1. HIE, Interoperability, and NHIN
Prof. Steven A. Demurjian, Sr.
Computer Science & Engineering Department
The University of Connecticut
371 Fairfield Road, Box U-255
Storrs, CT
(860)
Copyright © 2014 by S. Demurjian, Storrs, CT.

2. Objective of Presentation
Health Information Change a Growing Concern
Many Efforts are Ongoing/In Progress
Standards a Concern to Address Data Exchange
Many Efforts in Play
NHIN (
CONNECT
DIRECT (wiki.directproject.org)
Biosurviellance
We’ll Review Many Efforts by “Leveraging” Existing Materials and Progress
See set of PPTs on web page:

3. Towards a Nationwide Health Information Network (NHIN)
Where Should We Be in 2014
Building a NHIN
NHIN-2004
NHIN
NHIN-2007

4. US National HIT Strategic Plan
On July 21, 2004 the Department of Health and Human Services (DHHS) announced the decade of health information technology for “delivering consumer–centric and information-rich health care.”
The vision is to build a National* Health Information Network (NHIN) of regional health information exchanges formed by health care providers who will utilize electronic health record systems.
* Original term “National” has been changed on “Nationwide” in January 2006
Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004.

5. DHHS’ Framework for Health Information Technology: Building a NHIN
NHIN will be based on:
Electronic Health Record Systems (EHRS) that will enable
Regional Health Information Exchanges (RHIEs) organized via
Regional Health Information Organizations (RHIOs)
Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004.

6. President’s Strategic Framework for HIT

7. Authorized RHIO Inquiry Patient data to other RHIO
US Nationwide Health Information Network
Provider Record
Laboratory Results
Specialist Record
Records
Returned
Requests for Records
RHIO
Authorized RHIO Inquiry
Index of
where patients
have records
Another
RHIO
Temporary Aggregate Patient History
Patient data to other RHIO
Source: Jennie Harvell. The Decade of Health Information Technology – Framework for Strategic Actions. MMIS Conference, September 2004

8. US Health Information Network - 2014
Source: Dr. Peter Elkin, Mayo Clinic, MN

9. RHIOs as NHIN Components
Source: Dr. Peter Elkin, Mayo Clinic, MN, 2006
RHIOs as NHIN Components

10. Healthcare purchasers and payers
Nationwide Health Information Network (NHIN)
Emerging data shows the value that standardized health information exchange will provide to all stakeholders:
Healthcare purchasers and payers
Hospitals and other healthcare providers
Laboratories
Practicing clinicians
Public health
Source: John Glaser, Janet Marchibroda, Jim Schuping. CCBH. Washington, D.C. December 6-7, 2004
URL:

11. THE REQUEST FOR INFORMATION (RFI)
Building a NHIN
On November 15, 2004 Office of National Coordinator for Health Information Technology (ONC), Department of Health and Human Services (DHHS), released
THE REQUEST FOR INFORMATION (RFI)
on the Development and Adoption of a “National” Health Information Network
Over 500 responses from various healthcare stakeholders has been submitted.
URL:

12. PHDSC Model for Electronic Health Record-based Data Exchange
RHIO
EHR-PH
Info
Exchange

13. NHIN Development Process
In October 2005 DHHS Office of National Coordinator (ONC) awarded several NHIN contracts ($65M) as follows:
Standards Harmonization
EHR Certification
NHIN Architecture Prototypes
Health Information Security and Privacy
URL:

14. DHHS NHIN Contracts
Standards Harmonization - Harmonize the health care and technology standards used in health information interchange to address gaps and conflicts in current standards
EHR Certification - Set forth certification criteria for the many electronic health care record products and technologies currently available on the market
NHIN Prototypes - Develop and evaluate prototypes for the network architecture to assess the feasibility of developing a national health information network prototype
Privacy - Address privacy and security policy questions affecting the exchange of health information.
Work resulting from each of these projects will be used by HHS to develop and refine the business case for establishing the network.

