Centralized privacy audit trail and node to node authentication to create a secured domain. Patient Demographics Query Cross-Enterprise Document Sharing Registration, distribution and access across health enterprises of clinical documents forming a patient electronic health record Notification of Document Availability Notification of a remote provider/ health enterprise Lab Results Document Content Format of the Document Content and associated coded vocabulary For Display Document Format of the Document Content Imaging Information Sharing Format of the Document Content and associated coded vocabulary Medical Summary Document Content Format of the Document Content and associated coded vocabulary Cross-enterprise User Authentication Authentication & Auditing: Basis for Access Control Document Digital Signature Attesting true-copy and origin Patient Identifier Cross-referencing Map patient identifiers across independent identification domains

July 2005Interoperability for Lab - IHE Canada11 HIMSS 2005 – Show-Wide Interoperability Vendor System Ambulatory Showcase Booth Home PCP Multispecialty Clinic Diag Center Cross-enterprise Showcase Booth Cardiology Radiology IT Infrastructure In-Patient/Out-patient Vendor Booth HL7 Booth HIMSS RHIO with Cross-enterprise doc sharing (17 vendors)

July 2005Interoperability for Lab - IHE Canada12 HIMSS 2005 Interoperability Show Case Vendors Leadership Level CapMed/SanDiskEclipsys GE Healthcare IDXInterSystemsKryptiqQuovadx/CareScienceSiemensWebMD Participant Level AllscriptsCedaraCernerDictaphone Eastman Kodak EclipsysEmageonEpicETIAM INFINITT Tech. MedcomSoftMediNotesMedCommonsMidMark Mortara Instrument, Inc National Institute of Standards & Technology Standards & TechnologyNextGenNovell Open Text Sentillion Supporter Level AccessPtAGFAdbMotionDinmar – Oacis EMCHealthvisionHealthrampMcKesson Valco Data Systems

July 2005Interoperability for Lab - IHE Canada13 IHE North America Vendors ( ) Agfa HealthCare Allscripts Camtronics Medical Systems Cedara Software Corp. Cerner Corporation Dictaphone Corporation Dynamic Imaging, LLC Eastman Kodak Company Eclipsys Emageon Epic Systems Corporation ETIAM FujiFilm Medical Systems, USA, Inc. GE Healthcare Heartlab, Inc Hitachi Medical Corporation Hologic IDX Systems Corp. INFINITT Technology InSite One, Inc. Intelerad Medical Systems InterSystems Corporation Konica-Minolta Medical Imaging, USA, Inc. Kryptiq Marotech McKesson Information Solutions MedCommons Inc. MedCon, Inc. Merge eFilm Mortara Instrument, Inc. Novell, Inc. Philips Medical Systems QRS Diagnostic Quovadx St. Jude Medical A.B. Sectra Imtec A.B. St. Jude Medical A.B. Sectra Imtec A.B. Sentillion Siemens Medical Solutions Stentor Swissray International, Inc. Tiani Medgraph A.G. Tiani Spirit Gmbh Toshiba Medical Systems Company Vital Images WebMD Practice Services

July 2005Interoperability for Lab - IHE Canada14 community Clinical Encounter Clinical IT System Index of patients records (Document-level) Temporary Aggregate Patient History 4-Patient data presented to Physician Sharing System Clinic Record Specialist Record Hospital Record 2-Reference to Records for Inquiry IHE-XDS : Cross-Enterprise Document Sharing 3-RecordsReturned Reference to records Shared Document Repository

July 2005Interoperability for Lab - IHE Canada15 community Clinical Encounter Clinical IT System Index of patients records (Document-level) Temporary Aggregate Patient History 4-Patient data presented to Physician Sharing System Clinic Record Specialist Record Hospital Record 2-Reference to Records for Inquiry Document Content shared by IHE-XDS 3-RecordsReturned Reference to records Shared Document Repository Secured Sharing of: Medical Summaries Images & reports ECG Reports PDFs Lab Results + Notif of Doc Avail.

