Post on 26-Dec-2015
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Organizing IHE Integration Profilesrelated to the Electronic Health Record
Initial Thoughts
IHE ITI Tech Committee - November 2002
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IHE Integration Profiles Focused on the EHRIHE Integration Profiles Focused on the EHR
• An IHE Integration Profile organizes a set of coordinated, standards-based transactions between a subset of the functional components of healthcare enterprises in order to address a specific clinical or infrastructure need.
• IHE develops such solutions for IT systems integration in a stepwise and pragmatic manner, focusing on the most common integration challenges.
• IHE has developed close to 20 Integration Profiles focuses on Radiology, Laboratory, IT Infrastructure (MPI, Security, etc.) and is now expanding to Cardiology. This is an intra-enterprise, bottom-up approach.
• In this proposal, IHE explains how it intends to approach the longitudinal dimension of the EHR with a distributed, cross-enterprise, document centric, top-down point of view.
• The strategy is to progressively bridge the two approaches as new integration profiles are developed.
Feedback on this approach and expanding collaborations are sought.
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WardsAnesthesia
Pneumology
Order and others inputs
RegistriesKnowledge
Result andOthers outputs
(event)Process
EHR
Control (Rules, procedures,reporting)
Resources
Order and others inputs
DirectoriesKnowledge
Result andOthers outputs
(event)Process
EHR
Control (Rules, procedures,reporting)
Resources
General Practionner
Acute Care (Inpatient)
GPs and Clinics (Outpatient)
Nursing Homes
Other Specialized Careor Diagnostics Services
Continuity of Care: Patient Longitudinal Record Across Encounters
A typical patient goes through a sequence of encounters in different Care Setting (incl. Diagnostics Services).
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Order and others inputs
DirectoriesKnowledge
Result andOthers outputs
(event)Process
EHR
Control (Rules, procedures,reporting)
Resources
General Practionner
Order and others inputs
DirectoriesKnowledge
Result andOthers outputs
(event)
Process
EHR
Control (Rules, procedures,reporting)
Resources
General Practionner
WardsAnesthesia
Pneumology
Order and others inputs
RegistriesKnowledge
Result andOthers outputs
(event)Process
EHR
Control (Rules, procedures,reporting)
Resources
Acute Care (Inpatient)
GPs and Clinics (Outpatient)
Nursing Homes
Other Specialized Careor Diagnostics Services
EHR-S ≈ Entire SystemEHR-LR= The Longitudinal Record of a person’s health
Integration : Feeding & Accessing the Longitudinal Health Record Information
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Care Delivery Process
Act lifecycle
ServicesOrders Results
Act lifecycle
Selection of informations
Decide toAssess demand For care
Actions to order
Define an action plan
Identification End ofEncounter
Define healthcareObjective
EHR-CREHR-CR : EHR information supporting immediate care deliveryEHR-LREHR-LR : EHR information supporting long term care delivery
Two types of Integration : Health Record as used during care delivery Health Record as used across-encounters
EHR-CRR = read
KnowledgeDirectoriesEHR-LR
KnowledgeDirectoriesEHR-LR
R=Read
EHR-LR
CreateUpdate
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Order and others inputs
DirectoriesKnowledge
Result andOthers outputs
(event)Process
EHR
Control (Rules, procedures,reporting)
Resources
General Practionner
WardsAnesthesia
Pneumology
Order and others inputs
RegistriesKnowledge
Result andOthers outputs
(event)Process
EHR
Control (Rules, procedures,reporting)
Resources
Order and others inputs
DirectoriesKnowledge
Result andOthers outputs
(event)
Process
EHR
Control (Rules, procedures,reporting)
Resources
General Practionner
Acute Care (Inpatient)
GPs and Clinics (Outpatient)
Nursing Homes
Other Specialized Careor Diagnostics Services
EHR-S ≈ Entire SystemEHR-LR= The Longitudinal Record of a person’s healthEHR-CR= Care-delivery Record
Integration : Feeding & Accessing the Longitudinal Health Record Information
EHR-LR
EHR-CR
EHR-CREHR-CR
EHR-CR
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EHR-LR Documents Repository
Custodian for an unspecified time of Documents recorded from patient encounters.
EHR-LR Directory
EHR-LR Directory
EHR-LR Documents Virtual Repository
Custodian for an unspecified time of Documents recorded from local patient encounters.
