Healthcare IT Standards for EHR

and the Role of IHE

Herman Oosterwijk, OTech

Harshad Puppalwar, ST Electronics

© 2010 OTech Inc.

© 2010 OTech Inc.

Big Picture

HIS: (enterprise)

Admission Billing

Operations

RIS: (department)

Scheduling Ordering

Operations Reports

PACS: (department)

Acquisition Image management

Display and Archiving

EMR: (enterprise)

Results/Reports Patient longitudinal record

Images (or references)

HL7

DICOM

EHR:

Regional

PHR:

Personal

Other

© 2010 OTech Inc.

Standards 1. Workflow

Combo study

2. Data model

Patient ID

3. Profiles

IHE

4. Presentation

GSDF

5. Vocabularies

Body part, proc codes

6. Data formats

DICOM/HL7/propr

7. Protocols

DICOM/HL7/propr

8. Transport

TCP/IP

9. Link

Ethernet/Fibre channel

10. Physical

CAT 5, fiber

Plug

and play

© 2010 OTech Inc.

DICOM vs HL7

Scope is Imaging Scope beyond Imaging

Protocol is mainly Client/

Server

Based on object oriented

principles

Attributes encoded

Conformance specified in

Conformance statements

Conformance varies; site

dependent; requires on-site

modifications and validation (I/F

engine)

Protocol is event driven, i.e.

unsolicited events using “triggers”

Object oriented in v 3.0

Attributes are text strings

Encoding uses tags No tags

“standard” “guideline”

© 2010 OTech Inc.

Example Patient Registration Message

MSH|^~\&|MegaReg|UABHospC|ImgOrdMgr|UABImgCtr|20010529090131-0500||ADT^A01|01052901|P|2.3.1

EVN||200105290901||||200105290900

PID|||56782445^^^UAReg^PI~999855750^^^USSSA^SS||KLEINSAMPLE^BARRY^Q^JR||19620910|M||2028-9^^HL70005^RA99113^^XYZ|260 GOODWIN CREST DRIVE^^BIRMINGHAM^AL^35209^^H|||||||0105I30001^^^99DEF^AN

PV1||I|W^389^1^UABH^^^^3||||12345^MORGAN^REX^J^^^MD^0010^UAMC^L||67890^GRAINGER^LUCY^X^^^MD^0010^UAMC^L|MED|||||A0||13579^POTTER^SHERMAN^T^^^MD^0010^UAMC^L

OBX|1|NM|^Body Height||1.80|m^Meter^ISO+|||||F

OBX|2|NM|^Body Weight||79|kg^Kilogram^ISO+|||||F

AL1|1||^ASPIRIN

© 2010 OTech Inc.

DICOM Example Message

0008,0005-10-ISO_IR 100 (char set)

0008,0008-22-ORIGINAL\PRIMARY\AXIAL (image Type)

0008,0016-26-1.2.840.10008.5.1.4.1.1.2 (SOP Class)

0008,0018-46-1.2.840.1936523.4.5.1.198745.. (SOP Instance)

0008,0020-8-19990702 (study date)

0008,0030-6-113004 (study time)

0008,0050-10-046-73-303 (accession #)

0008,0060-2-CT (modality)

0008,0070-8-otechinc (manufacturer)

…….

7FE0,0010-64000-82368390288994988.. (pixel data)

Tag-Length-Value:

© 2010 OTech Inc.

How does IHE fit in?

• ADT in HL7: 60 messages, 20 segments each, 30

fields each = 600 data elements

• ADT in IHE: 4 messages, 3 segments each, 10

fields each = 30 data elements

• MWL in DICOM: 120 Attributes

• MWL in IHE: 42 Attributes

• MWL Keys for query; matching key attributes:

• Patient's Name(0010,0010)

• Patient ID(0010,0020)

• Accession Number(0008,0050)

• Requested Procedure ID(0040,1001)

© 2010 OTech Inc.

Relevant HL7 Messages

Broker

PACS

Modality Worklist Mgt

RadViewing/reporting

RIS

Order (1)

Admission (2)

Modality Result

(3)

© 2010 OTech Inc.