15. FHA Presentation to HIMSS National Capital Area Chapter January 15, Vish Sankaran Program Director Federal Health Architecture

16. The Tipping Point for Phase 2 is now at hand
Phase – 2008 Foundation for Health Information Exchange Established
In April, 2004
Executive Order 13335: Office of the national coordinator created
Executive Order 13410: Federal federal agencies required to implement HHS Secretary recognized standards and cost & quality transparency
In the last four years, ONC worked with Federal, States and private sector to:
Harmonize interoperable standards
Create Health IT certification for functionality, security, and interoperability
Launch the Nationwide Health Information Network
Address Policy variations
The Tipping Point for Phase 2 is now at hand

17. President-elect Obama’s Commitment to Electronic Health Systems
The goal is not to move from “paper silos” to “electronic silos”
The goal is an electronic health system that supports and requires the movement of interoperable health information supporting:
Continuity of Care
Population Needs (pandemics and other disasters)
Bench to Bedside Research
Disability Determination
In a January 9, 2009 speech at George Mason University
"To improve the quality of our healthcare while lowering
its cost, we will make the immediate investments necessary to ensure that, within five years, all of America’s medical records are computerized.”

18. “Secure Exchange of Interoperable Health Information”
FHA Mission
“Secure Exchange of Interoperable Health Information”
Working together to provide the tools and solutions to support the development and exchange of interoperable health information within the federal government and with the tribal, state, local and private sector, thereby, enabling better care, increased efficiency, and improved access to care for American citizens.
Effective Government 18 18

19. Agency Concept of Operations1
Business
Priorities 2
Architect
Solutions 3
Plan
Investments 4
Implement
Solutions 5
Measure
Progress
FHA can provide guidance / support in any phase of your operations. 19 19 19

20. 2009 Vision Agencies Collaborate to Reform Healthcare through IT
GOALS
Reduce Costs
Improve Quality
Increase
Access
POPULATIONS…
Elderly
Veterans
Military
Native Americans
Disabled
Children
Underserved
STAKEHOLDERS State, Local, Private
State Agencies
Local Agencies
Providers
Health IT Vendors
Payers
Others…..
COLLABORATION Federal Programs
Our Vision is to reform healthcare and centered on the citizen…
and how effective gov’t positively impacts quality, access and or effectiveness of the care ..
that results from federal agencies working together with each other and non-federal entities
As an outcome to our last meeting we developed this new framework. It begins with our VISION to reform healthcare.
The federal government has a significant stake – and role - in overall healthcare reform and the advancement of health information technology.  Some 40 percent of all healthcare expenditures are made by the federal government serving selected patient groups.        
The elements of healthcare reform are basic and our depicted as our GOALS _
We must improve the–
Improve Quality
Increase the Access to care
and finally reduce healthcare costs that are spiraling out of control.
Federal agencies have a vested interest in each of these components of reform.
In evaluating how we (the federal agencies) can have the most impact look at the POPULATIONS we serve. The list of populations depicted does not represent all the possibilities, but does provide a starting point.
From there, we look at where we can have the most impact – what programs serve the same populations, where are there opportunities to collaborate? How do they align with meeting our goals?
COLLABORATION is based on common needs in healthcare IT where agencies come together to create collaborative solutions that:
benefit multiple federal agencies;
bring solutions to achieve health information interoperability quickly;
and most importantly, serve their mission priorities to meet citizen needs.
RESULT
Improved Performance
PROCESS Solutions
Business
Needs
Architect
Investment
Implement 20 20 20

21. Common “Dial Tone” & Chain of trust
The Nationwide Health Information Network
State and Local Gov
Health Bank or PHR Support Organization
Community Health Centers
Community #1
CDC VA
FDA
DoD
SSA
Common “Dial Tone” & Chain of trust
Labs
Integrated Delivery System
Community #2
Pharmacies
The Internet
Standards, Specifications and Agreements for Secure Connections 21

22. CONNECT: Tools for Information Exchange
FHA’s CONNECT Initiative provides three related tools to enable organizations to connect to the NHIN:
The Gateway, which implements the core services defined by the NHIN
Enterprise Service Components, which provide robust tools for indexing patient identities, maintaining patient health documents, implementing business rules for authorizing the release of medical information and more
The Software Development Kit (SDK), which enables developers to customize the Gateway and add or replace enterprise service components 22

23. Collaboration you can be proud of!
CONNECT 2008 Progress
2008
2009
March 2008 CONNECT development started
Sep 2008
3 agencies demonstrated HIE with private sector
Dec 2008
6 agencies demonstrated HIE with private sector
2009
Plan to include all health agencies by end of year
Collaboration you can be proud of! 23

24. CONNECT Roadmap:
Participate in NHIN Trial Implementations
Develop first release of the Federal NHIN Gateway
Demonstrate value of connecting to the NHIN for agencies
Move selected agencies into production using NHIN
Use of NHIN to solve agency needs and improve performance
Distribute Gateway software to facilitate NHIN solution development by marketplace
Expand the set of agency programs using the NHIN
Begin the process of transitioning to gateway software provided by the marketplace
Complete process of transitioning to gateway software provided by the marketplace
Support every agency that performs health-related information exchanges using the NHIN
2008
2009
2010
2011

25. Private sector and Government Must Care
Data flow in our health care systems is a must for the coming years
Government – Ensure interoperability is in agency business and strategic plans.
Systems integrators: Support the federal, state, private providers and public health agencies transformation towards interoperability. Leverage the CONNECT tools as a means to integrate existing health information systems.
Product vendors: Create unique HIE solutions for the health marketplace by adding value on the CONNECT solution, or create your own products that provide NHIN services.
For this transformation to succeed, all of us must participate 25

26. What is Direct?
Allow individuals, providers and organizations to share information with best practices that have trust and privacy considerations
Health Information Service Provider (HISP)
Manage security/transport for directed exchange
Organizational model that performs HISP functions
Works to send/receive to organization or individual
Legal Business Associate Agreements with HIPAA
Includes all data collection, use, retention, and disclosure policies

27. One Possible Architecture

28. Biosurveillance Use Case
Transmit essential ambulatory care and emergency department visit, resource utilization, and lab result data from electronically enabled health care delivery and public health systems in standardized and anonymized format to authorized Public Health Agencies with less than one day lag time.
Source: HITSP Meeting, Arlington VA, September 20, 2006

29. AHIC Biosurveillance Use Case

30. AHIC-ONC BIO Consolidated Use Case
Biosurveillance
Patient-level data to Public Health
Message-based Submission
AHIC-ONC BIO Consolidated Use Case
HITSP
Biosurveillance – Patient-level and Resource Utilization Interoperability Specification
Transaction Package
Consumer/Patient Id X-ref
Transaction
Pseudonymize
Base
Std
HL7 QBP^Q23
RSP^K23
IHE XDS
Message-based
Scenario
IHE PIX PDQ
Component
Anonymize
Component
Encounter Msg
Component
Lab Report Message
Component
Radiology Msg
Component
Lab Terminology
Terminology
Standards
Base
Std
ISO
DTS/
25237
Base
Std
HL7V2.5
ADT^xxx
Base
Std
ISO ebRS 2.1/3.0
Base
Std
HL7 V2.5
Base
Std
HL7V2.5
ORU^R01
Base
Std
LOINC
HCPCS
HL7 V3
CPT
HL7 V2.5
CCC
SNOMED-CT
HIPAA
ICD 9/10
LOINC
DICOM
SNOMED-CT
NCCLS
UCUM
UB-92
URL
FIPS 5-2
HAVE

31. AHIC-ONC BIO Consolidated Use Case
Biosurveillance
Patient-Level Data to Public Health
Document-based Submission
AHIC-ONC BIO Consolidated Use Case
HITSP
Biosurveillance – Patient-level and Resource Utilization Interoperability Specification
Transaction Package
Consumer/Patient Id X-ref
Transaction Package
Manage Sharing of Docs
Document-based
Scenario
Transaction
Notif of Doc Availability
Transaction
Pseudonymize
Base
Std
HL7 QBP^Q23
RSP^K23
IHE XDS
IHE
XDS-I
IHE PIX PDQ
IHE
NAV
Component
Lab Report Document
Component
Anonymize
IHE
XDS-MS
IHE
XDS-LAB
Component
Lab Terminology
Terminology
Standards
Base
Std
HL7 CDA r2
Base
Std
ISO
DTS/
25237
Base
Std
ISO ebRS 2.1/3.0
Base
Std
HL7 V2.5
Base
Std
DICOM
Base
Std
LOINC
HCPCS
HL7 V3
CPT
HL7 V2.5
CCC
SNOMED-CT
SNOMED-CT
ICD 9/10
LOINC
HIPAA
NCCLS
UCUM
DICOM
UB-92
URL
FIPS 5-2
HAVE

32. Event Detection Hospital Ambulatory Care
Neighboring Jurisdictions
EHRS
Hospital
State Public Health Surveillance System
1- Report/retrieve symptoms, diagnosis & medication prescription data from EMRs
7 – Report on the positive case electronically & by phone
2 – Data mining of EMR notes
Ambulatory Care
3 – Notify on increased number of cases & recommend to order pathogen test
4 – Order
pathogen test
DHHS
Local Public Health Surveillance System
5 – Report
test results P U B L I C
6 – Report
positive
test result electronically & by phone
Media
Laboratory
Response Team
Pharmacy