EHR-LR Encounter/Documents Directory
EHR-LR Use Cases: Directory Concept, Core Actors D
ocu
men
t C
reat
or
Do
cum
ent
Cre
ato
r Do
cum
ent
Co
ns
um
er
Do
cum
ent
Co
ns
um
er
EHR-LR Directory
EHR-LR DirectoryEHR-LR Directory
EHR-LR Encounter/Documents Directory
EHR-LR Documents Repository
Custodian for an unspecified time of Documents recorded from patient encounters.
Registerand Provide Doc
Register Doc
RetrieveDoc
QueryDoc List
EHR-CR
EH
R-
CR
Not all transactions necessary to ensure management of a distributed and dynamic EHR-LR are depicted in this illustration.
EHR-LR
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Key Statements : IHE Focuses on the EHR-LRIHE Focuses on the EHR-LR
1. The EHR-LR (Longitudinal Record) federates patient encounter information managed by “EHRs within an enterprise” (EHR-CRs). EHR CRs (Care-delivery Record) may range from a large EHR of an IDN enterprise all the way down to a single practice management system.
2. EHR-LR includes repositories of encounter data that contribute to the patient’s longitudinal healthcare record. EHR-LR data will be stored in multiple repositories (depts., sites, domains).
3. Encounter data includes some information/state/workflow info that may not end up in the EHR-LR.
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Key Statements: What is in the EHR-LR ? What is in the EHR-LR ? 1. The EHR-LR data is made of discrete, persistent, logical
documents (structured or not) which may be accessed by a unique identifier.
2. Relevant clinical domain standards would be used to format EHR-LR data. This body of clinical domain standards and the domain clinical practice will dictate evolution.
3. EHR-LR will likely be initially focused on certain specialties (cardiology, oncology, etc) or a key information for continuity of care (CCR summaries only) and expand progressively.
4. Conversion between EHR-CR data “formats” and EHR-LR document “formats” is the responsibility of the EHR-CR.
5. At the end of an encounter, new document(s) are added to the EHR-LR. These new EHR-LR docs could be stored (in any form) in the EHR-CR where they are created or pushed to a separate EHR-LR repository (in a standard format).
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Key Statements : IHE ConstraintsIHE Constraints
1. The domains of EHR content are primarily clinical. Other information and services are needed to provide an operational EHR-LR environment (e.g. demographics, security, consents – IHE has already addressed some).
2. The EHR-LR and EHR-CR repositories may be using different Patient Ids.
3. The care-delivery view and form of current encounter data (EHR-CR) is out of scope of EHR-LR IHE Integration Profiles.
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Key Statements : Accessing EHR-LRAccessing EHR-LR1. EHR-LR shall provide a list of available documents for a
patient. Logical directories are necessary to provide such document lists.
2. The full burden of locating and filtering documents should not be placed on the EHR-LR consumer applications. The EHR-LR needs to have some meta-information about the documents it tracks.
3. There is a need for the EHR-LR to provide a means to retrieve the clinical documents that have been registered with full content fidelity.
4. There is a also a need for the EHR-LR to provide clinical data to consumer applications based on processing, extracting, or combining the content of multiple existing documents.
5. Documents may reference other documents including images, waveforms, etc.
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Acute Care (Inpatient)
EHR-LR= The Longitudinal Record of a person’s healthEHR-CR= Care-delivery Record
Integration Profiles : Current Profiles vs “EHR-LR Profiles
EHR-LR
EHR-CR
EHR-CR
EHR-CR
EHR-CR
Nursing Homes
Other Specialized Careor Diagnostics Services
IHEIntegration Profile
(e.g. IT Infrastructure
IHEIntegration Profile
(e.g. Lab, Cardio, etc)
IHEIntegration Profile
(e.g. Lab, Cardio, etc)
IHEIntegration Profile
(e.g. Lab, Cardio, etc)
IHEIntegration Profile
(e.g. Lab, Cardio, etc)
IHEIntegration Profile
(e.g. IT Infrastructure
IHEIntegration Profile
(e.g. IT Infrastructure
IHEIntegration Profile
(e.g. Lab, Cardio, etc)
GPs and Clinics (Outpatient)
Patient Access IHEIntegration Profile
Domain SpecificDoc Content
IHEIntegration Profile
Domain SpecificDoc Content
IHEIntegration Profile
Domain SpecificDoc Content
IHEIntegration Profile
(e.g. Cross-enterprise Security, LR Management, etc.
