Healthcare Information Exchange Software Testing...RHIO / HIE Regional Health Information...

May 20, 2009 AFour Technologies © 2009 1

Healthcare Information Exchange

Software Testing

AFour Technologies


Healthcare Background• With increasing healthcare costs and looming Medicare bankruptcy,

President George Bush issued an executive order for the

development and nationwide implementation of an interoperable

health information technology infrastructure to improve the quality

and efficiency of health care with the goal that most Americans will

have an EHR by 2014.

• In July 2004 the United States Department of Health and Human

Services released their vision of how America’s healthcare system

could be rebuilt during the next decade. That vision is in the process

of maturing and the lead in this effort is the Office of the National

Coordinator for Health Information Technology

http://en.wikipedia.org/wiki/United_States_Department_of_Health_and_Human_Services

http://en.wikipedia.org/wiki/United_States_Department_of_Health_and_Human_Services

http://en.wikipedia.org/wiki/Office_of_the_National_Coordinator_for_Health_Information_Technology

http://en.wikipedia.org/wiki/Office_of_the_National_Coordinator_for_Health_Information_Technology


RHIO / HIERegional Health Information Organizations (RHIOs) are key to the US National

Health Information Network (NHIN).[1] The Office for the National Coordinator has

contracted with the National Alliance for Health Information Technology to lead

workgroups of national experts in defining key terms including RHIO and to solicit

public comments. The effort began in late 2007 and has submitted their final

definition for public comment in May 2008

Definition of a RHIO - "A health information organization [HIO] that brings together

health care stakeholders within a defined geographic area and governs health

information exchange [HIE] among them for the purpose of improving health and care

in that community.“

Health information exchange (HIE) is "The electronic movement of health-related

information among organizations according to nationally recognized standards".

The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer,

more timely, efficient, effective, equitable, patient-centered care. HIEs also provide

the infrastructure for secondary use of clinical data for purposes such as public

health, clinical, biomedical, and consumer health informatics research as well as

institution and provider quality assessment and improvement.

http://en.wikipedia.org/wiki/United_States

http://en.wikipedia.org/wiki/National_Health_Information_Network

http://en.wikipedia.org/wiki/National_Health_Information_Network

http://en.wikipedia.org/wiki/Health_information_exchange


Key TermsEHR – Electronic Health Record

Comprises of HIE Systems and EMRs

EMR – Electronic Medical Record

Patient information in the electronic formats

Systems managing electronic medical records

HL7 – Health Level 7 Protocol

High level protocol defined by hl7 organization (www.hl7.org) accredited by ANSI

Identifies HIE standards

MPI – Master Person Index (Also referred as master patient index)

Store Demographic Information of Patients

Intelligent grouping of patient information from various EHRs

Retrieval of patient information based on query parameters

EMPI – (Enterprise master person index)

MPI is also referred as EMPI

http://www.hl7.org/


Initiatives• HIMSS (www.himss.org) Healthcare Information Management and System Society in

collaboration with ANSI have come up with HITSP to achieve vision of

implementation of interoperable electronic health records (EHR) by 2014

• HITSP (www.hitsp.org) - Health Information Technology Standards Panel is formed

with public and private industry collaboration and is active in coming up with

standards related to HER (Electronic Records System) and HIE (Health Information

Exchange Systems). HITSP implements standards of HL7

• IHE (www.ihe.net) - IHE is an initiative by healthcare professionals and industry to

improve the way computer systems in healthcare share information. IHE promotes

the coordinated use of established standards such as DICOM and HL7 to address

specific clinical need in support of optimal patient care.

Some key profiles from IHE are PIX, PDQ, XDS.b, CT, ATNA

• CCHIT (www.cchit.org) Center Commission for Health Information Technology is a

non profit organization recognized by Department of Health and Human Services

(HHS) . CCHIT provides certifications for various modules of EHR. Yearly certification

programs are offered by CCHIT.

ARRA 2011 - is a preliminary certification for EHR by CCHIT and accredited by HHS

(health and human services)

http://www.himss.org/

http://www.hitsp.org/

http://www.ihe.net/

http://www.cchit.org/


Initiatives• HL7 (www.hl7.org) is an open forum who is accredited by ANSI. HL7 defines

specifications for the Health Information Exchange (HIE) protocols. Latest version of

2.5.1 is recommended for implementation.

• DICOM - The DICOM 3.0 standard evolved from versions 1.0 (1985) and 2.0 (1988)

of a standard developed by the American College of Radiology (ACR) and National

Electrical Manufacturers Association (NEMA). This standard deals with the way

binary data exchanged across systems (e.g. digital images)

• HITECH - On February 17, 2009 a $787 Billion, the American Recovery and

Reinvestment Act of 2009 aka “the Stimulus Bill,” was signed into law by the federal

government. Included in this law is $22 Billion and $19.2 Billion of that is intended to

be used to increase the use of Electronic Health Records (EHR) by physicians and

hospitals; this portion of the bill is called, the Health Information Technology for

Economic and Clinical Health Act, or HITECH Act. The government firmly believes in

the benefits of using electronic health records and is ready to invest federal resources

to proliferate its use. Title XIII in Division A, pages 112 through 165 and Title IV in

Division B, pages 353 through 398, cover the HITECH portion of this economic

recovery act.

http://www.hl7.org/

http://www.recovery.gov/




http://www.himss.org/ASP/topics_ehr.asp

http://en.wikisource.org/wiki/American_Recovery_and_Reinvestment_Act_of_2009/Division_A/Title_XIII

http://en.wikisource.org/wiki/American_Recovery_and_Reinvestment_Act_of_2009/Division_B/Title_IV


EHR AccreditationsIHE Connectathon

IHE (www.ihe.net) organization conducts yearly evaluation events (usually in the

month of January / February) called Connectathon

IHE proposes various HIE specifications and publishes the specifications based

on feedback from open forum

These specifications are called profiles (e.g.)