July 2005Interoperability for Lab - IHE Canada16 community Clinical Encounter or PHR access Portal Index of patients records (Document-level) Temporary Aggregate Patient History 4-Patient data presented to Physician or Patient Sharing System Clinic Record Specialist Record Hospital Record 2-Reference to Records for Inquiry Full Integration of Portals (Doc & Patients) 3-RecordsReturned Reference to records Shared Document Repository

July 2005Interoperability for Lab - IHE Canada17 Sharing Lab Results with XDS in a Regional Health Information Network Lab B Physician Office Regional Health Information Network Lab A Hospital-to-Lab Lab-to- Physicians Hospital A

July 2005Interoperability for Lab - IHE Canada18 Sharing Lab Results with XDS in a Regional Health Information Network Lab B Physician Office Regional Health Information Network Lab A Hospital A Cross- Enterprise Registry

July 2005Interoperability for Lab - IHE Canada19 Sharing Lab Results with XDS in a Regional Health Information Network Lab B Physician Office Regional Health Information Network Lab A Hospital A Cross- Enterprise Registry Query for Documents Register Lab Report for sharing Prior Lab Report Register Lab Report for sharing

July 2005Interoperability for Lab - IHE Canada20 Sharing Lab Results with XDS in a Regional Health Information Network Lab B Physician Office Regional Health Information Network Lab A Hospital A Cross- Enterprise Registry Prior Lab Report Query for documents Lab Report Patient Id= 3547F45 Report 5/21/1998 : BloodWork B Report 2/18/2005 : Glucose A Notification of Doc Availability

July 2005Interoperability for Lab - IHE Canada21 IHE: Lab Report Sharing Ready to be implemented ? Gap 1: What standard for a Lab Report Document ? –Today: wrap a complete result in HL7 V2.x into an XDS Document. Already demonstrated at HIMSS –Mid-Term goal: represent lab result as CDA-R2 document with HL7 V3 Lab clinical statements (same as those of the real-time result message). IHE Lab to initiate work in Gap 2: Jurisdiction extensions Gap 3: Laboratory Terminology definition. Likely a national effort initially.

July 2005Interoperability for Lab - IHE Canada22 IHE: Interoperability for Health Info Networks By starting with a secured document sharing infrastructure, establish a generic platform on which to extend clinical content (more structure & coded terminology, specialized content). Solid SAML 2.0 authentication and document digital signature (need a PKI). Practical HL7 V3 approach with CDA-R2 (medical summaries) and other content (e.g. imaging, legacy content, PDF, etc.). Establishing a critical mass of products implementations, both in clinical applications and infrastructure for deployment in An architecture that caters to various regional and national architectures: centralized, decentralized and mixed. IHE-XDS is in use in Italy, with projects in Canada (Newfoundland), Norway and France.

July 2005Interoperability for Lab - IHE Canada23 Lab to Ambulatory EHR Interoperability Workflows Contract to Lab Model Collaborative Lab Model Initial Order Access Historical Lab Results Assessment and use case positioning (non-acute care) XDS + Access to Other Records Real-Time Result IHE Lab Scheduled Workflow IHE Lab scheduled Workflow Important ? Lab regional networks need to look beyond the classical lab messaging approaches used in hospital where real-time result are critical Document Sharing Paper Order XDS +

July 2005Interoperability for Lab - IHE Canada24 Lab to Ambulatory EHR Interoperability Conclusions IHE Lab Scheduled Workflow has a critical role to play: –Solid and proven specification with HL7 V2.5 critical improvements –Bring the rigor and effectiveness of IHE –Consistent approach for laboratories in acute care and ambulatory –Best springboard to HLV3 and Infoway strategic direction Access to historical lab results in a non-lab specific manner is critical: –Leverage IHE Cross-enterprise Document Sharing and associated Integration profiles (e.g. security). –Critical rationalization for ambulatory HER that will need to access other type of record than lab reports. Remaining gaps that need to be addressed (multi-jurisdiction ?): –Results and Orders Coded Terminology –Jurisdictions specific elements

July 2005Interoperability for Lab - IHE Canada25 More information…. IHE Web sites: Technical Frameworks, Supplements: Non-Technical Brochures : Calls for Participation IHE Fact Sheet and FAQ IHE Integration Profiles: Guidelines for Buyers IHE Connect-a-thon Results Vendor Products Integration Statements

July 2005Interoperability for Lab - IHE Canada26 W W W. I H E. N E T Providers and Vendors Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings