IHE IT Infrastructure Domain Update Karen Witting – IBM IT Infrastructure Technical Committee co-chair

IHE - Connecting standards to care Care providers work with vendors to coordinate the implementation of standards to meet their needs Care providers identify the key interoperability problems they face Drive industry to develop and make available standards-based solutions Implementers follow common guidelines in purchasing and integrating systems that deliver these solutions

IT Infrastructure Domain (ITI) Supports profiles which supply necessary infrastructure for sharing healthcare information. IT Infrastructure domain began in 2003 and now has 21 profiles that it supports. Key ITI profiles demonstrated today: Information Exchange: XDS (XDS.a & XDS.b), XDM, XDR, XDS-SD, RFD Security: ATNA, CT, XUA, BPPC Identity Management: PIX, PDQ (HL7 V2 & V3)

An Infrastructure Interoperability Component Is… Represents a common IT function or service that is used as a building block for a variety of use cases May be imbedded in an application, but is often deployed as a shared resource within a RHIO or Health Information Exchange Is a necessary ingredient, but is rarely visible to the end user

Document Exchange Integration Profiles XDR XDM Document Content and Modes of Document Exchange Doc Content Profiles Pre Surgery PPH P Consent BPPC Emergency EDR Scanned Doc XDS-SD Laboratory XD*-Lab PHR Exchange XPHR Discharge & Referrals XDS-MS Imaging XDS-I Document Exchange Integration Profiles Document Sharing XDS.a XDS.b Reliable Interchange XDR Media Interchange XDM Cross-Community Access XCA XDS Stored Query & Patient Identity Merge

New/updated in 2007 Information Exchange Security/Privacy Cross-Enterprise Document Sharing - b (XDS.b) ☼ Cross-Enterprise Sharing of Scanned Documents (XDS-SD) ☼ XDS Stored Query Transaction (addition to XDS) ☼ XDS Patient Identity Merge (addition to XDS) Cross Community Access (XCA) ☼ Retrieve Form for Data Capture (RFD) ☼ Cross-Enterprise Document Media Exchange (XDM) ☼ Cross-Enterprise Document Reliable Interchange (XDR) HL7 V3 based PIX and PDQ transactions ☼ Security/Privacy Cross-Enterprise User Assertion (XUA) ☼ Basic Patient Privacy Consents (BPPC) ☼ ▀ colored text designates 2006 profiles which were updated this year ☼ Designates profiles being demonstrated at HIMSS Interoperability Showcase 2007

2003-2005 Information Exchange Security/Privacy Retrieve Information for Display (RID) Patient Identifier Cross-Referencing (PIX)☼ Patient Synchronized Applications (PSA) Cross-Enterprise Document Sharing (XDS.a) ☼ Patient Demographics Query (PDQ) ☼ Notification of Document Availability (NAV) Patient Administration Management (PAM) Security/Privacy Enterprise User Authentication (EUA) Consistent Time (CT) ☼ Audit Trail and Node Authentication (ATNA) ☼ Personnel White Pages (PWP) Document Digital Signature (DSG) ▀ colored text designates profiles still in Trial Implementation ☼ Designates profiles being demonstrated at HIMSS Interoperability Showcase 2007

Categories of Healthcare Communication Services HIEs and RHIOs Patient and Provider ID Mgt Hospitals e.g. access to last 6 months historical labs and encounter summaries e.g. get a current list of allergies or med list from a source e.g. order a lab test, track status and receive results Security Document Sharing Dynamic Information Access Workflow Management Source persisted and attested health records Specific info snapshot provided on demand 2 or more entities synchronize a task

Health Information Exchanges Interoperability: Cross-enterprise Document Sharing Cross-Enterprise Document Sharing simplifies clinical data management by defining interoperable infrastructure. Transparency = Ease of Evolution Patients have guaranteed portability and providers may share information without concerns of aggregation errors. Digital Documents = Patients and providers empowerment Supports both centralized and decentralized repository architectures. Ease of federation nationally. Flexible privacy, Flexibility of configurations Addresses the need for a longitudinal healthcare data and its intend is for support of archival data. It does not address workflow or dynamic data access. Workflows addressed in a second step in a much simpler manner. Point-to-Point messages best suited for workflows mgt

Cross-Enterprise Document Sharing (XDS) Standards Used Healthcare Content Standards HL7 CDA, CEN EHRcom HL7, ASTM CCR DICOM … Electronic Business Standards ebXML Registry, SOAP, Web Services … Internet Standards HTML, HTTP, ISO, PDF, JPEG … Implemented world-wide by more than 30 vendors/open source. Final text published December 2006. Adopted in several national & regional projects (Italy, France, Canada, Austria, USA, etc.) IHE XDS: 42,300 “Google” references (Feb’ 07)

Why is IHE-XDS a breakthrough ? It based on an International Standards; ebXML registry: OASIS and ISO standard, Web Service/Soap/XML. Sharing of digital documents as “attested by the source”, meets the most urgent needs. A proven healthcare community data-sharing paradigm (Message feeding a central web server hinders use of EHRs). Efficient to support all types of Health IT Systems (IDNs, Hospitals, Ambulatory, Pharmacy, Diagnostics Centers, etc.) and all types of information (summaries, meds, images, lab reports, ECGs, etc.), structured and unstructured. Meets both the needs of point-to-point push communication and on-demand pull in a variety of centralized or distributed architectures. Offer a consistent, standards-based and functional record sharing for EHRs, PHRs & other IT Systems