33. Event Monitoring Hospital Ambulatory Care
Neighboring Jurisdictions
Hospital
EHRS
State Public Health Surveillance System
3 - Monitor ER visits & hospitalizations data from EMRs
1 – Send
health alert
2 - Monitor newly diagnosed cases & vaccination data from EMRs
9 – Send updates on the event
Ambulatory Care
4 – Order
pathogen test
6 – Send order to activate emergency
vaccination
Local Public Health Surveillance System
5 – Report
test results
10 – Send
health alert
to the public
DHHS P U B L I C
7 – Order/ Supply
vaccine
Media
8 – Monitor
vaccine
supplies
Lab
Response Team
Pharmacy

34. Event Management Hospital Ambulatory Care
Neighboring Jurisdictions
EHRS
Hospital
State Public Health Surveillance System
3 - Monitor ER visits, hospitalizations data from EMRs & utilization data
1 – Send
Outbreak updates
2 - Monitor newly diagnosed cases & vaccination data from EMRs
9 – Send outbreak updates
Ambulatory Care
4 – Order
pathogen test
6 – Send Rapid Flu Test Kits
10 – Send
outbreak updates
to the public
Local Public Health Surveillance System
5 – Report
test results
DHHS P U B L I C
9 – Activate
coordinated
response
7 – Deliver
vaccine
Media
8 – Monitor
vaccine
supplies
Lab
Response Team
Pharmacy

35. Cardiovascular Disease (CVD) Surveillance
Payor
Hospital
EHRS
State Public Health Surveillance System
9 - Monitor ER visits, hospitalizations data from EMRs & utilization data
1 – Conduct Routine Check-ups
4 – Prescribe Medication and Treatment Plan
11 – Send reports
Ambulatory Care
12– Conduct Surveys (BRFSS)
5 – Monitor Treatment
2 – Order
cholesterol test
7 – Report Data to Schools
Local CVD Surveillance System
3 – Report
test results
10 – Conduct Health
Education
DHHS P U B L I C
6 – Fill Prescription
8– Coordinate
Care
Media
Laboratory
School
Pharmacy

36. Asthma Surveillance Hospital Ambulatory Care
Payor
EHRS
State Public Health Surveillance System
9 - Monitor ER visits, hospitalizations data from EMRs & utilization data
1 – Conduct Routine Check-ups
4 – Prescribe Medication and Treatment Plan
11 – Send reports
Ambulatory Care
5 – Monitor Treatment
12– Conduct Surveys (BRFSS)
2 – Order
allergen test
7 – Report Data to Schools
Local Asthma Surveillance System
3 – Report
test results
10 – Conduct Health
Education
DHHS P U B L I C
6 – Fill Prescription
8– Coordinate
Care
Media
Laboratory
School
Pharmacy

37. State Health Department
EHR-PH System Prototype for Interoperability
in 21st Century Health Care System
Clinical Care
Public Health Surveillance
Hospital of Birth
State Health Department
ADT-
Birth Record
Newborn
Screening
Registry
HL7 2.4
HL7 3.0
Newborn Screening
Test
HL7 3.0
EHR-PH
Info Exchange
Hearing
Screening
Registry
HL7 3.0
HL7 3.0
Hearing
Screening
Test
HL7 2.4
Immunization
Registry
HL7 2.4
HL7 3.0
Immunization
Administration
HL7 2.4
Communicable
Disease
Registry
J2EE
HTB
External
Laboratory
J2EE
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Healthcare
Transaction
Viewer
HTB – Health Transaction Base
Source: Orlova, et al. HIMSS 2005,Dallas TX, February 13-17, 2005 and AMIA, Washington DC, November, 2005

38. EHR-PH System Prototype for Interoperability in 21st Century Health Care System
Clinical Care
Public Health Surveillance
Our Prototype
Shows how interoperability between healthcare systems can be achieved with a standards-based infrastructure
Is built upon existing systems in clinical care and public health programs
Enables electronic data reporting from a clinical setting to multiple public health systems
Enables translation of customized standards into HL7 3.0 messaging standard
Links clinical and public health systems to provide a continues view of the patient record across the systems involved
This presentation is structured according to the following outline.
The first section will describe the product vision.
The articulation of this vision will delineate the problem addressed by the product.
The second section will describe the features of the product in the first release.
The final section describes a typical project that makes use of these features.