DICOM has 2 Components

1. Communication Protocol:

• Addressing (AE Title, Port, IP address)

• Negotiation

• Roles

• Services (“commands”):

• Store, Print, Find (worklist-images)

© 2010 OTech Inc.

DICOM has 2 Components (cont.)

2. Data formats

• Object/image format:

• Header: related to patient and to image

• Encoding of pixel data (JPEG, MPEG, Wavelet)

© 2010 OTech Inc.

Use of Vocabularies

• Many objects make extensive use of Coded data

entries using standard vocabulary:

• Instead of specifying “Sagittal” for View Code, one

specifies:

• Code Value : R-112300

• Coding Scheme : SNOMED

• Scheme Version : Version 1.0

• Meaning : Sagittal

© 2010 OTech Inc.

IHE

• What is IHE?

• Role of IHE in the context of EHR’s

© 2010 OTech Inc.

The IHE Initiative

• The need for IHE

• A very simple example – SWF Profile

• IHE Profiles and Domains

• Benefits

• Latest developments

© 2010 OTech Inc.

Standards Alone Are Not Enough

• Focused on a single domain

• Mostly provide interoperability and communications

not workflows

• No clear mapping of information flow

• Narrow - may not consider relationships between

standards domains

• Don’t define the choreography among actors

• Some have issues, too many, too complex, version

problems, vendor interests

Need standards on how to implement standards

© 2010 OTech Inc.

RIS

Modality

PACS

ADT

Registration

Patient

Information

Order

Place

r

Print

Server

Film

Folder

Image

Display

Film

Lightbox

Report

Repository

Order

Filler

Examination

Orders

Acquisitio

n Modality

Image

Manager

& Archive

Procedure

Scheduled

Modality

Worklist

Acquisition

Completed

Images

Stored

Images

Printed

Images

Retrieve

d

Report

Report

Report

Acquisition

Completed H

L7

D

IC

OM

Scheduled Workflow (SWF) Overview

© 2010 OTech Inc.

Integrating the Healthcare Enterprise (IHE)

Use of established standards to address specific

clinical need in support of optimal patient care

• It is not a standard but an agreement on how to use

established standards between systems.

• IHE is organized by clinical and operational domains Cardiology, Eye Care, IT Infrastructure, Laboratory, Patient Care

Coordination, Patient Care Devices, Quality, Research and Public Health, Radiation Oncology, Radiology

• Each domain develops and maintains its own set of

Technical Framework documents

© 2010 OTech Inc.

IHE Domains

Cardiology (CARD)

Eye Care (EYECARE)

IT Infrastructure (ITI)

Laboratory (LAB)

Anatomic Pathology (ANAPATH)

Patient Care Coordination (PCC)

Patient Care Device (PCD)

Pharmacy (PHARM)

Quality, Research and Public Health (QRPH)

Radiation Oncology (RO)

Radiology (RAD)

IHE Domains

IHE Domains are responsible

for the development and

maintenance of the IHE

Technical Frameworks

Each domain has two

Committees.

• The Planning Committee

• The Technical Committee

Each domain is sponsored by a

professional society.

© 2010 OTech Inc.

SWF

Actor: Acquisition Modality Transactions: RAD-5, RAD-6,

RAD-7, RAD-8, RAD-10

Describe the solution to a specific integration problem

Typically contain:

• The system roles (Actors)

• Their transactions

• Standards

• Design details

Integration Profiles

© 2010 OTech Inc.

Cross-enterprise Document Sharing for Imaging Consistent sharing of images and radiology reports across enterprise boundaries