Patient Information Cross Sharing (PIX)

Patient Demographic Query (PDQ)

Cross Enterprise Document Sharing (XDS.b)

Audit Trail and Node Authentication (ATNA)

Consistent Time (CT)

CCHIT Certification

CCHIT provides certification to EHR systems (e.g.)

Comprehensive Certification - CCHIT Certified 2011

Preliminary Certification - Preliminary ARRA 2011

http://www.ihe.net/


Case Study – HIE Testing

Client

The client is a start up organization with range of

products catering to healthcare IT.

Flagship product is a middleware application for

HIE services.

Head office and business center at Seattle USA

and ODC at Bangalore India.

Engineering team size is 30 with 22 Developers

and 8 Test Engineers


Case Study – HIE TestingProduct – The product provides following key services

Connecting healthcare applications node (e.g. hospital systems, labs,

PHRs)

Storing demographic information of patients

Allowing patients to view and update their demographic information

Allowing patients to view and update their clinical information (e.g.

problems, allergies, medications)

Managing consents of information disclosure of patients

Integration with various EMRs (using HL7 2.3.1 and 2.5 versions)

Providing demographic information of patients upon requests to various

EHRs

Publishing updates to the patient information to all associated nodes

Intelligent automated grouping of patients based on the demographic

information

Admin assisted grouping of patient information

Integration with known systems such as Microsoft HealthVault

Integration with Cerner Health Information System



Business Challenge

Client is a start up organization

QA activities were more subjective

QA learnt product functionality after code complete with knowledge

transfer from developers

QA largely doing unit testing with very little test coverage

No process to certify major releases

No process to certify hot fixes

No test automation process

No performance testing process

Product documentation not updated

API documentation not frozen before API changes



Technologies

Microsoft Windows based technologies

Windows 2003 Server, Windows 2008 Server

.Net 2.0 and 3.5

SQL Server 2005, 2008

ASP.Net Web Services

SSL

UI is mix of web and Windows forms.

Test Tools

Mantis, Testlink, SOAPUI



Proposed Solution

Client approached AFour in order to help the client

establish QA organization and testing processes

Engagement is phased in multiple initiatives



Initiative 1 – Pilot to address immediate quality issues Included test automation

Included test strategy for consequent phases

Initiative 2 – IHE Compliance TestingTesting of PIX profile (Used Mesa Tools)

Testing of PDQ profile (Used Mesa Tools)

Testing of XDS.b profile (Used Mesa Tools)

Testing of ATNA profile (This is taken out of mandatory IHE compliance)

Testing of CT profile (This is verified with required configurations)

Initiative 3 – Managed “test execution” of a core product

componentTest Case Documentation

Managed Test Case Execution

Certified Test Release



Initiative 3 – introduced Tools and ProcessesIntroduced open source Defect Management System – Mantis

Introduced open source Test Management System – Testlink

Defined processes to manage defects and test cases

Initiative 4 – Managed “test execution” of entire product

(all components)Test Case Documentation

Managed Test Case Execution

Certified Test Release



Initiative 5 – Test AutomationAPI Automation (Web Services Automation)

UI Automation (using internal test automation tools / open source tools)

Initiative 6 – Performance Testing / Stress TestingSetup Performance Lab

Identify Performance Goals

Identify Performance Bottlenecks and verify fixes to the bottlenecks

Publish Performance Benchmarks



Business ImpactReduced number of test cases to organized 3000 test cases from 10000

test cases

Setup defined period of 3 weeks for one test pass execution against

undefined test pass execution period (spanning for 6 weeks)

Reduced number of post release issues to less than 10 times


Case Study – HIE TestingFuture Initiatives – API Documentation, Security Testing, Product

Documentation

QA Organization –

Team works in the mixed mode.

Team works at client premises and AFour premises

Test lead from AFour heads the team

Test lead reports to head of engineering / top management at

USA. No reporting to engineering team at India

COE from AFour premises provide solutions to the issues faced

by QA team at client premises



Gains for AFour TeamUsed SOAP UI for functional and performance testing

Worked on Web service testing

Worked on functional, performance testing of middleware testing

Mastered using MESA tools for IHE compliance testing of PIX, PDQ

and XDS.b profiles

Learnt about HL7 messages for various triggers such as ADT, ORM,

ORU, PPR, PDQ, PIX, MDM, etc.

Developed tools for HL7 version compatibility testing


Approach

Organized QA with Multiple Initiatives

Initiative 1 – Defining Effective Regression Pass for the Product

Initiative 2 – Migration of Older Defect Management System to New System

Initiative 3 – Prepared QA Strategy for Next 6 Months

Initiative 4 – Proposed Changes in Engineering Processes to Isolate P.S. and Core Engineering Activities


Thank You!

Healthcare Information Exchange Software Testing...RHIO / HIE Regional Health Information...

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