IHEIntegration ProfileX-Enterprise Security, MPI
LR Register, Retrieve.
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EHR-LR Integration Profiles : Infrastructure(s) + Content(s)
EHR-LR Security, MPILR Register, Retrieve. Integration Profile(s)
ZZZ Content Integration
Profile
YYY Content Integration
Profile
XXX Content Integration
Profile
In PatientIn PatientOutpatientOutpatientLinkLink
CardiologyCardiologySpecialist toSpecialist toAcuteAcute
OncologyOncologySpecialist toSpecialist toAcuteAcute
Etc….Etc….
. . . .
. . . .
EHR-LR Security, MPILR Register, Retrieve. Integration Profile(s)
EHR-LR Security, PIXLR Register, Retrieve. Integration Profile(s)
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Some examples applying this EHR ConceptSome examples applying this EHR Concept
• Following are three examples where the same “EHR-LR integration concept would be applicable:
• GP Office in multiple IDNs with an EHR-LR ASP: GP linkage to acute care
• Cardiologist Practices and Inpatient: a domain specific longitudinal record
• Region or Country-Wide: a broad cross-domain longitudinal record
• These examples largely rely on the same set of core-EHR-LR IHE Integration Profiles, but used with different configurations and policies. The EHR-LR documents content would greatly vary.
• These examples are not intended to be exhaustive, but attempt to demonstrate the balance that IHE is looking for a reasonably broad set of use cases that would share the same infrastructure (i.e. set of actors and transactions).
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EHR-LR Patient/Encounter Level Directory
EHR-LR Encounter/Documents Level Directory
Example : GP Office in multiple IDNswith an EHR-LR ASP
One Directory by IDN.Holds a reference to all encountersknown by the IDN, including thosefrom the GP
This Encounter Directory manages allencounters form the GP. It is an EHR-LRASP. This ASP system is also theprimary EHR-CR or all documentscreated by the GP’s encounters.EHR-LR Documents Repository
EHR-LR Patient/Encounter Level Directory
GP Practice Clinical Record Entry Document Creator and Consumer
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EHR-LR Encounter/Documents Level Directory
Example : Cardiologist Practices and Inpatient
IDN and associated Cardiologists establisha Central Directory.Holds a reference to all encountersknown by the IDN and Cardiologist
This Encounter Directory manages allencounters form the Cardiologists.It is an EHR-LR with all documentscreated by Cardiology encounters.
EHR-LR Documents Repository
Cardiologist Practice Clinical Record Document Creator and Consumer
EHR-LR Patient/Encounter Level Directory
CardiologyInpatient Clinical Record Document Creator and Consumer
CardiologyInpatient Clinical Record Document Creator and Consumer
Cardiologist Practice Clinical Record Document Creator and Consumer
Cardiologist Practice Clinical Record Document Creator and Consumer
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EHR-LR Patient Level Directory
EHR-LR Documents Repository
EHR-LR Encounter/Documents Level Directory
Example : Regional or Country-Wide (e.g. NHII)
One such Patient Directory by region.Shadows copies. Knows all lower leveldirectories where encounters are identified.
One such P/E Directory by region.Holds a reference to all encountersmade in the region.
One such E/D Directory by EncounterCustodian used by the health deliveryentity where the encounter happen
One or more document repository by document custodians used by the health delivery entity where the encounter happen or external.EHR-LR Documents Repository
EHR-LR Documents Repository
EHR-LR Encounter/Documents Level Directory
EHR-LR Encounter/Documents Level Directory
EHR-LR Patient/Encounter Level Directory
EHR-LR Patient/Encounter Level Directory
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IHE Integration Profiles Focused on the EHRIHE Integration Profiles Focused on the EHR • In this proposal, IHE has proposed an approach the longitudinal
dimension of the EHR, with a distributed, cross-enterprise, document centric, top-down point of view.
• The strategy is to progressively bridge the gap from these EHR-LR Integration Profiles with the current care-settings centric approach as new integration profiles are developed.
Feedback on this approach and expanding collaborations are sought.
Is this a useful “brick” ?
• The proposed strategy is a scoping exercise to address one of the many 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.
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Draft IHE IT Infrastructure RoadmapDraft IHE IT Infrastructure Roadmap
In support of the IHE Integration ProfilesIn support of the IHE Integration Profilesfocused on the EHRfocused on the EHR
Draft for Comments – 11/03To be finalized January 2004.
