Leveraging IHE to build RHIO Interoperability Charles Parisot GE Healthcare IHE IT Infrastructure Technical Committee co-chair

June 28-29, 2005Interoperability Strategy Workshop2 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

June 28-29, 2005Interoperability Strategy Workshop3 Lab Results Document Content Format of the Document Content and associated coded vocabulary For Display Document Format of the Document Content 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 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

June 28-29, 2005Interoperability Strategy Workshop4 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)

June 28-29, 2005Interoperability Strategy Workshop5 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

June 28-29, 2005Interoperability Strategy Workshop6 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

June 28-29, 2005Interoperability Strategy Workshop7 community Clinical Encounter Clinical IT System Index of patients records (Document-level) Temporary Aggregate Patient History 4-Patient data presented to Physician Sharing System 3-RecordsReturned Reference to records Clinic Record Specialist Record Hospital Record 2-Reference to Records for Inquiry At HIMSS in 2005 : IHE-XDS

June 28-29, 2005Interoperability Strategy Workshop8 community Clinical Encounter Clinical IT System Index of patients records (Document-level) Temporary Aggregate Patient History 3-RecordsReturned Reference to records Laboratory Results Specialist Record Hospital Record 2-Reference to Records for Inquiry At HIMSS in 2005 : IHE-XDS Sharing System Shared prototype content: Medical Summaries (Pre-CCR) Discharge Summaries (CDA-R1) Lab Results (HL7) Other (PDF)

June 28-29, 2005Interoperability Strategy Workshop9 community Clinical Encounter Clinical IT System Index of patients records (Document-level) 1-Patient Authorized Inquiry Temporary Aggregate Patient History 3-RecordsReturned Reference to records Laboratory Results Specialist Record Hospital Record 2-Reference to Records for Inquiry Demo a RHIO with IHE at HIMSS 2006 ? Sharing System Secured Sharing of: Medical Summaries Images & reports ECG Reports PDFs Lab Results ? + Notif of Doc Avail.

June 28-29, 2005Interoperability Strategy Workshop10 Document Life Cycle Management A two-way relationship between Original and Addendum Document Addendum Document 1 (Approved) Addendum Replacement Document Replacement Document 1 (Deprecated) Document 2 (transform) Transform Document 1 (Approved) A two-way relationship between Original and Replacement Document. A two-way relationship between Original and Transform (alternative format with same scope or DSG). Time Addendum to a registered document Replacing a registered document by a new document Registering an alternate form or a signature for a registered document Time

June 28-29, 2005Interoperability Strategy Workshop11 Local & Regional RHIOs Infrastructure and Interoperability Cross-Enterprise Document Sharing (XDS) minimizes clinical data management by the infrastructure. Transparency = Ease of Evolution XDS works with other IHE Integration Profiles: patient Id mgt, security, etc. Flexibility of RHIO configuration With introduction of new Integration Profiles, IHE ready to build regional health networks linking interoperable EHRs. Major milestone for 2006 RHIO projects Goal is to offer a consistent, standards-based and functional for EHRs and other ancillary systems.

June 28-29, 2005Interoperability Strategy Workshop12 Creating a Health Information Network with IHE Care Deliver y IT system Care Deliver y IT system Care Delivery IT system Tier 1 EHRs and Ancillaries

June 28-29, 2005Interoperability Strategy Workshop13 Creating a Health Information Network with IHE Care Deliver y IT system Care Deliver y IT system XDS Document Registry Document Entries Care Delivery IT system Tier 2 Community HIN What and Where ? XDS Document Repository XDS Document Repository XDS Document Repository

June 28-29, 2005Interoperability Strategy Workshop14 Creating a Health Information Network with IHE Care Deliver y IT system Care Deliver y IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consumer Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Who, What and Where ?

June 28-29, 2005Interoperability Strategy Workshop15 Creating a Health Information Network with IHE Care Deliver y IT system Care Deliver y IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consumer Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ?

June 28-29, 2005Interoperability Strategy Workshop16 Creating a Health Information Network with IHE Care Deliver y IT system Care Deliver y IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consumer Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ? Trusted !

June 28-29, 2005Interoperability Strategy Workshop17 Secured Node Document Consumer Retrieve Document Query Documents Patient Identity Source Patient Identity Feed Document Source Document Registry Document Repository Provide&Register Document Se t Register Document Set Secured Node ATNA creates a secured domain: User Accountability (Audit trail) Node-to-Node Access Control Node-level user authentication User access control provided by node BUT Registry/repository based User-Level Access Control and policy agreements is beyond XDS. User-level Access Control is provided by XUA Security for XDS Security for XDS Leverages IHE Audit Trail & Node Authentication A formal Security and Privacy profile is provided for XDS

June 28-29, 2005Interoperability Strategy Workshop18 Cross-Enterprise User Authentication Transaction Diagram Identity Provider 2 Request Assertion (of who this user is) 1 XDS Retrieve 3 Request User ID 4 User Identity 5 Authentication Assertion Record Auditable Event ATNA Audit Repository XDS Repository

June 28-29, 2005Interoperability Strategy Workshop19 Is it possible to federate multiple XDS-based HIN ? Care Delivery IT system Care Delivery IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consum er Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ? Trusted ! Care Delivery IT system Care Delivery IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consum er Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ? Trusted ! Care Delivery IT system Care Delivery IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consum er Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ? Trusted ! Care Delivery IT system Care Delivery IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consum er Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ? Trusted ! Care Delivery IT system Care Delivery IT system XDS Document Registry C-HIN Patient Identity Source Document Entries PDQ Consum er Care Delivery IT system Tier 2 Community HIN Patient Demo Supplier Patient Id X-Ref Mgr XDS Document Repository XDS Document Repository XDS Document Repository Patient Id X-Ref Mgr Time Server Who, What When and Where ? Trusted ! Tier2 Community-HINs e.g. XDS Affinity Domain

June 28-29, 2005Interoperability Strategy Workshop20 Federating Tier 2 Health Information Networks On IHE Roadmap for : X-Registry Federation (Addressed by ebXML Registry 3.0) Patient / Registry Locator Service Managed Identification Federated Identification T2 C-HIN B e.g. XDS Affinity Domain T2 C-HIN D e.g. XDS Affinity Domain RG What are the document registries where a patient has information ? Tier 3 HIN e.g. State Level

June 28-29, 2005Interoperability Strategy Workshop21 Federating Tier 2 Health Information Networks On IHE Roadmap for : X-Registry Federation Patient / Registry Locator Service T2 C-HIN A e.g. IDN Tier 3 HIN e.g. State Level Managed Identification Federated Identification T2 C-HIN B e.g. XDS Affinity Domain T2 C-HIN C e.g. IDN T2 C-HIN D e.g. XDS Affinity Domain RG +Adapt RG Integrating existing IDNs: Adaptor + Registry

June 28-29, 2005Interoperability Strategy Workshop22 Federating Tier 3 Health Information Networks On IHE Roadmap for : X-Registry Communication Patient / Registry Locator Service T1-RHIO A e.g. IDN e.g. State HIN T1-RHIO B e.g. XDS Affinity Domain T1-RHIO C e.g. IDN T1-RHIO D e.g. XDS Affinity Domain RG Patient / Registry Locator Service T1-RHIO A e.g. IDN e.g. State HIN T1-RHIO B e.g. XDS Affinity Domain T1-RHIO C e.g. IDN T1-RHIO D e.g. XDS Affinity Domain RG Patient / Registry Locator Service T1-RHIO A e.g. IDN e.g. State HIN T1-RHIO B e.g. XDS Affinity Domain T1-RHIO C e.g. IDN T1-RHIO D e.g. XDS Affinity Domain RG Patient / Registr y Locato r Servic e T1-RHIO A e.g. IDN e.g. State HIN T1-RHIO B e.g. XDS Affinity Domain T1-RHIO C e.g. IDN T1-RHIO D e.g. XDS Affinity Domain RG Patient / Registr y Locato r Servic e T1-RHIO A e.g. IDN e.g. State HIN T1-RHIO B e.g. XDS Affinity Domain T1-RHIO C e.g. IDN T1-RHIO D e.g. XDS Affinity Domain RG Nation-Wide Health Info network (Tier 4)

June 28-29, 2005Interoperability Strategy Workshop23 IHE: RHIOs Interoperability Partner IHE offers a solid technical foundation to establish interoperability for RHIOs. Standards-based, open, multi-vendor, provider-led. Yearly progress, validation testing built in, backed by a proven process. Implementation by many vendors. IHE welcomes RHIOs technical architects active involvement. The IHE Technical Framework accelerates RHIOs pilot development ( e.g. XDS Affinity Domain ). This is being applied: Norway, Italy, then Canada, soon USA, France, ?