XDS.a and XDS.b XDS.a Original XDS profile, pre 2007 Based on ebXML Reg/Rep 2.1 SOAP with attachments based Provide and Register Retrieve is HTTP GET XDS.b Based on a use of the Web Services and ebXML Reg/Reg standards that is consistent with the current developments and best practices in the industry Based on ebXML Reg/Rep 3.0 MTOM based Provide and Register MTOM based retrieve HL7 V3 Patient Identity Feed Actors are the same in both XDS.a and XDS.b Metadata is the same in both XDS.a and XDS.b

XDS.a Transactions Diagram

XDS.b Transactions Diagram

XDS Scenario + use of ATNA & CT Physician Office EHR System Teaching Hospital PACS ED Application EHR System PMS XDS Document Repository Community Clinic Lab Info. System PACS XDS Document Registry Query Document Register Document Secured Messaging Retrieve Document Provide & Register Docs Maintain Time ATNA Audit record repository CT Time server Maintain Time Record Audit Event Maintain Time Record Audit Event Record Audit Event

XDS Scenario + use of PIX & PDQ PDQ Query to Acquire Affinity Domain Patient ID Patient Identity Feed M8354673993 Patient Identity XRef Mgr 14355 M8354673993 L-716 A87631 Physician Office EHR System Patient Identity Feed M8354673993 A87631 L-716 Teaching Hospital PACS ED Application EHR System Affinity Domain Patient Identity Source M8354673993 Patient Identity Feed Patient Identity Feed Community Clinic Lab Info. System PACS XDS Document Repository XDS Document Repository PIX Query A87631 L-716 Document Registry PIX Query Query Document (using Pt Id) Register (using Pt ID) Provide & Register Docs PACS Retrieve Document ATNA Audit record repository CT Time server

Cross Community Access (XCA) Sharing of documents across communities Re-use of XDS.b transactions. Document Consumer consistency Requirements of Document Consumer are the same as for local document query and retrieval Out of scope: How to identify which communities to interact with How to identify the patient id to use when interacting

XCA Transaction Diagram minimum required

XCA Transaction Diagram

XCA Transaction Diagram

XCA Transaction Diagram

Cross Community Access Actors and Transactions Initiating Gateway On behalf of internal actors, initiates all transactions leaving the community Receives Registry Stored Query and Retrieve Document Set from Document Consumer Propagates transaction to local Document Registry and Repository, if appropriate Propagates transaction to other communities by contacting their Responding Gateway and sending: Cross Gateway Query and Cross Gateway Retrieve Responding Gateway Single contact point for all transactions coming in to the community. Propagates incoming transactions to local actors New Transactions: Cross Gateway Query: from Initiating Gateway to Receiving Gateway, mimics Registry Stored Query Cross Gateway Retrieve: from Initiating Gateway to Receiving Gateway, mimics Retrieve Document Set Document Consumer Supports Registry Stored query and Retrieve Document Set New requirement: propagation of the homeCommunityId requirement Applies to XDS.a, XDS.b and XCA profiles

XCA Process Flow Responding Gateway Initiating Gateway Responding RSQ – Registry Stored Query XGQ – Cross Gateway Query RDS – Retrieve Document Set XGR – Cross Gateway Query Community B Responding Gateway RSQ XDS Registry XGQ Community A Initiating Gateway RSQ RDS XDS Registry XDS Repository XDS Repository RSQ Community C RDS XGQ Responding Gateway RSQ XDS Registry XGR Document Consumer RDS XDS Repository

IHE IT Infrastructure – Schedule for 2007 Development Schedule: Planning Committee decision: December 2007 Issue Public Comment version: June 2008 Public Comment Due: July 2008 Issue Trial Implementation version: August 2008 IHE Connectathon: January 2009 HIMSS Demo: February 2009

IHE IT Infrastructure – Plan for 2008 New Supplements For 2008 Sharing of Value Sets Referral Request Emergency Contact Registry Query Asynchronous XDS.b Extended PDQ Significant updates to previous years profiles XDS-SD conformance to PCC TF New White Papers for 2008 Publish/Subscribe Infrastructure for XDS

IHE IT Infrastructure Roadmap 2008-2009+ Profile Candidates Continue Prior Profile Work Web Services and SOA for Healthcare Cross- Community Location Cross-Enterprise User Authentication (Phase 2) Advance White Papers to Profiles Aggregate Data Monitoring Configuration Management And then….

IHE IT Infrastructure Roadmap 2008-2009+ Profile Candidates Add New Work Cross-Enterprise Ordering Cross-Enterprise Workflow Scheduling XDS Affinity Domain Configuration XDS Templates Composite Documents Role-based Access Control Anonymization and Pseudonymization Mobile Security Master File Maintenance Service Discovery SNMP MIBs