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IHE IT Infrastructure Roadmap – HIMSS 2004 (1)IHE IT Infrastructure Roadmap – HIMSS 2004 (1)
EHR Security Common Data
Profiles RID PIX PSA
Profiles EUA CT
No content
Standards & Prerequisites CCOW v1.4 Patient Context HL7 v2.3.1 HL7 v2.4 HTTP WSDL 1.1 XHTML 1.0 XML 1.0
Standards & Prerequisites CCOW v 1.4 User Context Kerberos NTP SNTP
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IHE IT Infrastructure Roadmap - Next Stage (2)IHE IT Infrastructure Roadmap - Next Stage (2) EHR Security Common Data
Profiles EHR-LR- Provide Document- Register Document- Query Document(s)- Retrieve Document Patient Demographics Query - enterprise
Profiles Take-on Basic Security- Common Audit schema - Node authentication PKI User demographics directory- Healthcare staff- Patients?
Profiles LDAP base- Federated- Multiple information bases: equipment, organizations, users Reference code sets- Distribution- Update SNMP MIBS?- Event reports- Equipment calibration changes- Equipment and software change management & tracking- Event trending
Standards & Prerequisites Stage 0 IHE ITI profiles- PIX-enabled EMPI service CDA level 1- ASTM E31.28 CCR encoding
Standards & Prerequisites IHE Radiology Basic Security Stage 0 IHE ITI security profiles RFC 2798 ITU X.509(95) Stable Common Audit Message RFC
Standards & Prerequisites LDAP SNMP- MIB standards / registry Mature/stable standards for selected code sets
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IHE IT Infrastructure Roadmap – Stage 3 IHE IT Infrastructure Roadmap – Stage 3 EHR Security Common Data
Profiles EHR-LR- Solidify step 1- Add 2 composite information sets (candidates: allergies, discharge summaries, medication lists; consult with IHE clinicians on choices)- RAD plug-in Patient Demographics Query - multi-enterprise
Profiles Incorporate Kerberized standards into EUA- DICOM- HL7 v2 (v3?)- HL7 CCOW User PKI- Enterprise- Patients- Multi-enterprise?- Key distribution
Profiles Masterfile Maintenance Additional LDAP information sources RID configurability directory #1
Standards & Prerequisites Stage 1 IHE ITI profiles Additional CDA templates PKI for user identify management
Standards & Prerequisites Stage 1 IHE ITI security profiles Stable Kerberos support in:- HL7 v2.6- CCOW- DICOM PKCS#10 ISO/TS 17090
Standards & Prerequisites Stage 1 IHE ITI common data profiles HL7 v2 Masterfile maintenance Mature/stable standards for selected information sources Suitable LDAP schema definitions
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IHE IT Infrastructure Roadmap – Stage 4IHE IT Infrastructure Roadmap – Stage 4
EHR Security Common Data
Profiles EHR - Lab trending - Consents- Medication list
Profiles Add attribute certificates to PKI to support:- Basic RBAC- Consents? Multi-entity EUA Digital signatures
Profiles Additional LDAP information sources RID configurability directory #2 Workflow management preferences?
Standards & Prerequisites Stage 2 IHE ITI profiles IHE Lab profiles Basic RBAC
Standards & Prerequisites Stage 2 IHE ITI security profiles Mature attribute certificate distribution specification/standard ISO/TC 215 Privilege Management Infrastructure specification
Standards & Prerequisites Stage 2 IHE ITI common data profiles Mature/stable standards for selected information sources Suitable LDAP schema definitions
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IHE IT Infrastructure Roadmap – Stage 5IHE IT Infrastructure Roadmap – Stage 5
EHR Security Common Data
Profiles EHR-LR- More document types (general document templates)- More clinical domains (cardiology, nuclear medicine, pharmacy, ...)- Composite documents from multiple clinical domains.
Profiles Remote service access Anonymization Wide-area patient access Mobile applications- Wireless- Patient active homecare- Mobile providers Location-sensitive behaviors Patient identification standards
Profiles RID configurability directory #3- "Hanging protocols"
Standards & Prerequisites Stage 3 IHE ITI profiles IHE clinical domain uptake
Standards & Prerequisites Stage 3 IHE ITI security profiles Stable standards for mobile access security Stable standards for patient identification
Standards & Prerequisites Stage 3 IHE ITI common data profiles Suitable LDAP schema definitions