June 28-29, 2005Interoperability Strategy Workshop24 Clinical Encounter Clinical IT System 1-Expression of a need for additional information Index of patients records (Document-level) Temporary Aggregate Patient History 3-DocumentsReturned Document Repositories 4-Patient data presented to Physician 3-Reference to Docs from Inquiry 2- Inquiry for Docs Clinicians access XDS Services through their clinical IT system (EHRs)

June 28-29, 2005Interoperability Strategy Workshop25 Sharing Radiology Reports and Images with XDS in a Regional Health Information Network Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network PACS B PACS A Radiology-to-radiology Radiology-to- Physicians

June 28-29, 2005Interoperability Strategy Workshop26 Sharing Radiology Reports and Images in a Regional Health Information Network Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Cross- Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head B Study 5/21/1998 : CT Head B Report 2/18/2005 : Chest Xray A Study 2/18/2005 : Chest Xray A PACS B PACS A

June 28-29, 2005Interoperability Strategy Workshop27 Physicians and Systems within a Regional Health Network - Routine Imaging Referral Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Query for Documents Register Imaging Information for sharing Prior imaging Reports & Studies Cross- Enterprise Registry Register Imaging Information for sharing Patient Id= 3547F45 Report 5/21/1998 : CT Head B Study 5/21/1998 : CT Head B

June 28-29, 2005Interoperability Strategy Workshop28 Physicians and Systems within a Regional Health Network - Routine Imaging Referral Radiology Enterprise A Radiology Enterprise B Physician Office Regional Health Information Network Register Imaging Information for sharing Cross- Enterprise Registry Notification of Doc Availability Register Imaging Information for sharing

June 28-29, 2005Interoperability Strategy Workshop29 Physicians and Systems within a Regional Health Network for a Routine Imaging Referral Radiology Enterprise A Radiology Enterprise B Physician Office Prior Imaging Report & Study Regional Health Information Network Query for documents Imaging Report & Study Cross- Enterprise Registry Patient Id= 3547F45 Report 5/21/1998 : CT Head B Study 5/21/1998 : CT Head B Report 2/18/2005 : Chest Xray A Study 2/18/2005 : Chest Xray A Notification of Doc Availability

June 28-29, 2005Interoperability Strategy Workshop30 Regional Health Information Network Images and reports part of a shared health record Enterprise A Enterprise B Physician Office Retrieve Prior Documents Query for Documents Regional Health Information Network Query for documents Retrieve Documents Register Documents for sharing Retrieve Prior Documents Cross- Enterprise Registry Register Documents for sharing Notification of Doc Availability

June 28-29, 2005Interoperability Strategy Workshop31 or Lab Results Document Content Format of the Document Content and associated coded vocabulary For Display Document Content Format of the Document Content Requirements for care delivery IT system in a RHIO (e.g. EHR, Lab, Imaging, etc.) 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 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 Document Digital Signature Attesting true-copy and origin Patient Identifier Cross-referencing Map patient identifiers across independent identification domains Cross-enterprise User Authentication Authentication & Auditing: Basis for Access Control

June 28-29, 2005Interoperability Strategy Workshop32 IHE: Interoperability for RHIOs By starting with a secured document sharing infrastructure, RHIOs have a a platform on which to build 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 and other content (e.g. imaging, CCR, legacy, PDF, etc.). Establishing a critical mass of products implementations, both in clinical applications and infrastructure for deployment in An architecture that caters to various RHIOs architectures: centralized, decentralized and mixed (operational decision).

June 28-29, 2005Interoperability Strategy Workshop33 More information…. IHE Web sites: Technical Frameworks, Supplements –Fill in relevant supplements and frameworks 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

June 28-29, 2005Interoperability Strategy Workshop34 IHE Patient Id management for RHIOs Use of PIX and PDQ Integration Profiles

June 28-29, 2005Interoperability Strategy Workshop35 Patient Identification Management PIX Cross Referencing (coexist with PDQ) XDS Document Registry XDS Document Repository Patient Identity Source Patient Identification Domain C Patient Identification Domain XAD Patient Identification Domain D2 Document Entry Dm=XAD Pid=Px Patient Identity X-Ref Mgr Patient Identity Feed Dm=XAD, Pid=Px Patient ID Consumer Dm=C Pid=Pc XDS Document Source XDS Doc Dm=XAD Pid=Px XDS Doc Provide&Register Doc Set Patient ID Consumer XDS Document Consumer Dm=D2 Pid=Pd Dm=XAD Pid=Px Query Docs

June 28-29, 2005Interoperability Strategy Workshop36 Patient Identification Management PDQ Discovery + Local mapping (coexist with PIX) XDS Document Registry XDS Document Repository Patient Identity Source Patient Identification Domain C Patient Identification Domain XAD Patient Identification Domain D2 Document Entry Dm=XAD Pid=Px Patient Demographics Supplier Patient Identity Feed Dm=XAD, Pid=Px Patient Demo Consumer XDS Document Source XDS Doc Dm=XAD Pid=Px Demo graphics XDS Doc Provide&Register Doc Set Patient Demo Consumer XDS Document Consumer Demo graphics Dm=XAD Pid=Px Query Docs

June 28-29, 2005Interoperability Strategy Workshop37 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