Presentation of

Grouped

Procedures Manage individual

procedure image

subsets from a multi-procedure

acquisition for

viewing & reporting

Post-Processing

Workflow Manage worklists,

track status, perform

& notify image processing & CAD

steps

Reporting

Workflow Manage worklists,

track status, perform

& notify diagnostic reporting steps

Import

Reconciliation

Workflow Reconcile imported

data objects

Patient Information

Reconciliation Reconcile worklists,

status, and data

objects for unknown patients and

demographics

changes

Consistent

Presentation of

Images Create, store,

manage, retrieve

& use objects for hardcopy and

softcopy

grayscale

presentation

state

Evidence

Documents Create, store,

manage, retrieve

& use objects to record study

evidence

Key Image

Notes Create, store,

manage, retrieve

& use objects to flag significant

images

Simple Image

and Numeric

Reports Create, store,

manage, retrieve

& use simple diagnostic

reports with

optional image

NM Image Create, store,

manage, retrieve

& use NM image objects

Mammo Image Create, store,

manage, retrieve

& use Mammo image objects

Charge Posting Collect and post timely billable procedure

details

Access to Radiology Information Consistent access to images and reports

Portable Data for Imaging Consistent access to images and reports on CD Media

Other Radiology Relevant Profiles: ITI ATNA – Radiology Audit Trail Option, ITI RID, ITI PIX

create,

store,

manage, retrieve &

use images

manage

worklists, track

status, perform & notify

acquisition

related steps,

Scheduled Workflow Admit, order, schedule,

create,

store,

manage, retrieve &

use images

manage

worklists, track

status, perform & notify

acquisition

related steps,

Scheduled Workflow Admit, order, schedule,

IHE Integration Profiles - Radiology

© 2010 OTech Inc.

IHE brings together users and developers of healthcare information

technology (HIT) in an annually recurring four-step process

Define critical use cases

for information sharing

Specifications for communication

among systems to address these use cases, selecting established standards.

implements these

specifications called IHE Profiles

Tests systems at events

called Connectathons.

How Is It Organized?

© 2010 OTech Inc.

Connectathon Overview

Primary purpose: foster adoption of standards based

solutions in products

• Face-to-face interoperability testing event

• Tests implementation of Integration Profiles

capabilities defined in IHE Technical Frameworks

• Testing structured and supervised by Technical

Project Management Team

• Successful results recorded and published

• Used as preparation for demonstrations events

© 2010 OTech Inc.

Connectathon Scale

• 11th IHE North America Connectathon (Jan 11-15,

2010, Chicago)

• HIT industry's largest interoperability testing event

• Featured more than 150 systems from over 100

participating organizations - 500 systems engineers

• More than 3500 successful tests of IHE Integration

Profiles

Image Source: ihe.net

© 2010 OTech Inc.

Healthcare providers & staff

• Improved workflows

• Information whenever and

wherever needed

• Fewer opportunities for errors

• Fewer tedious tasks/repeated

work

• Improved report turnaround time

Vendors

• Align product interoperability with

industry consensus

• Decreased cost and complexity of

interface installation and

management

• Focus competition on functionality/

service space not information

transport space

Systems developed in accordance with IHE communicate with one

another better, are easier to implement, and enable care providers to

use information more effectively

Stakeholder Benefits

© 2010 OTech Inc.

Cross-Enterprise Document Sharing (XDS)

• Facilitates the registration, distribution and access across health

enterprises of patient electronic health records

• Managed through federated document repositories and a document

registry to create a longitudinal record of information about a patient

within a given clinical Affinity Domain

Benefits

• Management of the Electronic Health Record

• Registration, distribution and access across health enterprises of

patient electronic health records.

• Focused on providing a standards-based specification for managing

the sharing of documents between any healthcare enterprise,

ranging from a private physician office to a clinic to an acute care in-

patient facility.

© 2010 OTech Inc.

IHE Around the World

Source: ihe.net

© 2010 OTech Inc.

IHE in Asia

• HIMSS Asia Pacific IHE Showcases

• 2009, Kuala Lumpur, Malaysia

• Connectathon events

• 2009 in Kuala Lumpur, Malaysia

• 2010 scheduled in Korea

© 2010 OTech Inc.

When should you worry about IHE?

• Enterprise level Health IT initiatives

• Procuring equipment / systems

• Bringing disparate healthcare facilities together

• Federate & distribute Health Information systems

Remember, IHE can be incrementally implemented

© 2010 OTech Inc.

Thank You

• Harshad Puppalwar - harshad@stee.stengg.com

• Fiona Loke – lokewl@stee.stengg.com

© 2010 OTech Inc.

Summary

• Electronic Health Record implementations require

standards to interoperate

• Standards range from physical to protocols and from

data formats to coding and from workflow to good

practices

• IHE plays a critical role in the implementation to take

away optionality and specify profiles.