1. Integrating the Healthcare Enterprise IHE Technical Committee Status IHE ITI Plan Committee - February 2004

2. IHE IT Infrastructure-2004 5 Integration Profiles Enterprise User Authentication Provide users a single name and centralized authentication process across all systems Enterprise User Authentication Provide users a single name and centralized authentication process across all systems Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Retrieve Information for Display Access a patient’s clinical information and documents in a format ready to be presented to the requesting user Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Patient Identifier Cross-referencing for MPI Map patient identifiers across independent identification domains Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Synchronize multiple applications on a desktop to the same patient Patient Synchronized Applications Consistent Time Coordinate time across networked systems Consistent Time Coordinate time across networked systems

3. IHE IT Infrastructure – Plan for 2004-2005 IT Infrastructure Development Plan: IHE ITI Planning Committee decision:mid-FebruaryIHE ITI Planning Committee decision:mid-February Issue Public Comment version: June 2004 Public Comment Due:July 2004 Issue Trial Implementation version: August 2004Issue Trial Implementation version: August 2004 IHE Connectathon: January 2005 HIMSS Demo: February 2005HIMSS Demo: February 2005 Profiles discussed this week are: Audit Trail and Node AuthenticationAudit Trail and Node Authentication Personnel White Page DirectoryPersonnel White Page Directory Patient Demographics QueryPatient Demographics Query EHR-Cross-Enterprise Clinical Document SharingEHR-Cross-Enterprise Clinical Document Sharing

4. IHE Authentication Audit Trail Scope – Ensures that only permitted system/devices connect to network Authentication is node-to-node Note: User authentication covered by the EUA profile or local procedures. – Support for a central repository of audit information. Facilitates audit review and includes: General security events such as logins, file access, and detection of unauthorized activity Healthcare privacy events such as access to patient data and applications. Imaging privacy/security events such as access to patient images.

5. IHE Authentication and Audit Key technical properties – Node-to-node authentication uses X.509 certificates, but PKI is not specified by IHE yet. – Audit messages use a standardized XML format (IETF RFC Pending) – Transport for audit messages may use syslog or reliable syslog – Backwards compatibility with IHE Radiology (year 2002) is preserved.

6. Personnel White Pages Directory Scope White Pages Server Healthcare Staff Info Provide access to healthcare staff information to systems in a standard manner. Lab Reporting Electronic Medical Records Pharma Healthcare Staff Info

7. Personnel White Pages Directory Technical Properties LDAP based directory location service LDAP based requests of person info leveraging inetOrgPerson. Specializes for Healthcare: Contact Info (Phone Numbers, email address, etc), and user interface friendly info (Salutation, First name, Last name, office building, user certificate list-no PKI). Access certificate revocation list (no use rule defined).

8. Patient Demographics Query Abstract/Scope Allow quick retrieval of common patient name, identifier, and location in a standard manner at the point of care. Enable selection of correct patient when full identification data may not be available Protect patient- and enterprise-sensitive clinical information

9. Patient Demographics Query Key Technical Properties Employs HL7 Conformance Based Queries – Defined in HL7 Version 2.5, Chapter 5 – Query by Parameter (QBP) with Segment Pattern Response (RSP) User enters identifiers for patients of interest Server returns information in HL7 V2.5 patient data segments.

10. Introduction: EHR Cross-Enterprise Clinical Document Sharing First step towards the longitudinal dimension of the EHR: Focus: Clinical Information Exchange between EHRs in care settings to communicate with a distributed longitudinal EHR. Goal: Meet a broad range of EHR-LR (Longitudinal Record) needs with a distributed, cross-enterprise, document centric document content generic

11. Acute Care (Inpatient) GPs and Clinics (Outpatient) Nursing Homes Other Specialized Care (incl. Diagnostics Services) Continuity of Care : Patient Longitudinal Record Typically, a patient goes through a sequence of encounters in different Care Setting

12. Acute Care (Inpatient) GPs and Clinics (Outpatient) Nursing Homes Other Specialized Care or Diagnostics Services EHR-LR Integration Profiles: Publishing & Accessing the EHR-LR EHR-LR The EHR-LR (Longitudinal Record) brings together patient encounter information managed by multiple care delivery systems

13. Care Delivery Process Selection of informations Decide to Assess demand For care Actions to order Define an action plan Identification End of Encounter Define healthcare Objective EHR-Solution = EHR-LR (Longitudinal Record) + EHR-CR (Care Delivery Record) Two types of Integration : EHR-CR: Health Record as used during care delivery EHR-LR: Health Record as used across-encounters EHR-CR Read EHR-LR Read EHR-LR Create Update

14. Key Statements: EHR-LR Fundamentals Brings together patient encounter information managed by all types of care delivery systems. Cross-enterprise, possibly across large geographical regions, and may include many clinical domains. Typically collected and retained over a large period of time, providing a deep historic record for the patient. Supported by multiple repositories that contribute to the patient’s longitudinal healthcare record. Encounter data will very likely include some clinical documents, state and workflow information that will not be stored in the EHR-LR.

15. What is in the EHR-LR? Key Statements: What is in the EHR-LR? The EHR-LR data is made of discrete, persistent, clinical documents accessed by an unique identifier. It may also contain other dynamic objects which are not being addressed by IHE at this time. Metadata will be provided with each document by the EHR-CR and will be stored in the EHR-LR. EHR-LR data formats will follow relevant clinical domain standards defined by field experts. EHR-CR is responsible for converting its internal data formats to the standard EHR-LR documents. EHR-LR documents will kept in the EHR-CR or pushed to a separate EHR-LR repository.

16. Key Statements: IHE EHR Profiles Constraints Although the EHR-LR data domains are primarily clinical, other information and services are needed to provide a complete view of the patient longitudinal record. These include patient demographics, access security, consent policies and others – some have already been addressed by IHE integration profiles. The EHR-LR and EHR-CR repositories may be using different Patient Identification numbers. The longitudinal view is made possible by using standard cross-patient identification services (IHE PIX Integration Profile). The way data is stored and managed internally by the EHR-CR is out of scope for the EHR-LR IHE Integration Profiles.

17. Accessing the EHR-LR Key Statements: Accessing the EHR-LR EHR-LR shall make available a list of all published documents for a given patient/selection parameters. The selection of documents is the responsibility of the EHR- LR and not of the consumer applications. This is possible because of the document metadata kept in the EHR-LR. The EHR-LR must ensure full content fidelity for all clinical documents that have been published. The actual location of any particular document shall be transparent to the consumer application. EHR-CR may provide clinical data by processing, extracting, or combining multiple documents.

18. Key Statements: Deploying IHE EHR-LR Profiles The deployment of EHR-LR integration profiles will initially be focused on a small number of specialties (cardiology, oncology, etc), disease, and/or on key information for continuity of care (e.g. CCR summaries). The scope of the EHR-LR profiles will expand progressively as other specialties are included in the use cases.

19. EHR-CR Source – Healthcare point of service system where clinical information is first collected EHR-LR Directory – Index and metadata database for all published clinical documents EHR-LR Documents Repository – Maintains and stores published EHR-LR documents EHR-CR Consumer – Application system that needs access to EHR-LR documents and information Key Actors (Application Roles) EHR-LR Integration Profile: Key Actors (Application Roles)

20. Integration Model 1: EHR-LR with Source Repository 1.An EHR-CR completes a phase of care for a patient where it: 1.Registers documents with an EHR-LR Directory actor. 2.Keeps these documents in an EHR-LR Repository actor. 2.Any other EHR-CR may query an EHR-LR Directory actor, find out about documents related to all phases of care for the patient and chose to retrieve some of these documents from any EHR- LR Repository Actor (Used in use Case 1 & 2). EHR-CR Source EHR-LR Directory EHR-LR Repository EHR-LR Consumer Register Retrieve Query

21. Integration Model 2: EHR-LR with Third Party Repository 1.An EHR-CR completes a phase of care for a patient where it: 1.Registers documents with an EHR-LR Directory Actor. 2.Provides these documents to an EHR-LR Repository Actor. 2.Any other EHR-CR may query an EHR-LR Directory Actor, find out about documents related to all phases of care for the patient and chose to retrieve some of these documents from any EHR- LR Repository Actor (Used in use Case 1 & 2). EHR-CRSource EHR-LR Directory EHR-LRRepository EHR-LRConsumer Register Retrieve Query Provide-Transfer

22. EHR-CRConsumer Integration Model 3: Direct Patient Transfer-Referral 1.An EHR-CR completes a phase of care for a patient where it: Registers and Provides an EHR-CR Recipient Actor that a specific set of documents (newly created and priors of interest documents) are available from an EHR-LR Repository 2.The EHR-CR Recipient Actor receive both the registration and the documents. EHR-CRSource Register Provide-Transfer EHR-LR Directory EHR-LRRepository

23. Conclusion: EHR Cross-Enterprise Document Sharing Leverages HL7 CDA (Clinical Document Architecture) and ASTM CCR (Continuity of Care Record). The proposed strategy addresses one of the key integration problems in the realization of the EHR vision. IHE does not claim to master and address the definition and all aspects of a complete and interoperable EHR System. In collaboration with well established standards bodies and other EHR related initiatives world-wide (EHRCOM, CCR, HL7, etc.), IHE expects to contribute at a more cost-effective and rapid deployment.

24. IHE IT Infrastructure To join IT Infrastructure planning or technical committee: Contact Joyce Sensmeier, HIMSS. jsensmeier@himss.org Suggest new profiles to IHE IT Infrastructure Planning Produce new profiles in IHE IT Infrastructure Technical Committee